Management of adrenal incidentalomas

European Society of Endocrinology Clinical Practice Guideline in collaboration with the European Network for the Study of Adrenal Tumors

Martin Fassnacht, Wiebke Arlt, Irina Bancos, Henning Dralle, John Newell-Price, Anju Sahdev, Antoine Tabarin, Massimo Terzolo, Stylianos Tsagarakis, Olaf M. Dekkers

Research output: Contribution to journalReview article

278 Citations (Scopus)

Abstract

By definition, an adrenal incidentaloma is an asymptomatic adrenal mass detected on imaging not performed for suspected adrenal disease. In most cases, adrenal incidentalomas are nonfunctioning adrenocortical adenomas, but may also represent conditions requiring therapeutic intervention (e.g. adrenocortical carcinoma, pheochromocytoma, hormone-producing adenoma or metastasis). The purpose of this guideline is to provide clinicians with best possible evidence-based recommendations for clinical management of patients with adrenal incidentalomas based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. We predefined four main clinical questions crucial for the management of adrenal incidentaloma patients, addressing these four with systematic literature searches: (A) How to assess risk of malignancy?; (B) How to define and manage low-level autonomous cortisol secretion, formerly called 'subclinical' Cushing's syndrome?; (C) Who should have surgical treatment and how should it be performed?; (D) What follow-up is indicated if the adrenal incidentaloma is not surgically removed? Selected recommendations: (i) At the time of initial detection of an adrenal mass establishing whether the mass is benign or malignant is an important aim to avoid cumbersome and expensive follow-up imaging in those with benign disease. (ii) To exclude cortisol excess, a 1 mg overnight dexamethasone suppression test should be performed (applying a cut-off value of serum cortisol ≤50 nmol/L (1.8 μg/dL)). (iii) For patients without clinical signs of overt Cushing's syndrome but serum cortisol levels post 1 mg dexamethasone >138 nmol/L (>5 μg/dL), we propose the term 'autonomous cortisol secretion'. (iv) All patients with '(possible) autonomous cortisol' secretion should be screened for hypertension and type 2 diabetes mellitus, to ensure these are appropriately treated. (v) Surgical treatment should be considered in an individualized approach in patients with 'autonomous cortisol secretion' who also have comorbidities that are potentially related to cortisol excess. (vi) In principle, the appropriateness of surgical intervention should be guided by the likelihood of malignancy, the presence and degree of hormone excess, age, general health and patient preference. (vii) Surgery is not usually indicated in patients with an asymptomatic, nonfunctioning unilateral adrenal mass and obvious benign features on imaging studies. We provide guidance on which surgical approach should be considered for adrenal masses with radiological findings suspicious of malignancy. Furthermore, we offer recommendations for the follow-up of patients with adrenal incidentaloma who do not undergo adrenal surgery, for those with bilateral incidentalomas, for patients with extra-adrenal malignancy and adrenal masses and for young and elderly patients with adrenal incidentalomas.

Original languageEnglish (US)
Pages (from-to)G1-G34
JournalEuropean Journal of Endocrinology
Volume175
Issue number2
DOIs
StatePublished - Aug 1 2016

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Glandular and Epithelial Neoplasms
Practice Guidelines
Hydrocortisone
Cushing Syndrome
Dexamethasone
Neoplasms
Adrenocortical Adenoma
Hormones
Adrenocortical Carcinoma
Adrenal incidentaloma
Patient Preference
Pheochromocytoma
Serum
Adenoma
Type 2 Diabetes Mellitus
Comorbidity
Therapeutics
Guidelines
Neoplasm Metastasis
Hypertension

ASJC Scopus subject areas

  • Endocrinology
  • Endocrinology, Diabetes and Metabolism

Cite this

Management of adrenal incidentalomas : European Society of Endocrinology Clinical Practice Guideline in collaboration with the European Network for the Study of Adrenal Tumors. / Fassnacht, Martin; Arlt, Wiebke; Bancos, Irina; Dralle, Henning; Newell-Price, John; Sahdev, Anju; Tabarin, Antoine; Terzolo, Massimo; Tsagarakis, Stylianos; Dekkers, Olaf M.

In: European Journal of Endocrinology, Vol. 175, No. 2, 01.08.2016, p. G1-G34.

Research output: Contribution to journalReview article

Fassnacht, M, Arlt, W, Bancos, I, Dralle, H, Newell-Price, J, Sahdev, A, Tabarin, A, Terzolo, M, Tsagarakis, S & Dekkers, OM 2016, 'Management of adrenal incidentalomas: European Society of Endocrinology Clinical Practice Guideline in collaboration with the European Network for the Study of Adrenal Tumors', European Journal of Endocrinology, vol. 175, no. 2, pp. G1-G34. https://doi.org/10.1530/EJE-16-0467
Fassnacht, Martin ; Arlt, Wiebke ; Bancos, Irina ; Dralle, Henning ; Newell-Price, John ; Sahdev, Anju ; Tabarin, Antoine ; Terzolo, Massimo ; Tsagarakis, Stylianos ; Dekkers, Olaf M. / Management of adrenal incidentalomas : European Society of Endocrinology Clinical Practice Guideline in collaboration with the European Network for the Study of Adrenal Tumors. In: European Journal of Endocrinology. 2016 ; Vol. 175, No. 2. pp. G1-G34.
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