CBM 2002-1

Management of the Clinically Inapparent

Adrenal Mass (Incidentaloma)

January 1990 through October 2001, plus selected earlier citations

1142 Citations

Prepared by

Mary Conway, M.L.S., National Library of Medicine

Hema Padmanabhan, M.D., National Institute of Child Health and Human Development

2002 January

U.S. DEPARTMENT OF HEALTH

 AND HUMAN SERVICES

Public Health Service

National Institutes of Health

National Library of Medicine

Reference Section

8600 Rockville Pike

Bethesda, Maryland 20894
ii

SERIES NOTE

Each bibliography in the Current Bibliographies in Medicine (CBM) series covers a distinct subject area of

biomedicine and fulfills a current awareness function. Online databases and the Internet are the primary

sources for citations in these bibliographies. Relevance to the subject is the only criterion for inclusion of

works in a CBM; the format, ownership, or location of the material are not considered.

Other publications in the Current Bibliographies in Medicine series are available through the Library's

World Wide Web site at http://www.nlm.nih.gov/pubs/resources.html.

Comments and suggestions on this series may be addressed to:

Karen Patrias, Editor

Current Bibliographies in Medicine

Reference Section

National Library of Medicine

Bethesda, MD 20894

Phone: 301-496-6097

E-mail: custserv@nlm.nih.gov

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at 1-888-FINDNLM (301-594-5983 international) or e-mail custserv@nlm.nih.gov for information on

alternative ways to search.
iii

TABLE OF CONTENTS

 page

Introduction v

Sample Citations vii

Causes, Prevalence, and Natural History of Clinically Inapparent Adrenal Masses

Overviews 1

Causes 7

Prevalence 20

Natural History 23

Evaluation of Clinically Inapparent Adrenal Masses

Overviews 26

Biochemical Tests 32

Fine-Needle Aspiration Biopsy 38

Ultrasonography 40

Radiology and Radionuclide Imaging 41

Computer-Assisted Tomography (CT) and

 Magnetic Resonance Imaging (MRI) 46

Positron Emission Tomography (PET) and Single-Photon

 Emission-Computed Tomography (SPECT) 58

Other Diagnostic Techniques 59

Surgery of Clinically Inapparent Adrenal Masses

Overviews 62

Open Surgery 68

Laparoscopy 70

Surgical Outcome 75

Patient Follow-Up

Non-Surgically Treated Incidentalomas 82

Surgically Treated Incidentalomas 85

Additional Research Needed to Guide Practice 87
iv
v

INTRODUCTION

The adrenals are triangular glands that sit atop each kidney. They influence or regulate the body's

metabolism, salt and water balance, response to stress, and other important functions by secreting a variety

of hormones. Adrenal masses are among the most common tumors in humans, occurring in at least 3

percent of persons over age 50, according to recent estimates. Most adrenal masses cause no health

problems. A small proportion, however, can lead to a number of serious hormonal diseases, and

approximately one out of every 4,000 adrenal tumors is cancerous.

Clinically inapparent adrenal masses are discovered inadvertently, in the course of diagnostic testing or

treatment for other conditions, and thus are commonly known as incidentalomas. Improvements in

abdominal imaging techniques and technologies have resulted in the detection of an increasing number of

adrenal incidentalomas.

When detected, the clinically inapparent adrenal mass raises challenging questions for physicians and their

patients. For example, should the mass be removed? Is a nonsurgical approach indicated? What risks are

associated with either approach? Because the incidence of these masses increases with age, appropriate

management of adrenal tumors will be a growing challenge in our aging society.

Over the past several years, significant new information has become available regarding the epidemiology,

biology, screening, treatment, and follow-up of adrenal tumors. For example, recent refinements in the field

of minimally invasive general surgery have made laparoscopic adrenalectomy a widely used method for

removing adrenal masses. Moreover, recent reports suggest that 5 to 25 percent of patients with adrenal

incidentaloma have some form of subclinical hormonal dysfunction and may represent a population at

higher risk for metabolic disorders and cardiovascular disease. It will be important to identify those groups

with subclinical disease that will benefit from treatment.

This bibliography was prepared for the National Institutes of Health State-of-the-Science Conference titled

Management of the Clinically Inapparent Adrenal Mass (Incidentaloma) to be held February 4-6, 2002, in

Bethesda, Maryland. The primary sponsor of this meeting is the National Institute of Child Health and

Human Development. Co-sponsors include the National Cancer Institute and the National Institute of

Diabetes and Digestive and Kidney Diseases. This two-and-a-half-day conference will explore and assess

the current scientific knowledge regarding adrenal incidentalomas to enable health care providers and the

general public make informed decisions about this important public health issue. The conference will

address the following questions:

• What are the causes, prevalence, and natural history of clinically inapparent adrenal masses?

• Based on available scientific evidence, what is the appropriate evaluation of a clinically inapparent

adrenal mass?

• What criteria should guide the decision on surgical versus nonsurgical management of these

masses?

• If surgery is needed, what is the appropriate procedure?

• What is the appropriate followup for patients for each management approach?

• What additional research is needed to guide practice?

The bibliography contains selected citations to journal articles, books and book chapters, conference

proceedings and meeting abstracts, and audiovisuals published in all languages from 1990 forward; other

selected references from earlier years have also been included. The references have been arranged into six

broad categories that parallel the topics to be presented at the conference; an item may appear in more than

one category.
vi

The compilers wish to thank Stefan R. Bornstein, M.D., for his helpful explanation of this clinical problem

and guidance in the early stages of production. The compilers would also like to thank Oluchi Ukaegbu,

National Library of Medicine, for her valuable production assistance.

This publication is not copyrighted and may be freely reproduced. However any reproductions of this

bibliography, in whole or in part, should include all credits. If you wish to cite this bibliography, the correct

format is:

Conway, Mary; Padmanabhan, Hema, compilers. Management of the clinically inapparent adenal mass

(Incidentaloma) [bibliography on the Internet]. Bethesda (MD): National Library of Medicine (US); 2002

Jan [insert cited year month day in brackets]. 88 p. (Current bibliographies in medicine; no. 2002-1). 1142

citations from January 1990 through October 2001, plus selected earlier citations. Available from:

http://www.nlm.nih.gov/pubs/cbm/adrenal_incidentaloma.pdf
vii

SAMPLE CITATIONS

Citations are formatted according to the rules established for Index Medicus®*. Sample journal,

monograph, and audiovisual citations appear below. For journal articles written in a foreign language, the

English translation of the title displays in brackets; for monographs and audiovisuals the title is given in the

original language. In all cases the language of publication is shown by a three-letter abbreviation appearing

at the end of the citation.

Note also than an availability statement follows many journal article citations. This statement contains the

identification number (PMID) for the citation in the PubMed retrieval system. The user may enter this

number in PubMed on the NLM Web site (http://pubmed.gov/) to retrieve the record, which includes an

abstract for most articles and may also provide a link to the publisher's Internet site.

Journal Article:

 Authors Article Title Abbreviated Journal Date

 Title

Bittner DA, Ross DS. Incidentally discovered adrenal masses. Am J Surg. 1989 Aug;

158(2):159-61. Available from: PubMed; PMID 2757145

 Volume Issue Pages Availability

Monograph:

Authors/Editors Title Place of Publisher Date

 Publication

Lack EE. Pathology of the adrenal glands. New York: Churchill Livingstone; 1990.

389 p.

 Total No. of Pages

Audiovisual:

 Title Medium Designator Authors Producer

Laparoscopic left adrenalectomy for primary aldosteronism [videocassette]. Sardi A. Alton

Ochsner Medical Foundation, producer. Woodbury (CT): Cine-Med; c1993.

1 videocassette: 15 min., sound, color, 1/2 in..

 Physical Description Place of Publisher Date

 Publication

* For details of the formats used for references, see the following publications:

 Patrias, Karen. National Library of Medicine recommended formats for bibliographic citation.

 Bethesda (MD): The Library; 1991 Apr. Available from: NTIS, Springfield, VA; PB91-182030.

 Patrias, Karen. National Library of Medicine recommended formats for bibliographic citation.

 Supplement: Internet formats [Internet]. Bethesda (MD): The Library; 2001 Jul. Available from:

 http://www.nlm.nih.gov/pubs/formats/internet.pdf
viii
1

CAUSES, PREVALENCE, AND

NATURAL HISTORY OF CLINICALLY

INAPPARENT ADRENAL MASSES

Overviews

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Serendipitous adrenal masses: prevalence, significance, and

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Ackermann RJ. Adrenal disorders: know when to act and

what tests to give. Geriatrics. 1994 Jul;49(7):32-7. Available

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Adrenal tumors. A cause for concern? Mayo Clin Health

Lett. 2001 Apr;19(4):6. Consumer health information.

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Aki M, Kanagawa S. [Nonfunctional adrenocortical

adenoma: a case report]. Nishinihon J Urol. 1989;51(2):585-

7. (Jpn).

Albala DM, Chung CJ, Sueoka BL, Memoli VA, Heaney JA.

Hemorrhagic myelolipoma of adrenal gland after blunt

trauma. Urology. 1991 Dec;38(6):559-62. Available from:

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Ambrosi B, Re T, Passini E, Peverelli S, Sartorio A,

Colombo P. [Clinical and preclinical aspects of adrenal

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Andreis M, Avataneo T. [Computed tomography of nonfunctioning adrenal masses]. Radiol Med (Torino). 1985

Apr;71(4):206-10. Available from: PubMed; PMID 4048555

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Angeli A, Osella G, Ali A, Terzolo M. Adrenal

incidentaloma: an overview of clinical and epidemiological

data from the National Italian Study Group. Horm Res.

1997;47(4-6):279-83. Available from: PubMed; PMID

9167965

Aoyagi T, Ohki T, Hayakawa K, Ohashi M, Ishikawa H,

Hata M. [Usefulness of metoclopramide test in the

differential diagnosis of asymptomatic pheochromocytoma

from metastatic adrenal tumor: a case report]. Rinsho

Hinyokika. 1997;51(12):937-40. (Jpn).

Appetecchia M, Chilelli M, Sciarretta F, Anza M. Bilateral

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Aprill BS, Drake AJ 3rd, Lasseter DH, Shakir KM. Silent

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15;120(6):485-7. Comment in: Ann Intern Med. 1994 Sep

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2000 Oct;33(10):1177-89. Available from: PubMed; PMID

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1990 May;81(5):661-71. Available from: PubMed; PMID

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Auh YH, Anand J, Zirinsky K, Kazam E. Adrenal

hemangioma: a case report. J Comput Tomogr. 1986

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Aydintug S, Kocak S, Eraslan S. Primary non-functioning

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Barnett CC Jr, Varma DG, El-Naggar AK, Dackiw AP,

Porter GA, Pearson AS, Kudelka AP, Gagel RF, Evans DB,

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