title: Management of adrenal incidentalomas: European Society of Endocrinology Clinical Practice Guideline in collaboration with the European Network for the Study of Adrenal Tumors.
abstract: : By definition, an adrenal incidentaloma is an asymptomatic adrenal mass detected on imaging not performed for suspected adrenal disease. In most cases, adrenal incidentalomas are nonfunctioning adrenocortical adenomas, but may also represent conditions requiring therapeutic intervention (e.g. adrenocortical carcinoma, pheochromocytoma, hormone-producing adenoma or metastasis). The purpose of this guideline is to provide clinicians with best possible evidence-based recommendations for clinical management of patients with adrenal incidentalomas based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. We predefined four main clinical questions crucial for the management of adrenal incidentaloma patients, addressing these four with systematic literature searches: (A) How to assess risk of malignancy?; (B) How to define and manage low-level autonomous cortisol secretion, formerly called 'subclinical' Cushing's syndrome?; (C) Who should have surgical treatment and how should it be performed?; (D) What follow-up is indicated if the adrenal incidentaloma is not surgically removed? SELECTED RECOMMENDATIONS: (i) At the time of initial detection of an adrenal mass establishing whether the mass is benign or malignant is an important aim to avoid cumbersome and expensive follow-up imaging in those with benign disease. (ii) To exclude cortisol excess, a 1mg overnight dexamethasone suppression test should be performed (applying a cut-off value of serum cortisol ≤50nmol/L (1.8µg/dL)). (iii) For patients without clinical signs of overt Cushing's syndrome but serum cortisol levels post 1mg dexamethasone >138nmol/L (>5µg/dL), we propose the term 'autonomous cortisol secretion'. (iv) All patients with '(possible) autonomous cortisol' secretion should be screened for hypertension and type 2 diabetes mellitus, to ensure these are appropriately treated. (v) Surgical treatment should be considered in an individualized approach in patients with 'autonomous cortisol secretion' who also have comorbidities that are potentially related to cortisol excess. (vi) In principle, the appropriateness of surgical intervention should be guided by the likelihood of malignancy, the presence and degree of hormone excess, age, general health and patient preference. (vii) Surgery is not usually indicated in patients with an asymptomatic, nonfunctioning unilateral adrenal mass and obvious benign features on imaging studies. We provide guidance on which surgical approach should be considered for adrenal masses with radiological findings suspicious of malignancy. Furthermore, we offer recommendations for the follow-up of patients with adrenal incidentaloma who do not undergo adrenal surgery, for those with bilateral incidentalomas, for patients with extra-adrenal malignancy and adrenal masses and for young and elderly patients with adrenal incidentalomas.
authors.affiliation: Department of Internal Medicine IDivision of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany Comprehensive Cancer Center MainfrankenUniversity of Würzburg, Würzburg, Germany fassnacht_m@ukw.de.
authors.forename: Martin
authors.initials: M
authors.lastname: Fassnacht
authors.affiliation: Institute of Metabolism & Systems ResearchUniversity of Birmingham, Birmingham, UK Centre for EndocrinologyDiabetes and Metabolism, Birmingham Health Partners, Birmingham, UK.
authors.forename: Wiebke
authors.initials: W
authors.lastname: Arlt
authors.affiliation: Institute of Metabolism & Systems ResearchUniversity of Birmingham, Birmingham, UK Centre for EndocrinologyDiabetes and Metabolism, Birmingham Health Partners, Birmingham, UK Division of EndocrinologyMetabolism, Nutrition and Diabetes, Mayo Clinic, Rochester, Minnesota, USA.
authors.forename: Irina
authors.initials: I
authors.lastname: Bancos
authors.affiliation: Department of GeneralVisceral, and Vascular Surgery, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany.
authors.forename: Henning
authors.initials: H
authors.lastname: Dralle
authors.affiliation: Department of Oncology and MetabolismMedical School, University of Sheffield, Sheffield, UK Endocrine UnitRoyal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.
authors.forename: John
authors.initials: J
authors.lastname: Newell-Price
authors.affiliation: Department of ImagingSt Bartholomew's Hospital, Barts Health, London, UK.
authors.forename: Anju
authors.initials: A
authors.lastname: Sahdev
authors.affiliation: Department of Endocrinology and INSERM U862University and CHU of Bordeaux, Pessac, France.
authors.forename: Antoine
authors.initials: A
authors.lastname: Tabarin
authors.affiliation: Internal Medicine 1Department of Clinical and Biological Sciences, University of Turin, Turin, Italy.
authors.forename: Massimo
authors.initials: M
authors.lastname: Terzolo
authors.affiliation: Department of EndocrinologyDiabetes and Metabolism, Evangelismos Hospital, Athens, Greece.
authors.forename: Stylianos
authors.initials: S
authors.lastname: Tsagarakis
authors.affiliation: Departments of Clinical Epidemiology and Internal MedicineLeiden University Medical Centre, Leiden, The Netherlands Department of Clinical EpidemiologyAarhus University, Aarhus, Denmark.
authors.forename: Olaf M
authors.initials: OM
authors.lastname: Dekkers
mesh_terms: D000310:Adrenal Gland Neoplasms / Q000097:blood / Q000175:diagnosis* / Q000628:therapy*; D006801:Humans; D006854:Hydrocortisone / Q000097:blood*; D033162:Incidental Findings
chemical_list: D006854:Hydrocortisone