Incidentaloma of the adrenal glands: analysis of 9 surgical cases

In the assessment of incidentally discovered adrenal masses the detection of hormonal activity and the evaluation of benignity or malignity, either primary or metastatic, constitute the most important issues. This article reports 9 asymptomatic adrenal masses: The histopathological diagnosis consisted of cortical adenoma in 5 cases, adrenal metastatic mass in 2, respectively from a pulmonary microcytoma and from a renal carcinoma, a myelolipoma with leukemic infiltration and an hemorrhagic pseudocyst in the remnants. Evaluation of biochemical activity showed no endocrinological abnormality in all patients except in two cases of adenoma: the positivity of the 1 mg dexamethasone test, the low serum DHEAS levels and a concordant scintigraphic uptake were consistent with the pre-Cushing syndrome in the first case, whereas the ACTH inhibition revealed by low serum DHEAS levels without other hormonal alterations were the biochemical pattern in the second. Ultrasonography has been helpful in the diagnosis of adrenal mass in 6 cases, whereas CT scan allowed an etiopathogenetic diagnosis in 8 cases. All patients were submitted to adrenalectomy through the conventional surgical accesses; in 4 cases the adrenalectomy was performed as a associated intervention during vascular or gastrointestinal surgery. No postoperative death occurred. At follow-up ranging from 3 to 6 years, we recorded 4 deaths: the causes were represented by the progression of the primary malignancy in 2 patients that have been operated on for adrenal metastatic tumors, by hemorrhagic shock from an aorto-duodenal fistula and by systemic infectious complications respectively in the remnant two cases. The other patients were well and the endocrinological assessment showed normal findings. The Authors, according with data from literature, suggest an essential biochemical screening to evaluate the adrenal function in case of incidentally discovered mass: it is characterized by determination of plasma and urinary electrolytes, catecholamines, serum DHEAS and 17-OH progesterone levels, dexamethasone suppression test. In case of asymptomatic mass suspect for pheochromocytoma we advocate the MIBG scintigraphy.. The adrenocortical scintigraphy (NP 59) provides both anatomical and functional characterization of the adrenal glands: the concordant or discordant imaging patterns are useful in the diagnosis of benignity or malignancy. Although the management of patients with incidentally discovered masses remain controversial, we advocate adrenalectomy when they are hormonally hypersecreting, increasing in the diameter or malignant and in association with other abdominal operation.