Incidentally Discovered Adrenal Masses*

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Abstract
I. Introduction BEFORE 1974, the literature contained 178 clinical cases of nonhypersecretory adrenal cortical tumors (see Table 1 for nomenclature) (4). Since the early 1980s, incidentally discovered adrenal masses have become a common clinical problem as a result of the more widespread use of high resolution anatomical imaging procedures [computed tomography (CT), magnetic resonance imaging (MRI), ultrasound]. In patients without a known extraadrenal primary malignancy, the vast majority of these lesions are benign and nonhypersecretory (Fig. 1) (5, 6). These same lesions are present in a significant fraction (in some series the majority) of incidentally discovered adrenal masses in patients with known extraadrenal primary malignancies. However, it is important to distinguish these benign nonhypersecretory lesions from those in which intervention, or the lack thereof, may alter patient morbidity and mortality. These latter adrenal lesions would include biochemically hypersecretory masses and both primary and metastatic malignancies. The current clinical approach to incidentally discovered adrenal masses must balance diagnostic costs, discomfort, risks, consequences of false-positive results, and low disease prevalence against the value of making an expeditious diagnosis that may result in curative therapy in the minority of patients in whom intervention would be indicated. Widely practiced management algorithms are based heavily upon statistical models attempting to optimize these variables. Anatomical imaging (CT, MRI, and ultrasound) characteristics (7–9) and mass size (10–12) are frequently unable to reliably distinguish between these various etiologies. Fine needle aspiration (FNA) cytology is an invasive procedure with well documented risks of complications. FNA is most helpful in distinguishing adrenal from nonadrenal tissue (e.g. metastases), and is least helpful in distinguishing benign adrenal adenomas from primary adrenocortical carcinomas (4, 13–19). Adrenocortical scintigraphy noninvasively provides functional and anatomical information and is most useful in combination with a preceding biochemical evaluation. The high sensitivity of adrenocortical scintigraphy begins to diminish when mass size is less than 2 cm in diameter (20,21). This article reviews the prevalence of incidentally discovered adrenal masses, their differential diagnosis along with their prevalences, and currently used strategies for evaluation of adrenal masses.

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