High risk of malignancy in patients with incidentally discovered adrenal masses: accuracy of adrenal imaging and image-guided fine-needle aspiration cytology.
OBJECTIVE
The incidental finding of nonfunctioning adrenal masses (incidentalomas) is common, but no reliable criteria in differentiating between benign and malignant adrenal masses have been defined. The aim of this preliminary study was to assess the usefulness of adrenal imaging and image-guided fine-needle aspiration cytology in patients with nonfunctioning adrenal incidentalomas with the aim of excluding or confirming malignancy before surgery.


METHODS
Forty-two consecutive patients (18 men and 24 women; median age, 54 years; range, 25-75 years) with incidentally discovered adrenal masses of 3 cm or more in the greatest diameter were prospectively enrolled in the study. All patients underwent helical computerized tomography scan and image-guided fine-needle aspiration cytology, 33 (78.6%) underwent magnetic resonance imaging, and 26 (61.9%) underwent norcholesterol scintigraphy before adrenalectomy.


RESULTS
The revised final pathology showed 30 (71.4%) benign (26 adrenocortical adenomas, of which 3 were atypical, 2 ganglioneuromas, and 2 nonfunctioning benign pheochromocytomas) and 12 (28.6%, 95% CI = 15-42) adrenal malignancies (8 adrenocortical carcinomas and 4 unsuspected adrenal metastases). The definitive diagnosis of adrenocortical carcinoma was made according to Weiss criteria and confirmed on the basis of local invasion at surgery or metastases. The sensitivity, specificity and accuracy were 75%, 67% and 83% for computerized tomography scan, 92%, 95% and 94% for magnetic resonance imaging, 89%, 94% and 92% for norcholesterol scintigraphy, and 92%, 100% and 98% for fine-needle aspiration cytology. The sensitivity and accuracy of image-guided fine-needle aspiration cytology and magnetic resonance imaging together reached 100%. Immediate periprocedural complications of fine-needle aspiration cytology occurred in 2 (4.7%) patients: self-limited pneumothorax (n = 1), and severe pain (n = 1) requiring analgesic therapy. No postprocedural or late complications were observed.


CONCLUSIONS
With the aim of selecting for surgery patients with a non-functioning adrenal incidentaloma of 3 cm or more in diameter, the combination of magnetic resonance imaging and fine-needle aspiration cytology should be considered the strategy of choice.
Endocrine Surgery Unit, Department of Surgical & Gastroenterological Sciences, University of Padua, School of Medicine, Padova, Italy. flumachi@unipd.it
Franco
F
Lumachi
Simonetta
S
Borsato
Alberto
A
Tregnaghi
Filippo
F
Marino
Ambrogio
A
Fassina
Pietro
P
Zucchetta
Maria Cristina
MC
Marzola
Diego
D
Cecchin
Franco
F
Bui
Maurizio
M
Iacobone
Gennaro
G
Favia
D015071:19-Iodocholesterol / Q000031:analogs & derivatives; D000307:Adrenal Gland Diseases / Q000175:diagnosis / Q000000981:diagnostic imaging / Q000378:metabolism / Q000473:pathology / Q000601:surgery; D000310:Adrenal Gland Neoplasms / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000378:metabolism / Q000473:pathology / Q000601:surgery; D000315:Adrenalectomy; D018246:Adrenocortical Adenoma / Q000175:diagnosis / Q000000981:diagnostic imaging / Q000378:metabolism / Q000473:pathology / Q000601:surgery; D018268:Adrenocortical Carcinoma / Q000175:diagnosis / Q000000981:diagnostic imaging / Q000378:metabolism / Q000473:pathology / Q000601:surgery; D000328:Adult; D000368:Aged; D000450:Aldosterone / Q000097:blood; D044963:Biopsy, Fine-Needle; D004837:Epinephrine / Q000652:urine; D005260:Female; D005729:Ganglioneuroma / Q000175:diagnosis / Q000000981:diagnostic imaging / Q000378:metabolism / Q000473:pathology / Q000601:surgery; D006801:Humans; D006854:Hydrocortisone / Q000097:blood; D033162:Incidental Findings; D007457:Iodine Radioisotopes; D010535:Laparoscopy; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D009638:Norepinephrine / Q000652:urine; D010673:Pheochromocytoma / Q000175:diagnosis / Q000000981:diagnostic imaging / Q000378:metabolism / Q000473:pathology / Q000601:surgery; D011237:Predictive Value of Tests; D011446:Prospective Studies; D011860:Radiography, Abdominal; D012083:Renin / Q000097:blood; D012680:Sensitivity and Specificity; D014057:Tomography, X-Ray Computed
D007457:Iodine Radioisotopes; D015071:19-Iodocholesterol; D000450:Aldosterone; C035501:6-iodomethylcholesterol; D012083:Renin; D006854:Hydrocortisone; D009638:Norepinephrine; D004837:Epinephrine