World Journal of Endocrine Surgery

Register      Login

VOLUME 3 , ISSUE 3 ( September-December, 2011 ) > List of Articles

CASE REPORT

Adrenal Incidentaloma: A Cautionary Tale of Three Cases of Adrenocortical Carcinoma Arising from Apparently Benign Incidentalomas

Chris Armstrong, Janice L Pasieka, Adrian Harvey

Citation Information : Armstrong C, Pasieka JL, Harvey A. Adrenal Incidentaloma: A Cautionary Tale of Three Cases of Adrenocortical Carcinoma Arising from Apparently Benign Incidentalomas. World J Endoc Surg 2011; 3 (3):137-143.

DOI: 10.5005/jp-journals-10002-1078

Published Online: 01-12-2011

Copyright Statement:  Copyright © 2011; Jaypee Brothers Medical Publishers (P) Ltd.


Abstract

Unexpected incidental findings on cross-sectional imaging are becoming more commonplace in today's medical practice. These are likely due to ongoing improvements in the resolution of cross-sectional imaging and our increasing use of these tests combined with an aging population. In the case of the adrenal incidentalomas the majority of these represent benign nonfunctional adenomas and these are believed to have no malignant potential. On the contrary adrenocortical carcinoma (ACC) is an uncommon malignancy that carries a high mortality. Current biochemical and radiological follow-up investigations are expensive and are of limited benefit in the majority of cases of adrenal incidentalomas. This has created a dilemma for the proper diagnostic, clinical and radiologic follow-up as well as the triggers for surgical intervention. We present a series of three patients presenting with ACC that retrospectively arose from a small incidentally found adrenal lesion. Three patients were identified with ACC arising from an apparently benign adrenal incidentaloma. The average size of the original lesion was 1.6 cm whereas the average size of their adrenal tumor was 9.3 cm when they presented with ACC. Two of the three cases were found to develop functional tumors at the time of the diagnosis of ACC. Two of the three cases underwent surgical resection. The third patient was found to have metastatic disease at presentation and declined surgical intervention. We agree that current follow-up guidelines result in an increasing burden on our healthcare system; with expensive biochemical testing and imaging for what in most cases will prove to be a benign adenoma, these three cases have influenced our current strategies for follow-up. At the present time, we continue to follow the AAES/AACE guidelines. The development of improved methods of biochemical, radiologic and tissue diagnosis may help to improve our ability to recognize an ACC in this population at an earlier and potentially curable stage.


PDF Share
  1. The incidental adrenal mass on CT: Prevalence of adrenal disease in 1,049 consecutive adrenal masses in patients with no known malignancy. AJR Am J Roentgenol 2008;190(5):1163-68.
  2. Subclinical hormone secretion by incidentally discovered adrenal masses. Arch Surg 1994;129(3):291-96.
  3. Prevalence of adrenal incidentaloma in a contemporary computerized tomography series. J Endocrinol Invest 2006;29(4):298-302.
  4. Incidentally discovered adrenal tumors: An institutional perspective. Surgery 1991;110(6):1014-21.
  5. Imaging techniques for adrenal lesion characterization. Radiol Clin North Am 2008;46(1):65-78, vi.
  6. Prevalence and natural history of adrenal incidentalomas. Eur J Endocrinol 2003;149(4):273-85.
  7. The clinically inapparent adrenal mass: Update in diagnosis and management. Endocr Rev 2004;25(2):309-40.
  8. Recommended evaluation of adrenal incidentalomas is costly, has high falsepositive rates and confers a risk of fatal cancer that is similar to the risk of the adrenal lesion becoming malignant; time for a rethink? Eur J Endocrinol 2009;161(4):513-27.
  9. NIH Consens State Sci Statements 2002;19(2):1-25.
  10. Adrenal incidentalomas: Risk of adrenocortical carcinoma and clinical outcomes. J Surg Oncol Oct 1, 2010;102(5):450-53.
  11. Adrenocortical carcinomas: Twelve-year prospective experience. World J Surg Sep 1, 2004;28(9): 896-903.
  12. Adrenocortical carcinomas: Surgical trends and results of a 253-patient series from the French Association of Endocrine Surgeons study group. World J Surg July 2001; 25(7):891-97.
  13. American Association of clinical endocrinologists and American association of endocrine surgeons medical guidelines for the management of adrenal incidentaloma. Endocrine Practice 2009;15(Suppl 1) 1-20.
  14. Adrenal lesion frequency: A prospective, cross-sectional CT study in a defined region, including systematic re-evaluation. Acta Radiol 2010;51(10):1149-56.
  15. Clinical practice. The incidentally discovered adrenal mass. N Engl J Med 2007;356(6):601-10.
  16. Management of the clinically inapparent adrenal mass (“incidentaloma”). Ann Intern Med 2003;138(5):424-29.
  17. Incidentally discovered adrenal masses. Endocr Rev 1995;16(4):460-84.
  18. Adrenal incidentaloma. Br J Surg 1993;80(4):422-26.
  19. The adrenal incidentaloma. Can J Surg 1986;29(1):6-8.
  20. Adrenal incidentaloma: Does an adequate workup rule out surprises? Surgery 2010;148(2):392-97.
  21. Incidentally discovered adrenal mass. Radiol Clin North Am 2011;49(2):361-68.
  22. Adrenal incidentaloma: Evaluation and management. J Clin Pathol 2008;61(11):1168-73.
  23. The indeterminate adrenal lesion. Cancer Imaging 2010;10:102-13.
  24. The incidental indeterminate adrenal mass on CT (> 10 H) in patients without cancer: Is further imaging necessary? Follow-up of 321 consecutive indeterminate adrenal masses. AJR Am J Roentgenol 2007;189(5):1119-23.
  25. Diagnosis and treatment of adrenal incidentaloma a cost-effectiveness analysis. Endocrinol Metab Clin North Am 2000;29(1):69-90.
  26. Adrenocortical Cancer. Surgical Clinics of NA 2009;89(5):1255-67.
  27. Needle biopsy of incidentally discovered adrenal masses is rarely informative and potentially hazardous. Surgery 2007;142(4):497-502; discussion 502-04.
  28. Limited value of adrenal biopsy in the evaluation of adrenal neoplasm: A decade of experience. Arch Surg 2009;144(5):465-70.
  29. Micro RNA profiling of adrenocortical tumors reveals miR-483 as a marker of malignancy. Cancer 2010;117(8):1630-39.
  30. Micro RNA-195 suppresses tumorigenicity and regulates G1/S transition of human hepatocellular carcinoma cells. Hepatology 2009;50(1):113-21.
  31. Micro RNA-195 promotes apoptosis and suppresses tumorigenicity of human colorectal cancer cells. Biochem Biophys Res Commun 2010;400(2): 236-40.
  32. Transcriptome analysis reveals that p53 and {beta}-catenin alterations occur in a group of aggressive adrenocortical cancers. Cancer Res 2010;70(21):8276-81.
  33. Molecular classification and prognostication of adrenocortical tumors by transcriptome profiling. Clin Cancer Res 2009;15(2):668-76.
  34. Adrenocortical cancer: Pathophysiology and clinical management. Endocr Relat Cancer 2007;14(1):13-28.
  35. Managing incidental findings on abdominal CT: White paper of the ACR incidental findings committee. J Am Coll Radiol 2010;7(10):754-73.
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.