Adrenal incidentaloma (adrenaloma).
The management of adrenalomas should include the following: 1. A detailed history and physical examination to detect subtle evidence of hormonal hypersecretion or the possibility of metastatic carcinoma. 2. Hormonal studies: Short dexamethasone suppression test (2 mg of dexamethasone) followed by a high-dose dexamethasone suppression test (8 mg), CRH assay and analysis of the diurnal cortisol rhythm if serum cortisol value post dexamethasone is greater than 3 microg/dL, 24-hour (or spot) urinary catecholamine metabolites (metanephrine and normetanephrine), In the hypertensive or normotensive patient with serum potassium less than 3.9 nmol/L, the upright aldosterone level to plasma renin activity (PRA) ratio. 3. Additional studies, such as: Glucose tolerance test, Bone mineral density evaluation, Body composition and fat distribution by DEXA (Dual energy X-Ray absorptiometry). The role of FNA is limited. It may be helpful only in the patient with coexistent extradrenal carcinoma to confirm adrenal metastasis. Although genetic and molecular biology studies do not have wide clinical application, they should be encouraged and supported. Once all of these data are collected, the recommendations are: 1. All clearly nonfunctioning adrenalomas that are not suspicious for malignancy in asymptomatic patients should be observed for several years, mainly with hormonal studies, until their secretory and benign nature is confirmed. 2. All patients with adrenalomas and evidence of subclinical function, suspicion for malignancy (using size, imaging, FNA and molecular biology criteria) and symptoms, such as hypertension, obesity, impaired glucose tolerance, central fat deposition and reduced bone mineral density, should undergo laparoscopic adrenalectomy. The age, the overall medical condition and the anxiety of the patient should also be considered in the decision to operate on a patient with an adrenaloma.
Linos
Dimitrios A
DA
First Surgical Clinic Hygeia Hospital, Athens, Greece. dlinos@hms.harvard.edu