"When a patient or an imaging study identifies an incidental adrenal mass, the first upfront radiographic test is a non-contrast CT scan," says Neal E. Rowe, MD, FRCSC.
In this video, Neal E. Rowe, MD, FRCSC, highlights the publication “Diagnosis, management, and follow-up of the incidentally discovered adrenal mass: CUA Guideline Endorsed by the AUA.” Rowe is an assistant professor at the University of Ottawa in Canada and a panel chair for the guideline by the Canadian Urological Association.
Could you describe the background for this guideline?
I think the urology community had identified that we really didn't have a guideline document for incidental adrenal tumors. These are common lesions. So, any clinician ordering CT scans, there's a rate of 4% to 10% will have an incidental adrenal mass. There is some literature out there on this, but really, in urology, we've not had an effective or contemporary guideline document. I was chair of a working group that was formed with a large number of urologists, but also with radiologists and endocrinologists, who reviewed the evidence and made some evidence-based recommendations about how to evaluate, manage, and treat incidental adrenal masses.
What were some of the key recommendations that were outlined?
We wanted the guideline to be concise, but at the end of the day, we had 22 separate recommendation statements. Some of them are very straightforward or even clinical principle, so I won't review all of those. But I think some of the highlight ones would be when a patient or an imaging study identifies an incidental adrenal mass, the first upfront radiographic test is a non-contrast CT scan. Everyone should start with that, and that's one of our prime recommendations in the guideline. That helps differentiate adenomas from further indeterminate lesions. That's one of the main statements of the guideline. If masses have greater than 10 Hounsfield units on that first scan, then the patient should go on to have a contrast CT scan or chemical shift MRI. Those are key radiographic ones, and I think those are some of the prime ones people would be interested in.
In lesions that are determined to be an adenoma with low Hounsfield units, there's a number of recommendations for lesions in this group. All patients should be screened for hypercortisolism. If patients have hypertension, they should be screened for primary aldosteronism. And something that people will be very interested in is that if there's no clinical signs of pheochromocytoma for patients suspected of having an adenoma, they do not require catecholamines screening. Those are some of our main ones for the initial workup.
The other things are on the follow-up end. If patients have an incidental adrenal mass that is benign on imaging, non-functioning, and small–and by small, I mean less than 4 centimeters–they do not require subsequent testing or follow-up imaging. In benign lesions that are non-functioning but are large–meaning greater than 4 centimeters–they should probably have a subsequent imaging study 6 to 12 months down the road. Many patients will still have an indeterminant lesion, and then that requires a discussion with the patient about surgery or ongoing follow-up. We do feel based on the current evidence that lesions that are growing–and by growing, we mean 5 millimeters per year–they should probably have a discussion about surgical treatment.
This transcription has been edited for clarity.