Overview on Incidentaloma

1. OVERVIEW
ON
INCIDENTALOMA
DR. MOHAMMAD HASIBUL ISLAM, MS
SPECIALIST - UROLOGY
DEPT. OF UROLOGY, SQUARE HOSPITALS LTD

2. Incidentaloma
• Adrenal incidentalomas are unsuspected adrenal masses
greater than 1 cm in diameter identified on cross sectional
imaging performed for seemingly unrelated causes.
• The incidence of the incidental adrenal mass increases with age, with a
risk of less than 0.5% in individuals in their 20s and up to 7% in those
70 years of age or older
• Relative frequency of Adrenal Incidentalomas:
• Adenoma – 50%
• Cyst/Pseudocyst – 15%
• Nodular hyperplasia – 12%
• Myelolipoma – 10%
• Metastasis – 10%
• Pheochromocytoma – 5%
• Carcinoma – 2%
[Ref: Handbook of Urology, 3rd Ed. Siroky, pp:431]

3. Adrenal Adenoma
• Adrenal adenomas are the most common tumor arising
from adrenal gland and most often associated with the
cortex
• Incidence rises with age
• The essential evaluation of the small adrenal mass
requires differentiating nonfunctional benign adenoma
from functional or malignant lesions.
• Adenomas are by definition benign and vast majorities
are metabolically silent
• Some are hormonally active and result in
hyperaldosteronism or hypercortisolism.

4. D/D of Primary Adrenal masses
Tumorous
• Adrenocortical Hyperplasia
• Adenoma
• Carcinoma
• Pheochromocytoma
• Neuroblastoma
• Ganglioneuroma
• Medullary carcinoma
Nontumorous
• Adrenal cyst & pseudocyst
• Abscess
• Hematoma
• Amyloidosis
• Myelolipoma
• Hamartoma
[Ref: Handbook of Urology, 3rd Ed. Siroky, pp:427]

5. Evaluation of Adrenal mass
Investigations:
• Imaging
• Functional evaluation
• Radio-isotope scanning
• Biopsy (±)

6. Imaging investigation
• USG:
• 1st line of imaging investigation
• Differentiate between cyst and solid adrenal mass
• Doesn’t give detail anatomic definition like CT or MRI

7. Imaging investigation
• CT scan:
• Imaging procedure of choice
• Identify size, location, appearance, local or vascular
invasion, LN, metastasis
• Size < 4 cm are usually adenoma, but masses > 6 cm
should be considered malignant until proved otherwise.
• Unenhanced: attenuation of ≤ 10 HU indicated adenoma,
because of high intracytoplasmic lipid (70%)
• Contrast enhanced: Washout > 50% = adenoma
• Adrenal carcinomas : Presence of irregular borders,
irregular enhancement, calcifications, and necrotic areas
with cystic degeneration. Mean attenuation on
noncontrast CT scan is significantly higher (40 HU)

8. Imaging investigation
• MRI:
• Particularly useful for Pheochromocytoma
• High signal intensity on T2 image in pheochromocytoma
• Nonfunctional adenomas appear similar to normal
adrenal tissue on T2 image

9. [Ref: Campbell-Walsh Urology,10th Ed.

10. Radio-isotope scanning
Available radiopharmaceuticals:
• [131I] 6-iodomethylnorcholesterol
• [131I] 9-iodocholesterol
• [131I] MIBG
Used only to localize functioning adenoma or
pheochromocytoma
Hypersecreting tumors such as cortisol, aldosterone
androgen secreting adenomas demonstrate increased
uptake of [131I] 6-iodomethylnorcholesterol & [131I] 9-
iodocholesterol
Increased MIBG uptake indicates chromaffin tumors
Cortex
Medulla
[Ref: Handbook of Urology, 3rd Ed. Siroky, pp:428-429]

11. Functional evaluation
 Only 7% of Adenomas are hormonally active
 70% of Carcinomas are hormonally active
[Ref: Handbook of Urology, 3rd Ed. Siroky, pp:434]

12. Functional evaluation
For Hypercortisolism:
[Ref: Campbell-
Walsh
Urology,10th Ed.
pp:1696]

13. Functional evaluation
Further inv. for Hypercortisolism:
• Plasma ACTH level (N= 10-50 pg/ml)
• Pituitary MRI

14. [Ref: Campbell-Walsh Urology,10th Ed.

15. Functional evaluation
For Hyperaldosteronism:
• Serum Electrolyte: (1st inv.)
• Na – Slightly elevated
• K – Very low
An ARR of 20 along with
a concomitant aldosterone
concentration above 15
ng/mL are indicative of
Conn syndrome
[Ref: Campbell-Walsh Urology,10th Ed.

16. Functional evaluation
For Hyperaldosteronism: (Confirmatory tests)
• Fludrocortisone suppression test
• Oral Sodium loading test
• Captopril suppression test
[Ref: Campbell-Walsh
Urology,10th Ed.
pp:1698]

17. Functional evaluation
For Pheochromocytoma
[Ref: Handbook of Urology,
3rd Ed. Siroky, pp:437]

19. [Ref: Campbell-Walsh Urology,10th Ed.
pp:1705]

20. [Ref: Campbell-Walsh Urology,10th Ed.
pp:1704]

21. Adrenal biopsy
• Not routinely
recommended
• Used in case of
metastatic disease
• May be taken from
nonfunctioning
adenoma between 4-6
cm size
[Ref:
Campbell-
Walsh
Urology,10t
h Ed.
pp:1731]

22. Management
• Follow up
• Control of hormonal abnormality
• Surgical: Adrenalectomy

23. [Ref: Campbell-Walsh Urology,10th Ed.

24. Control of hormonal abnormality (Preparation
for surgery)
All the hormonally active adrenal masses should be
removed surgically
 For Hypercortisolism
* Stop after tapering
[Ref: Handbook of Urology,
3rd Ed. Siroky, pp:436]

25. For
Pheochromocytoma
[Ref:
Campbell-
Walsh
Urology,10
th Ed.
pp:1710]

26. [Ref: Campbell-Walsh Urology,10th Ed.

27. Surgery
[Ref: Campbell-Walsh
Urology,10th Ed.

28. Surgical Options
• Open
• Laparoscopic
• Robotic
Approach:
• Transperitonial
• Retroperitonial
[Ref: Campbell-Walsh Urology,10th Ed.

29. Fig:
Incisions for
Open
Adrenalecto
my
[Ref: Campbell-
Walsh Urology,10th
Ed. pp:1740,

30. Fig: Ports
for
Laparoscopi
c
Adrenalecto[Ref: Campbell-Walsh
Urology,10th Ed. pp:1745-

31. [Ref: Campbell-Walsh Urology,10th Ed.
pp:1745-1746]

32. Complications of Surgery
[Ref: Campbell-Walsh Urology,10th
Ed. pp:1750-1751]

33. Adrenalectomy
[Ref:
Campbell-
Walsh
Urology,10t
h Ed.
pp:1752]