INCIDENTALLY DISCOVERED ADRENAL MASS (INCIDENTALOMA) - INVESTIGATION AND MANAGEMENT OF 208 PATIENTS

OBJECTIVE Incidentally discovered adrenal masses are fairly common, al though there are some controversies concerning the results of hormonal investigation (especially DHEAS values) and the methods of management . We summarize our experience in diagnosis, pathological findings and treatment of a large group of patients with incidentally found adrenal tumours. DESIGN AND PATIENTS Our study included patients referred to the Department of Endocrinology of the Centre of Post-graduate Medical Education (Warsaw, Poland) during the last 10 years because of an adr enal tumour incidentally found on ultrasound scan. In all cases this w as confirmed by computed tomography. There were 208 patients (148 fema le and 60 male), 14-76 years old. Unilateral adrenal masses were found in 172 patients (right 106, left 66), while bilateral masses were dem onstrated in 36 patients. The size of the tumours ranged between 0.8 a nd 21.0 cm. The most common clinical abnormalities were hypertension ( 36 cases), obesity (23 cases), diabetes (8 cases), Addison's disease ( 6 cases). MEASUREMENTS Endocrine tests evaluating pituitary-adrenal fu nction (urinary excretion of 17-hydroxycorticosteroids, 17-ketosteroid s and catecholamines, plasma concentrations of ACTH, cortisol, DHEAS, androstendione and testosterone, dexamethasone suppression test and co rticotrophin-releasing hormone stimulation test). RESULTS Cortisol hyp ersecretion was noted in two patients with coexisting Gushing's diseas e and high normal 17-OHCS values with lack of dexamethasone suppressib ility were found in six other patients with pre-clinical Gushing's syn drome. More common were subtle hormonal abnormalities: low ACTH levels (in 33 out of 98 investigated patients), diminished dexamethasone sup pressibility and lack of ACTH response in the CRH test (in two out of 12 patients). Urinary catecholamine excretion was elevated in nine pat ients. In the group of 85 patients treated by surgery the most frequen t pathological findings were: adrenocortical adenoma (21), carcinoma ( 17), phaeochromocytoma (13), metastatic masses (12) and myelolipoma (1 0). The size of carcinomas ranged from 3.2 to 20.0 cm, while the size of non-malignant tumours ranged from 1.5 to 21.0 cm. CONCLUSIONS Every patient with an incidentally discovered adrenal mass has to be invest igated to detect malignancy and subtle hormonal overproduction, to sel ect the cases for surgical treatment. Most of the adrenocortical carci nomas were > 7.0 cm in diameter. For prophylactic purposes, adrenal in cidentalomas > 4.0 cm should be treated by surgery, while the smaller ones could be followed-up (with especial care for those between 3.0 an d 4.0 cm).