[Incidentaloma and subclinical disorders of the adrenal gland]

Autonomous secretion of adrenal hormones can follow a subclinical course or even be masked by other frequent diseases. Patients with incidentally discovered adrenal masses (incidentaloma) represent another diagnostic challenge. Their frequency has increased through the growing number of medical imaging procedures. Although the proportion of malignant or hormonally active lesions is low, patients with adrenal incidentalomas (> 1cm) should undergo an endocrine work-up in order to detect subclinical courses of Cushing's syndrome, pheochromocytoma or primary aldosteronism. Enhanced CT is of help in the assessment of the dignity of discovered lesions. In order to evaluate the hormonal activity, it is recommended to perform low dose dexamethason suppression test and to determine the plasma metanephrines and the aldosterone to renin ratio (in hypertensive patients). The therapy of suclinical Cushing's syndrome (operative vs. medicamentous therapy) remains a single-case decision in the absence of randomised prospective studies. All tumors with criterias for malignancy (> 4cm) and subclinical pheochromocytoma and aldosterone producing adenomas should undergo surgery. In the case of non operated tumors annual bichemical follow-up controls should be performed over a duration of 5 years. In the case of a significant gain of tumor size during follow-up, adrenalectomy should be considered.