ASO Author Reflections: How Should Adrenal Incidentalomas be Managed in the Current Era?
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ASO AUTHOR REFLECTIONS
ASO Author Reflections: How Should Adrenal Incidentalomas be Managed in the Current Era? Eren Berber, MD, MBA Departments of Endocrine and General Surgery, Cleveland Clinic, Cleveland, OH
PAST Every year, millions of patients are incidentally found to have adrenal tumors on cross-sectional imaging and need to be worked-up to rule out adrenocortical cancer (ACC), which is lethal if not recognized and treated early.1,2 Risk assessment is challenging, as imaging characteristics of benign and malignant tumors may overlap. Historically, adrenal incidentalomas (AIs) have been managed based on the recommendations from the 2002 National Institutes of Health (NIH) Consensus Statement3 and the 2009 American Association of Clinical Endocrinologists (AACE) and American Association of Endocrine Surgeons (AAES) guidelines.4 The recommendations provided from these two guidelines have underscored the predictive value of tumor size greater than 4–6 cm and non-contrast computed tomographic (CT) density [ 10 Hounsfield units for ACC. Although the ability of CT washout kinetics to identify benign lesions was mentioned in the latter guidelines, a recommendation for routine use was not made.4 Both of these guidelines recommended thorough hormonal testing, but tumor size was the primary parameter highlighted in the algorithms to guide the decision on surgical versus nonsurgical management of AIs. The risk of ACC by size was reported to be 2%, 6%, and 25% for AIs of \ 4, 4–6, and [ 6 cm, respectively, in the NIH statement.3 The AACE/ AAES algorithm included hormonal testing in the second step after an initial step that guided the decision based on a tumor size of \ 4 cm or C 4 cm and accompanying CT
Ó Society of Surgical Oncology 2020 First Received: 6 November 2020 Accepted: 7 November 2020 E. Berber, MD, MBA e-mail: [email protected]
findings (homogeneity, borders, and HU density \ 10 or C 10). Nevertheless, the low prevalence of malignancy (\ 15%) in adrenalectomy series underscores the low specificity of these historical preoperative risk assessments.1 PRESENT The studies used to establish historical guidelines have suffered from small sample sizes, use of low-resolution CT scanners, and the inclusion of purely surgical series.3 Recently, new studies analyzing high-resolution CT data from both surgical and non-surgical patients have been reported.2,5 Furthermore, the value of prioritizing a comprehensive hormonal work-up of these tumors has been recognized, as 10–15% of AIs and 40–80% of ACCs are hormonally active.2 According to recent data, the risk of ACC by size is 0.1%, 2.4%, and 19.5% for AIs of\ 4, 4–6, and [ 6 cm, respectively.2 Furthermore, the optimal cutoffs for size and non-contrast CT density to predict malignancy seem to be 4.6 cm and 20 HU, rather than the 4 cm and 10 HU previously used.2 A significant challenge for ACC risk assessment involves lipid-poor adenomas, which compromise 29% of all adrenal adenomas.1 According to the results of the current study, when pheochromocytomas, which are usual
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