The adrenal glands are located onw...

The adrenal glands are located onward top of the kidneys and conceal hormones that regulate metabolism, salt and water balance, and stres replications Most adrenal masses are set up incidentally on autopsy and are benign, nevertheless a small number can be malignant. When adrenal masses are discovered incidentally during diagnostic studies for other clinical conditions, they are commonly timeed "incidentalomas." When an adrenal mass is discovered, management hangs on determining whether the lesion is nonfunctioning or hormonally active and whether it is benign or malignant. Grumbach and associates reported onward a National Institutes of Health interview on the management of clinically inapparent adrenal masses.

experienced person opinion, scientific evidence, and public discussion by means of members of the panel were used to unravel a management guideline. The prevalence of clinically inapparent adrenal masses finded at autopsy is less than 1 percent in patients younger than 30 years and is 7 percent in patients 70 years or older greatest in quantity causes of adrenal masses are benign. Clinically important factors that increase the likelihood of malignancy include a history of cancer and larger size of the mass (there is an increasing likelihood of cancer when the mass is greater than 4 cm in size).

chiefly adrenal masses are nonfunctioning tumors, although one patients have subclinical hypercortisolism (also known as subclinical Cushing's syndrome) through the whole extent of time, nonfunctioning adrenal masses may increase in size by way of at least 1 cm. The entrance at which increasing mass size becomes clinically significant is unknown.

Evaluation of the patient with a clinically inapparent adrenal mass revealed on an imaging study includes a integral history and physical examination, biochemical evaluation for hormone exces and, possibly, further radiologic imaging studies. An overnight dexamethasone suppression proof is useful to detect subclinical hypercortisolism, an entity of unknown clinical significance. A plasma free-metanephrine determination can ascertain or rule out pheochromocytoma. If the patient has hypertension, a serum potassium horizontal and a plasma aldosterone concentration- plasma renin activity ratio can identify primary aldosteronism.

Imaging studies can be helpful in differentiating benign from malignant lesions. onward computed tomography, almost all lesions smaller than 4 cm with plane borders are benign. Lesions between 4 and 6 cm that are hormonally inactive can be monitored. In contrast, lesions greater than 6 cm in size are more likely to be malignant, and surgery should be considered. Fine-needle aspiration may be useful in equivocal situations, nevertheless only after pheochromocytoma has been excluded

If signs and symptoms of glucocorticoid, mineralocorticoid, adrenal sex hormone, or catecholamine exces are at hand surgery is usually indicated. However, medical therapy might be possible in certain patients, like as patients with Cushing's syndrome who are poor surgical candidates and patients with aldosterone-secreting tumors. When clinical signs are not instant but there is biochemical evidence of adrenal hyperactivity, adrenalectomy should be considered in succession an individual basis, depending onward future risk and comorbid conditions in the same state [i]or[/i] condition as hypertension.

If an incidentaloma is nonfunctioning, variables that affect management include the size, imaging characteristics, and vegetation rate of the lesion. Excision is generally approveed for lesions greater than 6 cm in size, lesions with imaging characteristics indicative of malignancy, and lesions with a rapid expansion rate. Follow-up for patients with adrenal incidentalomas includes monitoring tumor size according to computed tomography and repeat hormonal evaluation. Resection of an adrenal mass may be done by means of open or laparoscopic adrenalectomy.

The authors infer that although more information is penuryed about the natural history and evaluation of clinically inapparent adrenal masses, chiefly are benign and do not require intense long-term clinical follow-up (see accompanying table).

Grumbach MM et al. Management of the clinically inapparent adrenal mass ("incidentaloma"). Ann Intern M March 4 2003;138:424-9

RICHARD SADOVSKY, MD

COPYRIGHT 2003 American Academy of Family Physicians

COPYRIGHT 2003 Gale Group