[Adrenal incidentalomas: etiologic diagnostics and basic therapeutic management. A mini-review]

Since the late 1970s, the number of serendipitously discovered adrenal masses has progressively increased through the widespread use of great sensitivity/high resolution diagnostic imaging while abdomen scanning for extra-adrenal lesions. The majority of these masses are benign and without evidence of endocrine activity. Most adrenal incidentalomas are cortical adenomas whereas the prevalence of adrenocortical carcinomas and other adrenal masses (lipomas, myelolipomas, angio-myelo-lipomas, sarcomas, hamartomas, lymphomas) is relatively low. Computed tomography (CT), magnetic resonance (MR) and functional radioisotope imaging together with thorough biochemical-hormonal testing are carried out to define the aetiology of these lesions. An accurate management of adrenal incidentalomas requires an agreement among radiologist, endocrinologist, oncologist and surgeon. Arguments for benign incidentalomas are mainly small size (< 4 cm), low CT attenuation coefficients and/or typical features on RM imaging. Surgery is mandatory for secretory tumours (functioning cortical adenomas, pheochromocytoma) and for adrenal malignancies. Even modest hormonal activities, as sometimes exhibited from asymptomatic pheochromocytoma or in subclinical primary hypercortisolism/hyperaldosteronism, may be associated with morbidity of some importance. In accordance with international literature, the size of adrenal incidentalomas may be a discriminant criterion for their management: surgery is recommended for masses of large (> 6 cm) diameter or increasing at CT/RM follow-up reevaluation whereas the masses between 4/6 cm form an indeterminate group where the management varies from institution to institution. Laparoscopic transperitoneal as well as retro-peritoneoscopic procedures are gaining more and more attention for less invasive treatment of adrenal incidentalomas. According to 2002 USA-National Institutes of Health guidelines, further studies are necessary to better define natural history, CT and RM malignant features, functional aptitudes of adrenal incidentalomas in order to propose optimal modalities of follow-up and proper surgical strategies.