A 42-year-old woman is subjected to computed tomography (CT) scan of the abdomen for recurrent complaints of epigastric discomfort which revealed a 2.6 cm × 2 cm × 3 cm well rounded mass in her left adrenal gland, with a attenuation value of 5 HU, well enhancing on contrast administration. Washout study is not done. She was diagnosed with hypertension and diabetes since 2 years for which she is on amlodipine 5 mg/day and metformin 2 g/day. She has progressively gained weight since the birth of her last child birth ten years ago and currently is obese with a BMI 28 kg/m2. Her menstrual cycles are irregular since 5 years and bleeds every 2 months only after ingestion of a pill taken twice daily for a week. On examination, central obesity is present, supraclavicular areas are full. Skin appears normal with no thinning, bruising or striae. No proximal myopathy or hirsutism is noted. Management: The imaging characteristics indicate a benign lesion. Her clinical profile validates screening for pheochromocytoma, Cushing’s syndrome and primary hyperaldosteronism. All her tests are negative. She is advised to follow-up every 6 months with repeat imaging and biochemical testing.
How to perform follow-up in adrenal incidentalomas?
Medicine
• There is no consensus on appropriate follow-up evaluation for those who do not have surgery, and one must be guided by clinical evaluation and radiological diagnosis of the mass. After initial diagnostic evaluation, follow-up of adrenal incidentalomas includes imaging evaluation at 6–12 months to assess for mass enlargement.
• For lesions that do not increase in size, further radiological follow-up is not required. Biochemical testing annually (overnight 1 mg dexamethasone suppression test and fractionated plasma metanephrines) are done yearly for 4 years to exclude emergence of subclinical hormonal hypersecretion.
• Patients with an adrenal incidentaloma are at risk for tumor growth and development of hormonal alterations. A long-term follow-up study (12–120 months, median 25.5 months) of 64 patients with incidental adrenal masses revealed that cumulative risk of developing endocrine abnormalities was 17% at 1 year, 29% at 2 years, and 47% at 5 years; cumulative risk of mass enlargement was 6% at 1 year, 14% at 2 years, and 29% at 5 years.
• Patients with laboratory features of cortisol excess should be screened at annual intervals and recommended annual biochemical screening for catecholamine and cortisol excess for 4 years.
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