II. Epidemiology

  1. Incidental Adrenal Mass found on up to 3-4% of Abdominal CTs or MRIs
  2. Incidental Adrenal Masses found in 20% of autopsies

III. Differential Diagnosis of Incidental Adrenal Mass

  1. Adrenal Adenoma (51%)
    1. Non-functioning adenoma
    2. Functioning adenoma
      1. Cushing's Syndrome
      2. Pheochromocytoma
      3. Hyperaldosteronism
  2. Metastatic cancer (31%)
    1. Bronchogenic Carcinoma
    2. Renal Cell Carcinoma
    3. Melanoma
  3. Adrenal Carcinoma (1-4%)
  4. Adrenal Cyst (4%)
  5. Pheochromocytoma (4%)
  6. Adrenal Hyperplasia (2%)
  7. Lipoma (2%)
  8. Myelolipoma (2%)

IV. Labs

  1. Pheochromocytoma Screening
    1. Consider plasma free metanephrines (in all patients)
    2. 24-hour Urine Metanephrines
    3. 24-hour Urine Vanillylmandelic Acid (VMA)
  2. Cushing's Syndrome Screening
    1. Dexamethasone Suppression Test (in all patients)
    2. 24-hour Urinary free cortisol level
  3. Hyperaldosteronism Screening (hypertensive patients)
    1. Serum Potassium
    2. Plasma aldosterone to renin activity ratio

V. Imaging

  1. CT Abdomen
    1. With IV contrast
      1. Low attenuation lesions (<10 Hounsfield Units) is more consistent with benign lesions
    2. With delayed-phase (to perform washout calculations)
      1. Adrenal carcinoma has a low washout
  2. MRI Abdomen with Chemical Shift
    1. Chemical shift confirms lipid-rich adenoma
    2. Indicated if CT with IV contrast contraindicated
  3. Fluorodeoxyglucose-positron emission testing (FDG-PET)
    1. Indicated for lesions not definitively characterized on CT or MRI
    2. High Test Sensitivity for malignancy
    3. Decreased Test Specificity for malignancy (false positives possible)

VI. Evaluation: Reassuring findings suggestive of benign Adrenal Mass

  1. No history of other malignancy (lowers risk to 0.3% chance of cancer)
  2. Reassuring imaging findings suggestive of benign mass
    1. Lesions smaller than 4 cm with smooth borders
    2. Lipid-containing lesions
      1. CT with low attenuation (<10 Hounsfield Units) homogeneous mass
      2. MRI with signal loss on out-of-phase imaging
    3. Rapid-washout of IV iodinated contrast

VII. Indications: Follow-up Imaging

  1. Distinguish benign Lesions versus cancer
  2. Distinguish functioning versus non-functioning

VIII. Evaluation: Protocol

  1. Adrenal Mass on CT Scan <1 cm in greatest diameter (especially if fatty or cystic consistency)
    1. No further evaluation needed
  2. Adrenal Mass on CT Scan >4 cm in greatest diameter
    1. Evaluate endocrine labs above (especially to rule out Pheochromocytoma)
    2. Imaging
    3. Biopsy unless clearly benign (e.g. adrenal cyst, myelolipoma)
    4. Consult with surgery regarding possible excision
  3. Adrenal Mass 1-4 cm and lipid containing lesion on initial imaging (see above)
    1. Consider evaluating endocrine labs above (especially to rule out Pheochromocytoma)
    2. Repeat unenhanced CT Abdomen in 12 months to confirm no change
  4. Adrenal Mass 1-4 cm and not a lipid containing lesion
    1. Evaluate endocrine labs above (especially to rule out Pheochromocytoma)
    2. Perform CT Abdomen with IV contrast and delayed phase (or MRI as alternative)
    3. If CT or MRI non-diagnostic, consider FDG-PET
    4. Referral
      1. Endocrinology for functional adenomas
      2. General surgery for suspicious or non-diagnostic imaging

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Ontology: Adrenal mass (C0342500)

Concepts Disease or Syndrome (T047)
SnomedCT 237783006
Italian Massa surrenale
Japanese 副腎腫瘤, フクジンシュリュウ
Czech Rezistence nadledviny
English Mass of adrenal gland, Adrenal mass (disorder), Mass of adrenal gland (finding), adrenal masses, mass adrenal, adrenal mass, Adrenal gland mass, Adrenal mass, Adrenal Mass, Mass;adrenal
Spanish masa suprarrenal (trastorno), masa adrenal, masa suprarrenal (hallazgo), masa suprarrenal, Masa suprarrenal
Hungarian Mellékvese térfoglaló folyamata
Portuguese Massa suprarrenal
Dutch bijnier gezwel
French Masse de la glande surrénale
German Raumforderung der Nebenniere