Adrenal Masses

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Chapter 575 Adrenal Masses

575.1 Adrenal Incidentaloma

Perrin C. White

Adrenal masses are discovered with increasing frequency in patients undergoing abdominal imaging for reasons unrelated to the adrenal gland. The rate of detection of single adrenal masses has ranged from less than 1% to more than 4% of abdominal CT examinations in adults. The unexpected discovery of such a mass presents the clinician with a dilemma in terms of diagnostic steps to undertake and treatment interventions to recommend. The differential diagnosis of adrenal incidentaloma includes benign lesions such as cysts, hemorrhagic cysts, hematomas, and myelolipomas. These lesions can usually be identified on CT or MRI. If the nature of the lesion is not readily apparent, additional evaluation is required. Included in the differential diagnosis of lesions requiring additional evaluation are benign adenomas, pheochromocytomas, adrenocortical carcinoma, and metastasis from an extra-adrenal primary carcinoma. Benign, hormonally inactive adrenocortical adenomas make up the majority of incidentalomas. Careful history, physical examination, and endocrine evaluation must be performed to seek evidence of autonomous cortisol, androgen, mineralocorticoid, or catecholamine secretion. Functional tumors require removal. If the adrenal mass is nonfunctional and larger than 4-6 cm, recommendations are to proceed with surgical resection of the mass. Lesions of 3 cm or less should be followed clinically with periodic re-imaging. Treatment must be individualized; nonsecreting adrenal incidentalomas may enlarge and become hyperfunctioning. Nuclear scan, and occasionally fine-needle aspiration, may be helpful in defining the mass.

575.2 Adrenal Calcification

Perrin C. White

Calcification within the adrenal glands may occur in a wide variety of situations, some serious and others of no obvious consequence. Adrenal calcifications are often detected as incidental findings in radiographic studies of the abdomen in infants and children. The physician may elicit a history of anoxia or trauma at birth. Hemorrhage into the adrenal gland at or immediately after birth is probably the most common factor that leads to subsequent calcification. Although it is advisable to assess the adrenocortical reserve of such patients, there is rarely any functional disorder.

Neuroblastomas, ganglioneuromas, cortical carcinomas, pheochromocytomas, and cysts of the adrenal gland may be responsible for calcifications, particularly if hemorrhage has occurred within the tumor. Calcification in such lesions is almost always unilateral.

In the past, tuberculosis was a common cause both of calcification within the adrenals and of Addison disease. Calcifications may also develop in the adrenal glands of children who recover from the Waterhouse-Friderichsen syndrome; such patients are usually asymptomatic. Infants with Wolman disease, a rare lipid disorder due to deficiency of lysosomal acid lipase, have extensive bilateral calcifications of the adrenal glands (Chapter 80.2).

Bibliography

Hindman N, Israel GM. Adrenal gland and adrenal mass calcification. Eur Radiol. 2005;15:1163-1167.

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