Management of the adrenal "incidentaloma"

The suprarenal fossa has been a clinically silent area of the body where nonfunctional lesions of soccer ball size could go undetected until they disturbed functions of adjacent organs. Unless an adrenal tumor was suspected by biochemical or clinical screening information, early diagnosis was an exception, and localization usually required invasive techniques. With the advent of noninvasive computer-assisted radiologic and sonographic techniques, surgeons now have the reverse problem of early diagnosis of asymptomatic adrenal mass: do we need to know about nonfunctioning "incidentalomas" and what further action is compelled by their discovery? Sophisticated adrenal imaging techniques, even if noninvasive, should be be utilized as a localizing technique after the biochemical determination of adrenal disease is established. Localization should not precede the biochemical confirmation of endocrine active adrenal disease. For adrenal masses discovered in asymptomatic patients, predictability of curative adrenal surgery is only as good as the strength of the causal link between the clinical evidence of adrenal disease and the localizing information; thus the indication for operation does not rely solely upon the resolving power of adrenal imaging to demonstrate adrenal masses. This causal link is not strengthened by one radiographic test that confirms the results of another in the absence of evidence that adds functional significance to the radiographic findings. For the "incidentaloma" of the adrenal that might represent neoplasm, techniques similar to those employed for thyroid masses should be used for diagnosis rather than the routine prescription of operation based on the mere presence of a space-occupying lesion. Direct correlation of imaging studies applied to prior patient findings is necessary before operation is indicated for adrenal "incidentalomas."