Multimedialna platforma wiedzy medycznej Internetowa Księgarnia Medyczna Kalendarium Konferencji
Endokrynologia Polska
MENU
Shortcuts Submit an article Author Guidelines Polish Society of Endocrinology Reviewers 2023 Redeem voucher

open access

Vol 68, No 3 (2017)
Review paper
Submitted: 2016-07-07
Accepted: 2016-07-08
Published online: 2017-06-21
View PDF Download PDF file View HTML
Get Citation

Diagnostic pitfalls of adrenal incidentaloma

Ewa Cyrańska-Chyrek1, Małgorzata Grzymisławska2, Marek Ruchała1
DOI: 10.5603/EP.2017.0028
·
Pubmed: 28660993
·
Endokrynol Pol 2017;68(3):360-377.
Affiliations
  1. Department of Endocrinology, Metabolism, and Internal Medicine, University of Medical Sciences, Poznan, Poland, Poland
  2. Department of Anatomy, University of Medical Sciences, Poznan, Poland

open access

Vol 68, No 3 (2017)
Reviews — Postgraduate Education
Submitted: 2016-07-07
Accepted: 2016-07-08
Published online: 2017-06-21

Abstract

Adrenal incidentaloma (AI) includes all lesions with diameter ≥ 1 cm found incidentally during imaging examinations not associated with suspected adrenal pathology. Every adrenal incidentaloma requires a detailed hormonal and imaging assessment. Initial diagnosis includes radiological phenotypical evaluation (particularly in CT, or in case of contraindications — in MRI) and biochemical assessment of tumour hormonal activity (which includes cortisol circadian rhythm, salivary cortisol concentration, 24-hour urinary free-cortisol and metanephrines test, short cortisol and dexamethasone suppression test, ACTH level assessment, aldosterone and ARO concentration, adrenal androgen concentration). Each diagnostic step is associated with limitations and method imperfections. The influence of administered medications, age and concomitant diseases must be taken into account when interpreting test results. It is important to remember abovementioned factors may cause false positive or false negative test results. The following paper is to summarize the etiology of the most common diagnostic mishaps which frequently lead to misdiagnoses, an increase in patient’s anxiety and, as a consequence, in the introduction of improper therapy or its discontinuation. The awareness of biochemical and imaging test limitations, and the knowledge of false positive and false negative result sources, allows for the optimisation of the diagnostic process. Simultaneously, the analyzed factors may contribute to a decrease in unnecessary and frequently repeated tests. Additionally, it may imply avoiding the costs of unjustified deep diagnostics.

Abstract

Adrenal incidentaloma (AI) includes all lesions with diameter ≥ 1 cm found incidentally during imaging examinations not associated with suspected adrenal pathology. Every adrenal incidentaloma requires a detailed hormonal and imaging assessment. Initial diagnosis includes radiological phenotypical evaluation (particularly in CT, or in case of contraindications — in MRI) and biochemical assessment of tumour hormonal activity (which includes cortisol circadian rhythm, salivary cortisol concentration, 24-hour urinary free-cortisol and metanephrines test, short cortisol and dexamethasone suppression test, ACTH level assessment, aldosterone and ARO concentration, adrenal androgen concentration). Each diagnostic step is associated with limitations and method imperfections. The influence of administered medications, age and concomitant diseases must be taken into account when interpreting test results. It is important to remember abovementioned factors may cause false positive or false negative test results. The following paper is to summarize the etiology of the most common diagnostic mishaps which frequently lead to misdiagnoses, an increase in patient’s anxiety and, as a consequence, in the introduction of improper therapy or its discontinuation. The awareness of biochemical and imaging test limitations, and the knowledge of false positive and false negative result sources, allows for the optimisation of the diagnostic process. Simultaneously, the analyzed factors may contribute to a decrease in unnecessary and frequently repeated tests. Additionally, it may imply avoiding the costs of unjustified deep diagnostics.

Full Text:

View PDF Download PDF file View HTML
Get Citation

Keywords

adrenal adenoma; incidentaloma; hormonal diagnostics; false positive results

About this article
Title

Diagnostic pitfalls of adrenal incidentaloma

Journal

Endokrynologia Polska

Issue

Vol 68, No 3 (2017)

Article type

Review paper

Pages

360-377

Published online

2017-06-21

Page views

4451

Article views/downloads

5168

DOI

10.5603/EP.2017.0028

Pubmed

28660993

Bibliographic record

Endokrynol Pol 2017;68(3):360-377.

Keywords

adrenal adenoma
incidentaloma
hormonal diagnostics
false positive results

Authors

Ewa Cyrańska-Chyrek
Małgorzata Grzymisławska
Marek Ruchała

References (46)
  1. Kievit J, Haak HR. Diagnosis and treatment of adrenal incidentaloma. A cost-effectiveness analysis. Endocrinol Metab Clin North Am. 2000; 29(1): 69–90, viii.
    PubMed
  2. Bastounis EA, Karayiannakis AJ, Anapliotou ML, et al. Incidentalomas of the adrenal gland: diagnostic and therapeutic implications. Am Surg. 1997; 63(4): 356–360.
    PubMed
  3. Barzon L, Scaroni C, Sonino N, et al. Risk factors and long-term follow-up of adrenal incidentalomas. J Clin Endocrinol Metab. 1999; 84(2): 520–526.
    CrossRefPubMed
  4. Słapa R, Kasperlik-Załuska A, Migda B, et al. Elastografia fali poprzecznej guzów nadnerczy jest możliwa do wykonania i może pomóc w różnicowaniu zmian litych z torbielowatymi — doniesienie wstępne. Endokrynologia Polska. 2014; 65(2): 119–124.
    CrossRef
  5. Trojan J, Schwarz W, Sarrazin C, et al. Role of ultrasonography in the detection of small adrenal masses. Ultraschall Med. 2002; 23(2): 96–100.
    CrossRefPubMed
  6. Stajgis M, Stajgis M, Guzikowska-Ruszkowska I, et al. Stajgis M, Stajgis M, Guzikowska-Ruszkowska I, Horst-Sikorska W, Paprzycki W, CT diagnostic imaging of adrenal adenomas, Polish Journal of Radiology. 2005; 70(2): 62–68.
  7. Boland GWL, Dwamena BA, Jagtiani Sangwaiya M, et al. Characterization of adrenal masses by using FDG PET: a systematic review and meta-analysis of diagnostic test performance. Radiology. 2011; 259(1): 117–126.
    CrossRefPubMed
  8. Ilias I, Sahdev A, Reznek RH, et al. The optimal imaging of adrenal tumours: a comparison of different methods. Endocr Relat Cancer. 2007; 14(3): 587–599.
    CrossRefPubMed
  9. Blake MA, Kalra MK, Maher MM, et al. Pheochromocytoma: an imaging chameleon. Radiographics. 2004; 24 Suppl 1: S87–S99.
    CrossRefPubMed
  10. Sangwaiya MJ, Boland GWL, Cronin CG, et al. Incidental adrenal lesions: accuracy of characterization with contrast-enhanced washout multidetector CT--10-minute delayed imaging protocol revisited in a large patient cohort. Radiology. 2010; 256(2): 504–510.
    CrossRefPubMed
  11. Korobkin M. CT characterization of adrenal masses: the time has come. Radiology. 2000; 217(3): 629–632.
    CrossRefPubMed
  12. Caoili EM, Korobkin M, Francis IR, et al. Adrenal masses: characterization with combined unenhanced and delayed enhanced CT. Radiology. 2002; 222(3): 629–633.
    CrossRefPubMed
  13. Haider MA, Ghai S, Jhaveri K, et al. Chemical shift MR imaging of hyperattenuating (>10 HU) adrenal masses: does it still have a role? Radiology. 2004; 231(3): 711–716.
    CrossRefPubMed
  14. Kimura T, Usui T, Inamoto S, et al. Image in endocrinology. Pheochromocytoma with subclinical Cushing's syndrome caused by corticomedullary mixed tumor of the adrenal gland. J Clin Endocrinol Metab. 2009; 94(3): 746–747.
    CrossRefPubMed
  15. Katabathina VS, Flaherty E, Kaza R, et al. Adrenal collision tumors and their mimics: multimodality imaging findings. Cancer Imaging. 2013; 13(4): 602–610.
    CrossRefPubMed
  16. Schwartz LH, Macari M, Huvos AG, et al. Collision tumors of the adrenal gland: demonstration and characterization at MR imaging. Radiology. 1996; 201(3): 757–760.
    CrossRefPubMed
  17. Thorin-Savouré A, Tissier-Rible F, Guignat L, et al. Collision/composite tumors of the adrenal gland: a pitfall of scintigraphy imaging and hormone assays in the detection of adrenal metastasis. J Clin Endocrinol Metab. 2005; 90(8): 4924–4929.
    CrossRefPubMed
  18. Katabathina VS, Flaherty E, Kaza R, et al. Adrenal collision tumors and their mimics: multimodality imaging findings. Cancer Imaging. 2013; 13(4): 602–610.
    CrossRefPubMed
  19. Sato H, Igarashi H, Kishimoto Y, et al. Combined tumor consisting of non-functioning adrenocortical adenoma and pheochromocytoma in the same gland. International Journal of Urology. 2002; 9(7): 398–401.
    CrossRef
  20. Cotesta D, Petramala L, Serra V, et al. Pheochromocytoma associated with adrenocortical tumor in the same gland. Two case reports and literature review. Minerva Endocrinol. 2006; 31(2): 183–189.
    PubMed
  21. Arnaldi G, Boscaro M. Adrenal incidentaloma. Best Pract Res Clin Endocrinol Metab. 2012; 26(4): 405–419.
    CrossRefPubMed
  22. Nieman LK. Approach to the patient with an adrenal incidentaloma. J Clin Endocrinol Metab. 2010; 95(9): 4106–4113.
    CrossRefPubMed
  23. Terzolo M, Reimondo G, Angeli A. Definition of an optimal strategy to evaluate and follow-up adrenal incidentalomas: time for further research. Eur J Endocrinol. 2009; 161(4): 529–532.
    CrossRefPubMed
  24. Meinardi JR, Wolffenbuttel BHR, Dullaart RPF. Cyclic Cushing's syndrome: a clinical challenge. Eur J Endocrinol. 2007; 157(3): 245–254.
    CrossRefPubMed
  25. Newell-Price J, Trainer P, Besser M, et al. The diagnosis and differential diagnosis of Cushing's syndrome and pseudo-Cushing's states. Endocr Rev. 1998; 19(5): 647–672.
    CrossRefPubMed
  26. Mericq MV, Cutler GB. High fluid intake increases urine free cortisol excretion in normal subjects. J Clin Endocrinol Metab. 1998; 83(2): 682–684.
    CrossRefPubMed
  27. Raff H, Raff JL, Findling JW. Late-night salivary cortisol as a screening test for Cushing's syndrome. J Clin Endocrinol Metab. 1998; 83(8): 2681–2686.
    CrossRefPubMed
  28. Poll EM, Kreitschmann-Andermahr I, Langejuergen Y, et al. Saliva collection method affects predictability of serum cortisol. Clin Chim Acta. 2007; 382(1-2): 15–19.
    CrossRefPubMed
  29. Carrasco CA, García M, Goycoolea M, et al. Reproducibility and performance of one or two samples of salivary cortisol in the diagnosis of Cushing's syndrome using an automated immunoassay system. Endocrine. 2012; 41(3): 487–493.
    CrossRefPubMed
  30. Carroll Ty, Raff H, Findling JW. Late-night salivary cortisol for the diagnosis of Cushing syndrome: a meta-analysis. Endocr Pract. 2009; 15(4): 335–342.
    CrossRefPubMed
  31. Viardot A, Huber P, Puder JJ, et al. Reproducibility of nighttime salivary cortisol and its use in the diagnosis of hypercortisolism compared with urinary free cortisol and overnight dexamethasone suppression test. J Clin Endocrinol Metab. 2005; 90(10): 5730–5736.
    CrossRefPubMed
  32. Wood PJ, Barth JH, Freedman DB, et al. Evidence for the low dose dexamethasone suppression test to screen for Cushing's syndrome--recommendations for a protocol for biochemistry laboratories. Ann Clin Biochem. 1997; 34 ( Pt 3): 222–229.
    CrossRefPubMed
  33. Findling JW, Raff H. Newer diagnostic techniques and problems in Cushing's disease. Endocrinol Metab Clin North Am. 1999; 28(1): 191–210.
    PubMed
  34. Holleman F, Endert E, Prummel MF, et al. Evaluation of endocrine tests. B: screening for hypercortisolism. Neth J Med. 2005; 63(9): 348–353.
    PubMed
  35. Morelli V, Reimondo G, Giordano R, et al. Long-term follow-up in adrenal incidentalomas: an Italian multicenter study. J Clin Endocrinol Metab. 2014; 99(3): 827–834.
    CrossRefPubMed
  36. Bednarczuk T, Bolanowski M, Sworczak K, et al. Przypadkowo wykryty guz nadnercza (incydentaloma) u dorosłych — zasady postępowania rekomendowane przez Polskie Towarzystwo Endokrynologiczne. Endokrynologia Polska. 2016; 67(2): 234–258.
    CrossRef
  37. Meikle AW. Dexamethasone suppression tests: usefulness of simultaneous measurement of plasma cortisol and dexamethasone. Clin Endocrinol (Oxf). 1982; 16(4): 401–408.
    PubMed
  38. Grupa Robocza Polskiego Towarzystwa Nadciśnienia Tętniczego. Wytyczne dotyczące diagnostyki i leczenia chorych z guzem chromochłonnym. Nadciśnienie Tętnicze. 2006; 10: 1–19.
  39. Baudin E, Bidart JM, Bachelot A, Ducreux M, Elias D, Ruffié P, Schlumberger M., Impact of chromogranin A measurement in the work-up of neuroendocrine tumors, Ann Oncol. 2001;12 Suppl 2:S79-82.
  40. Glinicki P, Jeske W, Chromogranina A. Glinicki P, Jeske W, Chromogranina A (CgA) — charakterystyka dostępnych metod badawczych i uwarunkowań mogących mieć wpływ na uzyskane wyniki, Endokrynol Pol. 2009; 60(5): 415–419.
  41. Terzolo M, Stigliano A, Chiodini I, et al. Italian Association of Clinical Endocrinologists. AME position statement on adrenal incidentaloma. Eur J Endocrinol. 2011; 164(6): 851–870.
    CrossRefPubMed
  42. Ahmed AH, Gordon RD, Taylor PJ, et al. Are women more at risk of false-positive primary aldosteronism screening and unnecessary suppression testing than men? J Clin Endocrinol Metab. 2011; 96(2): E340–E346.
    CrossRefPubMed
  43. Funder J, Carey R, Fardella C, et al. Case detection, diagnosis, and treatment of patients with primary aldosteronism: an Endocrine Society clinical practice guideline. Eur J Endocrinol. 2009 [Epub ahead of print].
    CrossRefPubMed
  44. Young WF. Primary aldosteronism: renaissance of a syndrome. Clin Endocrinol (Oxf). 2007; 66(5): 607–618.
    CrossRefPubMed
  45. Dworakowska D., Drabarek A., Wenzel I., Babińska A., Świątkowska-Stodulska R., Sworczak K., Rak kory nadnercza (ACC) — przegląd piśmiennictwa i doświadczenia własne. Endokrynol Pol 2014; 65 (6): 492–512, DOI: 10.5603/EP.2014.0069
  46. Martin K, Chang R, Ehrmann D, et al. Evaluation and Treatment of Hirsutism in Premenopausal Women: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism. 2008; 93(4): 1105–1120.
    CrossRef

Regulations

Important: This website uses cookies. More >>

The cookies allow us to identify your computer and find out details about your last visit. They remembering whether you've visited the site before, so that you remain logged in - or to help us work out how many new website visitors we get each month. Most internet browsers accept cookies automatically, but you can change the settings of your browser to erase cookies or prevent automatic acceptance if you prefer.

Via MedicaWydawcą jest  VM Media Group sp. z o.o., Grupa Via Medica, ul. Świętokrzyska 73, 80–180 Gdańsk

tel.:+48 58 320 94 94, faks:+48 58 320 94 60, e-mail:  viamedica@viamedica.pl