Clinical analysis of adrenal incidentaloma in children / 中华实用儿科临床杂志

Objective:To explore the clinical characteristics and treatment regimens of adrenal incidentaloma (AI) in children.Methods:Clinical data of 38 children with AI treated in the Department of Urology, Children′s Hospital of Nanjing Medical University from December 2016 to October 2021 were retrospectively analyzed.A total of 38 children were divided into neonatal group and non-neonatal group according to their age at first diagnosis.The neonatal group had 7 males and 9 females patients, of whom 7 cases were detected with AI during prenatal examinations, 9 cases were diagnosed postnatally.Four children in neonatal group had AI in the left adrenal gland and 12 cases in the right, with the maximum diameter of tumor (MDT) ranging from 16-48 mm.In the non-neonatal group, there were 14 males and 8 females patients aged 7 months and 1 day to 12 years and 1 month, and the MDT was 29-131 mm.Paired t test was used to compare the age and MDT of benign and malignant tumors. Results:In the neonatal group, 3 patients were surgically treated, with 2 cases and 1 case of neuroblastoma and teratoma confirmed by postoperative histology, respectively.The remaining 13 patients in the neonatal group were followed up for 1-31 months, with 8 cases and 5 cases of complete remission and significantly decreased tumor volume, respectively.In the non-neonatal group, there were 3, 9 and 10 patients received open biopsy, laparoscopic adrenalectomy, and open adrenalectomy, respectively.Of these 22 surgically treated cases, 8 cases had a benign lesion, including ganglioneuroma ( n=4), adrenocortical adenoma ( n=1), adrenal cyst ( n=1), teratoma ( n=1), and pheochromocytoma ( n=1); while 14 cases had a malignant lesion, including neuroblastoma ( n=8), ganglioneuroblastoma ( n=5), and adrenocortical carcinoma ( n=1). The mean age of patients with malignant tumors was significantly younger than those with benign tumors[(38.94±35.44) months vs.(95.89±41.43) months, t=3.63, P=0.001]. The mean MDT in malignant tumors was significantly longer than that of benign tumors[(64.43±25.20) mm vs.(41.44±15.66) mm, t=2.45, P=0.023]. Conclusions:AI in children has a high risk of malignancy.Therefore, more detailed examinations are needed to detect tumor markers and endocrinological parameters, and imaging tests such as non-contrast and CT examination should be performed as early as possible.AI in children is predominantly neuroblastic tumors.For non-neonatal patients, surgery should be performed as early as possible.For AI found in the neonatal period and prenatal examination, expectant management is feasible if the tumor is relatively small and limited to the adrenal gland without distant metastases.

Normotensive pheochromocytoma presenting as adrenal incidentaloma: A case report

Background@#Pheochromocytomas are rare catecholamine-secreting tumors that usually present with hypertension and palpitations. However, a subset of pheochromocytoma patients is asymptomatic, presenting as adrenal incidentaloma on imaging.@*Case@#We present a case of a 32-year-old normotensive female who presented with a right suprarenal mass on abdominal ultrasound. Diagnosis of pheochromocytoma was made after biochemical testing revealed elevated 24- hour urine metanephrine of 1.96 mg/24hrs (NV:0-1 mg/24hrs) and epinephrine of 129 mcg/24hrs (NV: 2-24 mcg/24hrs). In addition, plasma chromogranin A was elevated at 225.38 ng/ml (NV:<100 ng/ml). CT scan of the abdomen showed a 3.0 x 4.0 x 3.0 cm heterogeneous well-circumscribed right adrenal mass, with 87Hu on contrast, an absolute washout of 21%, and a relative washout of 13% on a delayed scan. After adequate preoperative medical therapy with an alpha-adrenergic blocker, a right laparoscopic adrenalectomy was done, with histopathologic confirmation of pheochromocytoma. Repeat 24-hour urine metanephrine measurements done on multiple follow-ups after surgery were normal.@*Conclusion@#Asymptomatic pheochromocytoma should be included in the differential diagnoses of adrenal incidentalomas. As in our case, patients with normotension and adrenal incidentalomas should still undergo biochemical workup to rule out the presence of pheochromocytoma. Long-term complications from chronic exposure to high catecholamine levels lead to significant adverse cardiovascular effects. Early detection, adequate perioperative preparation, and timely surgical intervention can prevent a potential catastrophe.

Prevalence of reported incidental adrenal findings in chest computerized tomography scans performed during the COVID-19 pandemic in a single center in Northeast Brazil

ABSTRACT Objective: We investigated the prevalence of adrenal incidentalomas (AIs) in a nonselected Brazilian population in chest computed tomography (CT) performed during the COVID-19 pandemic. Materials and methods: This was a retrospective cross-sectional observational study using chest CT reports from a tertiary in- and outpatient radiology clinic from March to September 2020. AIs were defined by changes in the shape, size, or density of the gland initially identified in the released report. Individuals with multiple studies were included, and duplicates were removed. Exams with positive findings were reviewed by a single radiologist. Results: A total of 10,329 chest CTs were reviewed, and after duplicate removal, 8,207 exams were included. The median age was 45 years [IQR 35-59 years], and 4,667 (56.8%) were female. Thirty-eight lesions were identified in 36 patients (prevalence 0.44%). A higher prevalence was observed with age, with 94.4% of the findings in patients aged 40 years and over (RR 9.98 IC 2.39-41.58, p 0.002), but there was no significant difference between the sexes. Seventeen lesions (44.7%) had more than 10 HU, and five lesions (12.1%) were more than 4 cm. Conclusions: The prevalence of AIs in an unselected and unreviewed population in a Brazilian clinic is low. The impact on the health system caused by AIs discovered during the pandemic should be small regarding the need for specialized follow-up.

Management of primary adrenal lymphoma with intracranial invasion / 中华内分泌代谢杂志

Primary adrenal lymphoma (PAL) is a rare extranodular lymphoma. It is subject to misdiagnosis due to atypical clinical and imaging features. Histopathology is required to establish the diagnosis. Patients often present to the Endocrinology Department upon revelation of adrenal incidentalomas by imaging. PAL is often accompanied by invasion of other tissues and organs, with a high mortality rate and a poor prognosis. In this paper, the clinical features of a patient with primary adrenal lymphoma and intracranial invasion were summarized, and the pathogenesis, clinical manifestations, diagnosis and treatment of this disease were reviewed.

Reporte de caso de feocromocitoma bilateral asociado a mutación del gen TMEM127. Primer caso chileno / Bilateral pheochromocytoma associates with TMEM127 gene mutation. Report of one case

Up to 40% of Pheochromocytoma/paraganglioma syndromes are associated with germline mutations. Therefore, they are considered familial and heritable. We report a 65 year old woman with hypertension, bilateral adrenal nodules found in the CT scan and elevated urinary metanephrines. Her genetic testing showed a c.117_120delGTCT TMEM127 gene mutation. She was subjected to a laparoscopic bilateral adrenal excision. After five years of follow up, no recurrence of the disease has been recorded.

Clinical characteristics of rare adrenal angiomyolipoma / 中华泌尿外科杂志

Objective:To analyze the clinical characteristics of rare adrenal angiomyolipoma.Methods:Clinical data of 5 patients with adrenal angiomyolipoma admitted to West China Hospital of Sichuan University from April 2009 to April 2019 were retrospectively analyzed. There were 2 males and 3 females. Age ranged from 40 to 57 years old, with an average of 46.7(40-57) years old. Clinical manifestations included right upper abdominal mass in 1 case, pain in the lower back in 1 case, and no significant symptoms were found in the rest. One patient was complicated with hypertension, one patient was complicated with decreased activities of epinephrine, norepinephrine and renin activity (orthosis), and the other patients had no abnormal hormones. 2 patients underwent abdominal ultrasound with " strong echo mass in adrenal area" , and all underwent enhanced abdominal CT with " space occupying lesion in adrenal area" , which was specifically manifested as tumors with mixed density in fat, blood vessels, muscle and so on. The average tumor diameter was 5.8(2.3-9.1) cm, including 2 cases on the left, 3 cases on the right, and 1 case with renal angiomyolipoma. All patients underwent laparoscopic adrenal tumor resection.Results:All the 5 patients underwent surgical resection successfully and were diagnosed as adrenal angiomyolipoma by pathological examination of tumor specimens after surgery. There was no significant change in blood pressure level of patients with hypertension after surgery. Follow-up time was 2-7 years and no recurrence.Conclusions:Adrenal angiomyolipoma is an extremely rare benign nonfunctional disease, which is more common in middle age. Most of the patients had no clinical history and signs. The tumor has no hormone secretion function and can be basically diagnosed with CT and other imaging examinations. The final diagnosis depends on pathological examination. After operation, the prognosis of adrenal angiomyolipoma is good.

Rare presentation of right Adrenal Mass: Extramedullary haematopoiesis in a patient with Thalassaemia Intermedia / Journal of the ASEAN Federation of Endocrine Societies

@#Extramedullary hematopoiesis (EMH) is a rare cause of adrenal mass. We present a 44-year-old woman who has thalassaemia intermedia, referred to Endocrinology clinic for huge adrenal mass. Along with a paraspinal lesion discovered in this patient, the leading diagnosis was EMH. The patient was treated with hypertransfusion and hydroxyurea, which led to a reduction in the size of the right adrenal mass and paraspinal mass. This case highlights the challenges in managing this rare condition. Although EMH is a rare cause of adrenal mass, the diagnosis must be considered in any patient with a history of a congenital hemolytic disorder, to avoid unnecessary surgical procedures.

Application of liquid chromatography-tandem mass spectrometry in the clinical diagnosis and treatment of adrenal incidentaloma / 中华检验医学杂志

With the development of diagnostic techniques, the diagnosis rate of adrenal incidental tumors is increasing. Disease related hormones can be detected to evaluate the endocrine function of tumors for diagnosis and treatment, especially by liquid chromatography-tandem mass spectrometry (LC-MS/MS). LC-MS/MS has the advantages of high sensitivity, specificity and multi-component, and has become the gold standard method for the detection of small molecule hormones.Mass spectrometry has advantages in the detection of glucocorticoids, halo corticoids, sex hormones and catecholamine metabolites.LC-MS/MS still has some limitations in clinical practice, which are manifested as low degree of automation and lack of standardization.After the improvement of the clinical application of LC-MS/MS and the establishment of reference scope, the clinical judgment on the endocrine function of AI will be more standardized.

Neoplasia oncocítica adrenocortical de potencial maligno incierto: reporte de un caso / Adrenocortical oncocytic neoplasm with uncertain malignant potential: a case report

Resumen Objetivo Describir el caso clínico de una paciente con neoplasia oncocitica adrenocortical, tratado quirúrgicamente en una clínica de Lima, Perú. Caso clínico Paciente mujer de 26 años ingresa a emergencia por dolor abdominal inespecífico. Se evidencia tumoración de 15x14x12 cm dependiente de glándula suprarrenal izquierda por lo que se decide tratamiento quirúrgico. Al análisis patológico se evidencia neoplasia oncocítica de potencial maligno incierto. Discusión Las neoplasias oncocíticas adrenocorticales son entidades poco frecuentes, con escasos reportes de casos de esta enfermedad. Para clasificarlas, se usa la escala de Weiss modificada. Obtenemos una neoplasia oncocítica de potencial maligno incierto, cuyo tratamiento incluye la cirugía de resección de tumor y observación. Conclusión Considerar a las neoplasias oncocíticas dentro del diagnóstico diferencial de incidentalomas adrenales.

Objective To describe a case report of a oncocytic adrenocortical neoplasm, treated surgically in a clinic in Lima, Peru. Case report A 26-year-old woman is admitted to the emergency due to nonspecific abdominal pain. A tumor measuring 15x14x12 cm dependent on left adrenal gland is evidenced, so surgical treatment is decided. Pathological analysis evidences oncocytic neoplasia of uncertain malignant potential. Discussion Oncocytic adrenocortical neoplasms are rare entities, with few case reports of this disease. To classify them, the modified Weiss scale is used. We obtain an oncocytic neoplasm of uncertain malignant potential, whose treatment includes surgery for tumor resection and observation. Conclusion Consider oncocytic neoplasms within the differential diagnosis of adrenal incidentalomas.

Is Follow-up of Adrenal Incidentalomas Always Mandatory?

Adrenal masses are mainly detected unexpectedly by an imaging study performed for reasons unrelated to any suspect of adrenal diseases. Such masses are commonly defined as “adrenal incidentalomas” and represent a public health challenge because they are increasingly recognized in current medical practice. Management of adrenal incidentalomas is currently matter of debate. Although there is consensus on the need of a multidisciplinary expert team evaluation and surgical approach in patients with significant hormonal excess and/or radiological findings suspicious of malignancy demonstrated at the diagnosis or during follow-up, the inconsistency between official guidelines and the consequent diffuse uncertainty on management of small adrenal incidentalomas still represents a considerable problem in terms of clinical choices in real practice. The aim of the present work is to review the proposed strategies on how to manage patients with adrenal incidentalomas that are not candidates to immediate surgery. The recent European Society of Endocrinology/European Network for the Study of Adrenal Tumors guidelines have supported the view to avoid surveillance in patients with clear benign adrenal lesions <4 cm and/or without any hormonal secretion; however, newer prospective studies are needed to confirm safety of this strategy, in particular in younger patients.

Limited significance of repeated long-term radiological and hormonal examination in nonfunctioning adrenal incidentalomas

ABSTRACT Purpose: The purposes of the present study were to evaluate growth rate of nonfunctioning adrenal incidentalomas (AIs) and their development to hormonal hypersecretion on follow-up. Materials and methods: A retrospective study was conducted from the electronic medical records. A total of 314 patients were diagnosed with adrenal tumors between 2000 and 2016. After excluding patients who had overt adrenal endocrine disorders or whose adrenal tumors were clinically diagnosed as metastatic malignancies, we investigated 108 patients with nonfunctioning AIs including characteristics, the treatment, the way of follow-up and pathology. Results: Fifteen patients received immediate adrenalectomy because of the initial tumor size or patient's preference. Pathological examination revealed malignancy in 2 patients. In the remaining 93 patients, radiological examinations were performed periodically. Tumor enlargement of ≥ 1.0cm was observed in 8.6% of the patients who were followed up as nonfunctioning AIs with a median follow-up period of 61.5 months (range: 4-192). Eleven patients underwent adrenalectomy. On the pathological examinations, all of the tumors, which showed a size increase, were diagnosed as benign tumors. Regarding the followed up patients without adrenalectomy, only 2.4% of the patients had tumor enlargement during the prolonged follow-up. Furthermore, none of the patients developed hormonal hypersecretion or clinical signs such as obesity, glucose intolerance or poorly controlled hypertension. Conclusions: Tumor enlargement of AIs did not correlate with malignancy. The value of repeat radiological and hormonal examinations may be limited in the long-term follow-up of patients whose AIs are not enlarged.

Analysis of risk factors for intraoperative hemodynamic instability in adrenal incident pheochromocytoma / 中华泌尿外科杂志

Objective To evaluate the risk factors for intraoperative hemodynamic instability (HI) in patients with adrenal incident pheochromocytoma.Methods Perioperative clinical parameters of patients undergoing surgery for adrenal incident pheochromocytoma at the First Hospital of Peking University from January 2001 to July 2018 were analyzed.There were 39 males and 41 females,with mean age of 45.1 years (13-76 years old).The median tumor length was 5.1 cm (1.5-14.0 cm),with 25 cases (31.3％) on the left side,55 cases (68.8％) on the right side.There were 37 cases combined with coronary heart disease or diabetes or BMI≥24 kg/m2.Patients were divided into hemodynamic instability (HI group) and hemodynamic stability group (HS group) by whether intraoperative hemodynamic instability occurred.The differences of demographic characteristics and clinical parameters between the two groups were compared.Logistic regression analysis was done for seeking the risk factors for hemodynamic instability during surgery.Results There were 54 cases (67.5％) in the HS group and 26 cases (32.5％) in the HI group.Univariate analysis showed that there was no significant difference in age [(44.06 ± 13.58) years old vs.(47.35 ± 16.11) years old],combined with coronary heart disease or diabetes or BMI≥24 kg/m2 [50.0％(27/54) vs.38.5％ (10/26)],tumor long diameter [median 5.0 cm(1.5-14.0 cm) vs.6.0cm(1.5-13.5 cm)],tumor location [left:29.6％ (16/54) vs.34.6％ (9/26)],preoperative catecholamine test positive [44.4％ (20/45) vs.50.0％ (10/20)],open surgery [27.8％ (15/54) vs.34.6％ (9/26)]and preoperative non-alpha blockers[13.0％ (7/54) vs.30.8％ (8/26)] between HS group and HI group (P ＞ 0.05).Further logistic regression analysis was used to analyze the risk factors of intraoperative hemodynamic instability.Multivariate analysis found that patients who preoperative non-alpha blockers before surgery were independent risk factor for HI (OR =4.574,95 ％ CI 1.273-16.432,P =0.020).Conclusions Preoperative non-alpha blocker in patients with adrenal incidental pheochromocytoma could be independent risk factor for intraoperative hemodynamic instability.Therefore,it is recommended that patients with adrenal incidental tumors,especially those who fail to rule out pheochromocytoma,take preoperative alpha blockers.

Prevalencia de mielolipoma como diagnóstico incidental de masas adrenales en tomografías abdominales realizadas en el Hospital Universitario San Vicente Fundación de Medellín / Prevalence of adrenal myelolipoma during abdominal computed tomography at Hospital Universitario San Vicente Fundación

RESUMEN Objetivo: el mielolipoma es un tumor suprarrenal poco frecuente, benigno y no funcional. Representa el 2,6-3 % de los casos reportados de masas adrenales incidentales. Es más frecuente en adultos entre la quinta y séptima década de la vida. El objetivo del estudio es evaluar la prevalencia de mielolipoma como masa adrenal incidental en tomografías abdominales en 1 año, en un hospital universitario de cuarto nivel. Metodología: estudio retrospectivo. Se revisaron todas las tomografías de abdomen simples o contrastadas realizadas en el periodo 2014 al 2015 en el Hospital Universitario San Vicente Fundación de Medellín. De estas, se extrajeron las que reportaban masas adrenales incidentales con diagnóstico de mielolipoma. Se revisaron las historias clínicas de los pacientes con este hallazgo y sus características clínicas respectivas. Resultados: se revisaron 4.288 estudios tomográficos de abdomen correspondientes a 3.709 pacientes. Se encontraron 108 masas adrenales incidentales y los mielolipomas fueron el 1,85 % de estos. En los pacientes evaluados con TAC abdominal por diferentes razones, la posibilidad de identificar mielolipomas fue de 0,05 %. El promedio de edad de presentación fue 57 años. Ambos casos de mielolipomas fueron masas unilaterales, derechas, con un tamaño promedio de 31 mm y con un promedio de -84,5 unidades Hounsfield (UH). En ningún caso se realizó estudio hormonal o de manejo quirúrgico. Discusión: en este estudio se presenta la prevalencia y características clínicas del mielolipoma adrenal con presentación inicial como masas adrenales incidentales. Se encontró que el 1,85 % de las masas adrenales incidentales tienen como etiología el mielolipoma. En nuestro conocimiento no hay estudios en Colombia que evalúen la prevalencia de mielolipoma en TAC abdominales. En conclusión, el mielolipoma es un tumor adrenal infrecuente.

SUMMARY Objective: Adrenal myelolipoma is an infrequent benign tumor. Myelolipoma represents 2,6-3 % of all adrenal incidentalomas. This tumor is more frequent in aged individuals. Our aim was to evaluate the prevalence of myelolipoma in patients with adrenal incidentaloma detected by abdominal computed tomography (CT) during 1 year at a university tertiary care hospital. Methods: Retrospective study. All abdominal CT done at the Hospital Universitario San Vicente Fundación, Medellín, Colombia, with or without contrast, were reviewed from 2014 to 2015. Of all adrenal incidentalomas, those with diagnosis of adrenal mielolipoma were further evaluated. The clinical and laboratory data were extracted. Results: 4288 abdominal CT were reviewed in 3709 patients. 108 adrenal incidentalomas were found. Of those, two cases were adrenal myelolipomas. The frequency of mielolipoma presenting as adrenal incidentalomas was 1.85 % with a prevalence in abdominal CT of 0.05 %. The mean age at presentation was 57 years. Both cases were unilateral right masses; the mean size was 31 mm and a mean of -84.5 Hounsfield units. Hormonal studies or surgical management was no performed. Discussion: This study report the prevalence and clinical characteristics of adrenal myelolipoma presenting as adrenal incidentalomas. 1.85 % of adrenal incidentalomas are myelolipomas. To our knowledge, there are no studies in Colombia evaluating the prevalence of this disease in abdominal CT scans. In conclusion, myelolipoma is an infrequent adrenal tumor.

Mielolipoma suprarrenal: doce años de experiencia en su diagnóstico, tratamiento y seguimiento / Adrenal myelolipoma: twelve-years' experience in diagnosis, treatment and follow-up

Introducción: Los mielolipomas suprarrenales son tumores benignos e infrecuentes, formados por tejido adiposo y hematopoyético. Se consideran incidentalomas porque se diagnostican fortuitamente en estudios de imagen investigando síntomas abdominales o lumbares o en chequeos rutinarios. Son hormonalmente inactivos casi siempre. Se operan si presentan gran tamaño y usualmente se mantienen estables durante su evolución natural. Objetivos: Identificar las características de los mielolipomas suprarrenales y describir su evolución natural. Métodos: Se realizó un estudio descriptivo retrospectivo en 17 pacientes con mielolipomas suprarrenales diagnosticados por tomografía axial computarizada entre enero de 2006 y abril de 2018. Se estudiaron variables clínicas, hormonales y tomográficas al inicio en 17 pacientes y evolutivamente en 5 pacientes no operados. Se utilizaron medidas de resumen para las variables cualitativas (número y porcentajes) y para las cuantitativas (media y desviación estándar). Resultados: La edad promedio fue 52,9 años y la distribución por sexo: 13 mujeres y 4 hombres (razón 3,2:1). Se indicó tomografía axial computarizada en 11 pacientes por síntomas dolorosos. El tamaño promedio fue 5,6 cm. En 8 tumores el diámetro fue de 6 cm y más. En 9 pacientes se realizó adrenalectomía laparoscópica. Durante la evolución natural, que promedió 5 años y 1 mes, una paciente presentó crecimiento de sus dos masas bilaterales; la derecha se extirpó por sobrepasar los 6 cm. Conclusiones: Los mielolipomas suprarrenales fueron benignos, alcanzaron gran tamaño y provocaron síntomas dolorosos. Fueron hormonalmente inactivos en su mayoría. Evolutivamente, el crecimiento fue muy infrecuente y no hubo transformación maligna ni desarrollo de hiperfunción endocrina(AU)

Introduction: Suprarenal myelolipomas are infrequent benign tumors formed by adipose and hematopoietic tissue. They are considered to be incidentalomas because they are found and diagnosed accidentally in imaging studies intended for abdominal or lumbar problems, or in routine checkups. Suprarenal myelolipomas are almost always hormonally inactive. They are operated on when they are large, and they usually remain stable during their natural evolution. Objectives: Identify the characteristics of suprarenal myelolipomas and describe their natural evolution. Methods: A retrospective descriptive study was conducted of 17 patients with suprarenal myelolipomas diagnosed by computerized axial tomography from January 2006 to April 2018. Clinical, hormonal and tomographic variables were analyzed initially in 17 patients and evolutionarily in 5 non-operated patients. Summary measurements were used for qualitative variables (number and percentages) and for quantitative variables (mean and standard deviation). Results: Mean age was 52.9 years and sex distribution was 13 women and 4 men (ratio of 3.2:1). Computerized axial tomography was indicated for 11 patients with pain symptoms. Average size was 5.6 cm. In 8 tumors the diameter was 6 cm or more. Laparoscopic adrenalectomy was performed on 9 patients. During natural evolution, which averaged 5 years and 1 month, one female patient experienced growth of her two bilateral masses, and the one on the right side was removed for it exceeded 6 cm. Conclusions: The study suprarenal myelolipomas were large, benign and caused pain symptoms. Most were hormonally inactive. In evolutionary terms, growth was very infrequent and there was no malignant transformation or development of endocrine hyperfunction(AU)

¿Como optimizar el diagnóstico funcional de los incidentalomas suprrarenales? Importancia de un estudio protocolizado / How to optimize the functional diagnosis of suprarenal incidenta- lomas? Importance of a protocolized study

Adrenal incidentalomas are an increasingly common pathology. Although historically they have been considered largely non-functioning, recent evidence suggests that the usually performed study is incomplete and/or not sensitive enough. In the last decade the clinical spectrum of adrenal hypercortisolism has expanded considerably, including milder cases which are also associated with cardiovascular morbidity and even mortality. Furthermore, primary aldosteronism has also expanded beyond the classic phenotype with advanced vascular damage, resistant hypertension and hypokalemia, currently including asymptomatic, normotensive and normokalemic patients. For this reason, a correct protocolized study is essential in all adrenal incidentalomas, including a precise radiological characterization, as well as a systematic hormonal evaluation using more sensitive cut points. The findings of this workup are relevant, because they allow a more individualized approach to the medical and surgical management of these patients.

Los incidentalomas suprarrenales son una patología cada vez más frecuente. Si bien históricamente han sido considerados no funcionantes en su gran mayoría, evidencia reciente sugiere que el estudio habitual es incompleto y/o poco sensible. En la última década el espectro clínico del hipercortisolismo de origen adrenal se ha ampliado de forma considerable, incluyendo casos leves que también se asocian a morbilidad cardiovascular e incluso mortalidad. Por otro lado, el hiperaldosteronismo primario también ha expandido su fenotipo más allá del clásicamente descrito con daño vascular avanzado, hipertensión resistente e hipokalemia, abarcando en la actualidad a pacientes asintomáticos, normotensos y normokalemicos. Por esta razón es imprescindible un correcto estudio protocolizado en todo incidentaloma suprarrenal, incluyendo una precisa caracterización radiológica, así como una evaluación hormonal sistemática utilizando puntos de corte más sensibles. Los hallazgos de este estudio son relevantes, pues permiten guiar de forma más individualizada el manejo médico y quirúrgico de estos pacientes.

Characteristics of Adrenal Incidentalomas in a Large, Prospective Computed Tomography-Based Multicenter Study: The COAR Study in Korea

PURPOSE: Previous studies on adrenal incidentalomas (AIs) are limited by their retrospective design, small numbers of patients, Western populations, or use of an outdated imaging technique. We investigated the characteristics of AIs in Korean patients and compared them with those reported in the largest retrospective study in Italy to discover the effects of improved imaging techniques and ethnicity differences. MATERIALS AND METHODS: This was a prospective, multicenter, cross-sectional observational study including 1005 Korean patients. Levels of plasma adrenocorticotrophic hormone, 24-h urinary free cortisol (UFC), serum cortisol after a 1 mg-dexamethasone suppression test, 24-h urinary fractionated metanephrine, and plasma aldosterone and plasma renin activity were measured. All AIs were characterized using computed tomography (CT). RESULTS: Compared with the results of the Italian study, AIs in Korean patients were observed more frequently in men and predominantly on the left side. Korean patients with AIs were slightly younger, and fewer patients underwent surgery. Most AIs were nonfunctional in both studies, while fewer subclinical hypercortisolism and more primary aldosteronism (PA) cases were detected in Korean patients. In our study, high UFC levels showed very low sensitivity, compared to those in the Italian study. In pheochromocytoma or PA cases, there were no hormonal differences between the studies. AIs in Korean patients were smaller, such that a lower cutoff size for detecting adrenocortical carcinoma (ACC) could be warranted. CONCLUSION: Recent advances in CT technology were leveraged to provide accurate characteristics of AIs and to detect smaller ACCs.

Adenoma corticoadrenal, presentándose como un incidentaloma: presentación de un caso y revisión de la literatura / Adrenocortical adenoma, presenting as an incidentaloma: case report and literature review

Resumen Objetivo: Presentamos un caso clínico con diagnóstico de incidentaloma adrenal no funcionante asintomático y analizamos las implicaciones clínicas y el abordaje realizado. Caso clínico: Se reporta el caso de un masculino de 53 años, asintomático, con hallazgo ecográfico accidental de imagen hipoecoica de contornos bien definidos en la glándula suprarrenal derecha que presentó incremento en su tamaño. Su estudio hormonal fue negativo para hiperfunción adrenal. Resultados: Se realizó suprarrenalectomía laparoscópica con técnica de 4 trocares con resección completa de la lesión. El paciente presentó buena evolución posquirúrgica. El estudio anatomopatológico concluyó el diagnóstico de adenoma corticoadrenal no funcionante. Conclusión: Ante el hallazgo de una masa adrenal mayor de 1 cm corresponde realizar una identificación hormonal y una evaluación del riesgo de malignidad en los pacientes, los cuales, junto con parámetros imagenológicos y los síntomas presentados, permitirán definir las complicaciones en el manejo y el pronóstico del paciente. El diagnóstico diferencial de los adenomas adrenales está basado en la identificación hormonal, el conocimiento radiológico y el grado de compromiso de la lesión. El abordaje laparoscópico es de elección en las lesiones pequeñas y sin sospecha de malignidad.

Objective: We present a clinical case with diagnosis of an asymptomatic nonfunctional adrenal incidentaloma, in which we discuss the clinical implications and the approach. Clinical case: Male patient, 53 years old with an accidental sonographic finding, characterized by a hypoechoic image of well-defined contours in the right adrenal gland of less than 2 cm. The hormonal test showed no adrenal hyperfunctioning. Laparoscopic adrenalectomy technique is performed with 4 trocars with complete excision of the lesion. The patient presented good postoperative evolution. Results: The pathology study showed a well-defined and benign tumor lesion of the adrenal gland, being similar to the fascicular zone and cortical hyperplasia next to it. The diagnosis is a non-functioning adenoma of the adrenal gland derived from the fascicular zone. Conclusion: Given the finding of an adrenal mass greater than 1 cm mass corresponds perform a hormonal identification and risk assessment of malignancy in patients, which with imaging parameters (echogenicity, bilateralism and the adjacent commitment) and symptoms presented allow to identify the complications in the management and prognosis of the patient. The differential diagnosis of adrenal adenomas is based on the hormonal evaluation, radiological knowledge and the commitment of the injury.

Adrenal incidentaloma: a case of asymptomatic pheochromocytoma / 고신대학교의과대학학술지

An incidentaloma is a tumor found incidentally without clinical symptoms or suspicion; the lesion may be adrenal, pituitary, or thyroidal. We report the case of an asymptomatic individual with preoperatively undiagnosed pheochromocytoma (size: 4.86 cm) that was revealed using elective nonadrenal surgical procedures. The patient demonstrated peri- and post-operative hypertensive crisis and tachycardia. Three days after the dramatic onset of symptoms, the patient expired due to pulmonary edema, multiple organ failure, and terminal sepsis, despite administration of extracorporeal membrane oxygenation-assisted cardiopulmonary resuscitation. A left medial kidney mass obtained at autopsy confirmed pheochromocytoma.

Cirugía del incidentaloma suprarrenal / Adrenal incidentaloma surgery

Introducción: la incidencia de incidentalomas suprarrenales ha aumentado con el uso de técnicas modernas de imagen y la indicación quirúrgica se basa en la sospecha de malignidad o hiperfunción. Objetivos: revisar una casuística de incidentalomas suprarrenales operados. Pacientes y método: 16 pacientes operados entre los años 2010 y 2017 en dos instituciones de asistencia médica. Se describen aspectos diagnósticos, técnica operatoria y morbimortalidad de los procedimientos. esultados: la mayoría de los procedimientos se realizaron por abordaje laparoscópico, destacándose tres complicaciones intraoperatorias, sin mortalidad en la serie. La lesión más frecuentemente encontrada fue el adenoma no funcionante. Discusión: la llave diagnóstica, clave en la decisión de seguir u operar un incidentaloma suprarrenal, es la imagenología. El protocolo de seguimiento continúa siendo objeto de debate actualmente, así como la indicación de cirugía en lesiones funcionantes subclínicas. Conclusiones: la suprarrenalectomía laparoscópica es una cirugía segura, con cifras de morbimortalidad en el rango descrito por la literatura.

Background: the incidence of adrenal incidentalomas has increased with the use of modern imaging techniques and surgical indication is based on suspected malignancy or hyperfunction. Objective: to review a casuistry of surgically treated adrenal incidentalomas. Method: 16 patients operated between 2010 and 2016 in two health care institutions. The study describes diagnostic aspects, operative techniques and morbimortality of the procedures. Results: most of the procedures were performed by laparoscopic approach, 3 intraoperative complications arose, there being no deaths in the series. The most frequently encountered lesion was non-functioning adenoma. Discussion: imaging constitutes the diagnostic key which results essential to make a decision as to whether to follow or operate an adrenal incidentaloma. Follow-up protocols are still under discussion, as is indication of surgery in subclinical functional lesions Conclusions: laparoscopic adrenalectomy is a safe surgery, with morbidity and mortality rates which lie within the range described by relevant literature.

Introdução: a incidência de incidentalomas suprarrenais aumentou com o uso de técnicas modernas de imagem e a indicação de cirurgia está baseada na suspeita de malignidade ou hiperfunção. Objetivos: revisar una casuística de incidentalomas suprarrenais operados. Pacientes e método: 16 pacientes operados no período 2010-2017 emduas instituições de assistência médica. Foram descritos os aspectos diagnósticos, técnica operatória e morbimortalidade dos procedimentos. Resultados: a maioria dos procedimentos foram realizados por laparoscopia, registrando-se 3 complicações intraoperatórias, sem mortalidade na série. A lesão mais frequentemente encontrada foi o adenoma não funcionante. Discussão: os aspectos diagnósticos de um incidentaloma suprarrenal, fundamentais na tomada de decisão entre fazer um seguimento ou uma cirurgia, são as imagens. O protocolo de seguimento continua sendo causa de debate atualmente, como também a indicação de cirurgia nas lesões funcionantes subclínicas. Conclusões: a suprarrenalectomia laparoscópica é uma cirurgia segura, com valores de morbimortalidade dentro dos intervalos descritos na literatura.

Large adrenal leiomyoma presented as adrenal incidentaloma in an AIDS patient: A rare entity

The literature on adrenal gland tumour in HIV-infected patients is scarce. We report a 46-year-old Malay man with HIV and Hepatitis C infection presenting with a large nonfunctioning adrenal tumour. Computed tomography showed a large right adrenal tumour with heterogeneous enhancement and central necrosis. A high index of suspicion of a malignant tumour or pheochromocytoma led us to surgical removal of the adrenal gland. In this case report, we highlight important features to look for during pre-op evaluation of a large adrenal mass. Appropriate action should be taken when there is a suspicion of a pheochromocytoma or malignancy.