Diagnostics and treatment of adrenal tumors detected accidentally
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Clinical Department of Endocrinology, Diabetology and Internal Diseases, Faculty of Medical Sciences, Collegium Medicum, University of Warmia and Mazury in Olsztyn, Poland
Submission date: 2018-05-19
Final revision date: 2018-10-22
Acceptance date: 2018-10-22
Online publication date: 2018-12-15
Corresponding author
Magdalena Maria Stefanowicz-Rutkowska   

Clinical Department of Endocrinology, Diabetology and Internal Diseases, Faculty of Medical Sciences, Collegium Medicum, University of Warmia and Mazury in Olsztyn, Kościuszki, 61/22, 10-587 Olsztyn, Poland.
Pol. Ann. Med. 2019;26(2):158-164
The adrenal glands are paired and located in the retroperitoneal space, above the upper pole of the kidney. Adrenal tumors depending on the histopathological structure, may be divided into: epithelial, mesenchymal, lymphoid and adrenal medulla tumors. Depending on the etiology, distinguishes between tumors, inflammatory tumors, true adrenal cysts, pseudocysts and parasitic adenomas and proliferative processes. The adrenal incydentaloma is a pathological tissue in the adrenal gland, with a diameter of ≥ 1 cm, diagnosed during diagnostics for reasons other than adrenal pathology.

The work aims to discuss the latest available diagnostic and therapeutic methods of incidentalomas, which are an increasing clinical problem, due to the increasing availability of imaging ultrasonography and computed tomography.

Material and methods:
The paper was based on the available literature of the subject, magazines and the latest guidelines.

Results and discussion:
In diagnosing adrenal tumors, imaging diagnostics (ultrasonography, computed tomography, magnetic resonance, positron emission tomography, scintigraphy, fine needle aspiration biopsy), hormonal (ACTH, cortisol, dexamethasone suppression tests, diurnal excretion of free cortisol in urine and/or 17 hydroxycorthoroids, plasma renin activity, aldosterone, dehydroepiandrosterone sulphate, androstenedione, 17-alpha-hydroxyprogesterone, chromogranin A, metanephrins in plasma and excreted in urine and biochemic. Adrenal glands may have hormonal activity: a pheochromocytoma usually produces adrenaline and norepinephrine, and rarely dopamine; adrenocortical tumors that excessive produce cortisol cause ACTH-independent Cushing’s syndrome; adrenal tumors may also secrete excess aldosterone and androgens.

Adrenal incydentaloma are common in everyday clinical practice and its treatment is established on the basis of interviews, physical examination, tumor phenotype in computed tomography and tumor hormonal activity.

We thank the anonymous referees for their useful suggestions.
The work was not financed by any scientific research institution, association or other entity, the authors did not receive any grant.
The authors have no potential conflicts of interest.
Słapa RZ, Jakubowski WS, Dobruch-Sobczak K, Kasperlik-Załuska AA. Standards of ultrasound imaging of the adrenal glands. J Ultrason. 2015;15(63):377–387.
Fassnacht M, Libé R, Kroiss M, Allolio B. Adrenocortical carcinoma: a clinician’s update. Nat Rev Endocrinol. 2011;7:323–335.
Groussin L, Kirschner LS, Vincent–Dejean C. Molecular analysis of the cyclic AMP–dependent protein kinase A (PKA) regulatory subunit 1A (PRKAR1A) gene in patients with Carney complex and primary pigmented nodular adrenocortical disease (PPNAD) reveals novel mutations and clues for pathophysiology: augmented PKA signaling is associated with adrenal tumorigenesis in PPNAD. Am J Hum Genet. 2002;71(6):1433–1442.
Kerkhofs TM, Roumen RM, Demeyere TB, van der Linden AN, Haak HR. Adrenal tumors with unexpected outcome: a review of the literature. Int J Endocrinol. 2015;710514:1–7.
Mozos A, Ye H, Chuang WY, et al. Most primary adrenal lymphomas are diffuse large B–cell lymphomas with non–germinal center B–cell phenotype, BCL6 gene rearrangement and poor prognosis. Mod Pathol. 2009;22(9):1210–1217.
Pacak K, Eisenhofer G, Ahlman H, et al. Pheochromocytoma: recommendations for clinical practice from the First International Symposium. October 2005. Nat Clin Pract Endocrinol Metab. 2007;3(2):92–102.
Sebastiano C, Zhao X, Deng FM, Das K. Cystic lesions of the adrenal gland: our experience over the last 20 years. Hum Pathol. 2013;44(9):1797–1803.
Baudin E, Leboulleux S, Al Ghuzlan A, et al. Therapeutic management of advanced adrenocortical carcinoma: what do we know in 2011? Horm Cancer. 2011;2(6):363–371.
Bednarczuk T, Bolanowski M, Sworczak K, et al. Adrenal incidentaloma in adults–management recommendations by the Polish Society of Endocrinology. Endokrynol Pol. 2016;67(2):234–258.
Terzolo M, Stigliano A, Chiodini I, et al. AME position statement on adrenal incidentaloma. Eur J Endocrinol. 2011;164(6):851–870.
Grumbach MM, Biller BM, Braunstein GD, et al. Management of the clinically inapparent adrenal mass (“incidentaloma”). Ann Intern Med. 2003;138(5):424–429.
Papierska L, Nowak K. [Morphological and functional imaging of the adrenal glans]. Post Nauk Med. 2013;23(11):819–825 [in Polish].
Gajraj H, Young AE. Adrenal incidentaloma. Br J Surg. 1993;80:422–426.
NIH state-of-the-science statement on management of the clinically inapparent adrenal mass (“incidentaloma”). NIH Consens State Sci Statements. 2002;19(2):1–25.
Dietrich CF, Wehrmann T, Hoffmann C, Herrmann G, Caspary WF, Seifert H. Detection of the adrenal glands by endoscopic or transabdominal ultrasound. Endoscopy. 1997;29(9):859–864.
Bertherat J, Bertagna X. Pathogenesis of adrenocortical cancer. Best Pract Res Clin Endocrinol Metab. 2009;23:261–271.
Lenders JW, Duh QY, Eisenhofer G, et al; Endocrine Society. Pheochromocytoma and paraganglioma: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2014;99(6):1915–1942.
Sangwaiya M, Boland G, Cronin CG, Blake MA, Halpern EF, Hahn PF. Incidental adrenal lesions: accuracy of characterization with contrast-enhanced washout multidetector CT – 10 minut delayed imaging protocol revisited in a large- patient cohort. Radiology. 2010;256(2):504–510.
Podgórska J, Cieszanowska A, Bednerczuk T. Adrenal imaging. Endokrynol Pol. 2012;63(1):71–81.
La Cava G, Imperiale A, Olianti C, et al. SPECT semiquantitative analysis of adrenocortical 131I-6β-iodomethyl-norcholesterol uptake to discriminate subclinical and preclinical functioning adrenal incidentaloma. J Nucl Med. 2003;44(7):1057–1064.
Zeiger MA, Thompson GB, Duh QY, et al. American Association of Clinical Endocrinologists and American Association of Endocrine Surgeons medical guidelines for the management of adrenal incidentalomas. Endocr Pract. 2009;15(Suppl 1):1–20.
Arnaldi G, Angeli A, Atkinson AB, et al. Diagnosis and complications of Cushing’s syndrome: a consensus statement. J Clin Endocrinol Metab. 2003;88(12):5593–5602.
Funder JW, Carey RM, Fardella C, et al.; Endocrine Society. Case detection, diagnosis, and treatment of patients with primary aldosteronism: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2008;93(9):3266–3281.
Nieman LK, Biller BMK, Findling JW, et al. The Diagnosis of Cushing’s Syndrome: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2008;93(5):1526–1540.
Dumitrescu CE, Collins MT. McCune–Albright syndrome. Orphanet J Rare Dis. 2008;3(1):1–12.
Ambroziak U, Bednarczuk T. [Basic bochemical studies and their interpretation in adrenal diseases]. In: Otto M, ed. [Diagnosis and treatment of adrenal diseases]. Warszawa: PZWL. 2013:25–35 [in Polish].
Stratakis CA. Cushing syndrome caused by adrenocortical tumors and hyperplasias (corticotrophin–independent Cushing syndrome). Endocr Dev. 2008;13:117–132.
Zgliczyński W. [Progress in diagnosis and teatment of Cushing’s disease]. Post Nauk Med. 2008;2:69–74.
Di Dalmazi DG, Vicennati V, Rinaldi E, et al. Progressively increased patterns of subclinical cortisol hypersecretion in adrenal incidentalomas differently predict major metabolic and cardiovascular outcomes: a large cross-sectional study. Eur J Endocrinol. 2012;166(4):669–667.
Hirsch D, Shimon I, Manisterski Y, et al. Cushing’s syndrome: comparison between Cushing’s disease and adrenal Cushing’s. Endocrine. 2018;63(2):712–720.
Fassnacht M, Arlt W, Bancos I, et al. Management of adrenal incidentalomas: European society of endocrinology clinical practice guideline in collaboration with the european network for the study of adrenal tumors. Eur J Endocrinol. 2016;175(2):1–34.
Kline GA. Primary Aldosteronism: unnecessary complexity in definition and diagnosis as a barrier to wider clinical care. Clin Endocrinol. 2015;82(6):779–784.
Zografos G, Perysinakis I, Vassilatou E. Subclinical Cushing’s syndrome: Current concepts and trends. Hormones. 2014;13(3):323–337.
Li L, Yang G, Dou J, et al. The role of cortisol/ACTH ratio for screening of subclinical hypercortisolism in patients with adrenal incidentalomas. Exp Clin Endocrinol Diabetes. 2018;126(2):71–76.
Rossi G.P, Cesari M, Cuspidi C. Long-term control of arterial hypertension and regression of left ventricular hypertrophy with treatment of primary aldosteronism. Hypertension. 2013;62(1):62–69.
Stavropoulos K, Imprialos KP, Katsiki N, et al. Primary aldosteronism in patients with adrenal incidentaloma: Is screening appropriate for everyone?. J Clin Hypertens. 2018;20(5):942–948.
Cyrańska-Chyrek E, Grzymisławska M, Ruchała M. Diagnostic pitfalls of adrenal incidentaloma. Endokrynol Pol. 2017;68(3):360–377.
Musella M, Conzo G, Milone M, et al. Preoperative workup in the assessment of adrenal incidentalomas: outcome from 282 consecutive laparoscopic adrenalectomies. BMC Surg. 2013;13(1):57–64.
Otto M, Dzwonkowski J. Adrenal-preserving surgery of adrenal tumours. Endokrynol Pol. 2015;66(1):80–96.
Celejewski K, Pogorzelski R, Toutounchi S, et al. Adrenal Incidentaloma – Diagnostic and Treating Problem – Own Experience. Open Medicine. 2018;13:281–284.
Hong AR, Kim JH, Park KS, et al. Optimal follow-up strategies for adrenal incidentalomas: reappraisal of the 2016 ESE-ENSAT guidelines in real clinical practice. Eur J Endocrinol. 2017;177(6):475–483.
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