When the adrenal gland is silent, but the CT speaks: How to approach the so-called incidentalomas?

Intro

Imagine going for a CT scan of your abdomen for back pain or a kidney exam -- and a radiologist notices “some kind of deposit” on your adrenal gland. You have no symptoms, you feel fine -- but suddenly you have a “find.” You have just become another of the thousands of people in whom he has been exposed adrenal incidentaloma. What does that mean? Is it dangerous? And how does one know if it is “just” a fat adenoma, or a hormonal time bomb?

What is incidentaloma and why are we finding it more and more often today?

Incidentaloma is an accidentally caught deposit on the adrenal gland, usually during an examination performed for another reason. It must be greater than 1 cm, and it's not about metastasis — thus not part of a known oncological disease.

“Today, we encounter incidentaloma in 2-5% of the population, but in people over 80 years old in up to 10% of cases,” says Prof. Karel Pacák. “But this does not mean that the number of tumors is increasing — we are better at detecting them thanks to modern technology. “

Incidentalomas are the most common finding among adrenal tumors and in most cases are benign, hormonally inactive adenomas. But not always.

Two key questions of every incidentalom

When a bearing is found, two questions must first of all be answered:

1. Is the tumor hormonally active?
   That is, it produces an excess of hormones such as cortisol, aldosterone or catecholamines, which can “quietly” do damage to the body (high pressure, diabetes, osteoporosis, infertility...).
2. Is the finding benign or malignant?
   The shape, size and density of the foci on CT/MR help to estimate the risk of malignancy. If the density in the native CT is below 10 Hounsfield units (HU), it is almost certainly a harmless adipose adenoma. Conversely, foci above 30 HU or rapidly growing tumors are suspected of malignancy.

When is it necessary to pay attention?

• Tumor size > 4 cm
• Size increase > 1 cm per year
• Functional activity (e.g. increased cortisol or aldosterone)
• Unusual appearance in imaging examination (e.g. inhomogeneous structure, irregular edges)

Prof. Pacák recommends that the incidentaloma always be examined thoroughly, even if it is small and the patient does not have difficulties:

“It's not just about size, it's about context. Hormones can be treacherous. A patient can live with high pressure for years and not know that a small adrenal tumor is to blame. “

What if hormonal activity is detected?

The most common is subclinical Cushing — that is, slightly elevated cortisol levels without obvious symptoms. But even that can increase the risk of diabetes or heart attack. Also primary hyperaldosteronism (called Conn's syndrome) often only manifests itself as hypertension — it can be treated surgically.

Therefore, it is essential to always complement the hormonal examination. This includes the determination of cortisol, metanephrine, aldosterone and other markers as suspected.

What happens next with the incidentaloma?

The decision depends on the results of the examination:

• Inactive and < 4 cm: follow-up (e.g. control CT/MR at 6-12 months).
• Hormonally active or > 4 cm, possibly suspicious appearance: surgical removal is recommended.
• Bilateral bearings: It is necessary to consider adrenal insufficiency — that is, impaired adrenal function.

Biopsy is usually not recommended, exceptions are the suspicion of lymphoma or the need to distinguish it from metastases in a known cancer.

Summary

Incidentalomas are more common than we think -- there can be hundreds of thousands of them in the population. Most are harmless, but some produce hormones or are risky in size or appearance. Therefore, a thorough examination is always in place.

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