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# Management of Clinically Inapparent Adrenal Mass

*Evidence Reports/Technology Assessments, No. 56*

Joseph Lau, MD, EPC/Project Director, Ethan Balk, MD, MPH, Assistant Project Director, Michael Rothberg, MD, John PA Ioannidis, MD, Deirdre DeVine, MLitt, Priscilla Chew, MPH, Bruce Kupelnick, BA, and Kimberly Miller, BA.

Agency for Healthcare Research and Quality (US)2002 May
Report No.: 02-E0141-58763-101-6

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## Structured Abstract

#### Objective:

This evidence report on the Management of the Clinically				Inapparent Adrenal Mass was requested by the Office of Medical Application and				Research (OMAR) at the National Institutes of Health for a State-of-the-Science				Conference. The widespread use of computed tomography (CT), magnetic resonance				imaging (MRI), and ultrasound imaging (US) has resulted in the incidental discovery				of asymptomatic adrenal masses (also referred to as incidentaloma) that has created				a management dilemma.

#### Search Strategy:

Studies for the review of the primary literature were				primarily identified through searches of the English language literature published				between 1966 and March 2001 in Medline, BIOSIS, and Embase.

#### Selection Criteria:

Adrenal incidentaloma can occur in a variety of				situations and authors have used a wide range of definitions for this condition.				Because incidentaloma is not a specific disease entity, we accepted all studies that				used their own definitions. Articles were selected for their relevance to answering				five key questions.

#### Data Collection and Analysis:

           The literature search yielded over 5,000 independent citations. We evaluated over					600 articles and included about 200 English language articles in the evidence					report. Specific inclusion criteria and methods of synthesis were developed for					each of the key questions. Relevant data from each article were abstracted into					evidence tables. Information from the evidence tables was synthesized into					summary tables describing the findings of each study.

#### Main Results:

            Forty-five studies provided data about the prevalence of incidentaloma or the					distribution of adrenal pathologies. Thirty-two studies evaluated diagnostic					tests to differentiate adrenal masses. Over 80 studies provided outcome					information on adrenal surgery techniques. Thirty-two studies reported					prognostic information on patients with adrenal carcinoma after surgical					excision, and nine articles reported follow-up results of untreated					incidentaloma. Most of these studies were retrospective and the overall					methodological quality was low.

Because incidentaloma is not a disease entity, the prevalence of incidentaloma					will vary with the circumstances. One study used transabdominal ultrasound for					general health examination reported 11 verified adrenal masses out of 41,357					subjects (prevalence 0.027 percent). Combining individual cases from several					studies, the prevalence of adenoma among incidentaloma was 41 percent,					metastases 19 percent, adrenocortical carcinoma 10 percent, myelolipoma 9					percent, and pheochromocytoma 8 percent, and other mostly benign lesions					comprised the remainder of the lesions. The distribution of pathology varies					with the definition of incidentaloma applied.

Most of the diagnostic studies were conducted for the purpose of diagnosing					adrenal malignancy. In general, unenhanced or immediate enhanced CT had fair					test characteristics. Delayed enhanced CT or MRI using the mass to spleen ratio					had excellent test performance. Combined unenhanced CT with MRI improved the					accuracy in one study. Scintigraphy had fair to excellent sensitivity and					specificity. Fine needle aspiration had good to excellent test performance;					however, inconclusive biopsies were common. In one small study, DHEAS had					perfect sensitivity, but poor specificity.

The clinical outcomes of various surgical adrenalectomy approaches were					reassessed. Evidence suggests that laparoscopic adrenalectomy in general results					in less blood loss and fewer major complications. The optimal surgical approach					may depend on the size and the type of tumor.

Limited follow-up data on patients with untreated incidentaloma found most tumors					remain unchanged in size, some tumors disappeared or decreased in size, and					about one-sixth of the tumors increased in size but none of these were					adrenocortical carcinoma.

#### Conclusions:

           With few exceptions, the overall methodological quality of the studies we					examined was low. Future studies of incidentaloma need to broadly cover diverse					manifestations of this condition but individual studies should apply rigorous					inclusion criteria for each of the manifestations or provide thorough					descriptions and careful analyses of well-defined subgroups. Future studies					should incorporate rigorous methodologies to properly assess the clinical					usefulness of various diagnostic tests and follow-up strategies for adrenal					incidentalomas. An international registry of patients with well-documented					adrenal incidentaloma may provide the best means of collecting these data.

## Contents

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                        - Preface
                        - Summary
                        - 1. Introduction                           - Overview
                          - Clinically Inapparent Adrenal Mass
                          - Survival for Adrenocortical Carcinoma
                          - Management of Adrenal Incidentaloma
                        - 2. Methods                           - Key Questions Addressed in this Report
                          - Definition of Adrenal Incidentaloma
                          - Literature Search
                          - Study Selection
                          - Summarizing the Literature
                        - 3. Results                           - Findings for Specific Questions
                        - 4. Conclusions
                        - 5. Future Research                           - The Need to Understand Issues Related to the Diagnosis of Incidentaloma
                          - Diagnostic Tests to Evaluate Adrenal Mass
                          - Assessment of Surgical Techniques for Adrenalectomy
                          - Follow up of Untreated Adrenal Masses
                          - The Need for an International Registry of Adrenal Incidentaloma
                        - Evidence Tables
                        - Appendix A: Literature Search Strategies
                        - Appendix B: Acknowledgments
                        - Appendix C
                        - Appendix D: Acronyms and Abbreviations
                        - References

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Prepared for: Agency for Healthcare Research and                            Quality, U.S. Department of Health and Human Services.1             Contract No. 290-97-0019. Prepared by: New England Medical Center Evidence-based Practice Center.

#### Suggested citation:

Lau J, Balk E, Rothberg M, et al. Management of Clinically Inapparent Adrenal Mass (Evidence Report/Technology Assessment No. 56 (Prepared by New England Medical Center Evidence-based Practice Center under Contract No. 290-97-0019). AHRQ Publication No. 02-E014. Rockville, MD: Agency for Healthcare Research and Quality. May 2002.

This report may be used, in whole or in part, as the basis for development of				clinical practice guidelines and other quality enhancement tools, or as a basis for				reimbursement and coverage policies. Endorsement by the Agency for Healthcare				Research and Quality (AHRQ) or the U.S. Department of Health and Human Services				(DHHS) of such derivative products may not be stated or implied.

AHRQ is the lead Federal agency charged with supporting research designed to improve				the quality of health care, reduce its cost, address patient safety and medical				errors, and broaden access to essential services. AHRQ sponsors and conducts				research that provides evidence-based information on health care outcomes; quality;				and cost, use, and access. The information helps heath care decisionmakers—patients				and clinicians, health system leaders, and policymakers—make more informed decisions				and improve the quality of health care services.

The authors of this report are responsible for its content. Statements in the report              should not be construed as endorsement by the Agency for Healthcare Research and              Quality or the U.S. Department of Health and Human Services of a particular drug,              device, test, treatment, or other clinical service.

                        - 1
                        - 
2101 East Jefferson Street, Rockville, MD 20852. www​.ahrq.gov

Copyright Notice

Bookshelf ID: NBK36558

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                    - Cite this Page Lau J, Balk E, Rothberg M, et al. Management of Clinically Inapparent Adrenal Mass. Rockville (MD): Agency for Healthcare Research and Quality (US); 2002 May. (Evidence Reports/Technology Assessments, No. 56.)

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