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Recommended evaluation of adrenal incidentalomas is costly, has high false positive rates and confers a risk of fatal cancer that is similar to the risk of the adrenal lesion becoming malignant; time for a re-think?

T Cawood, Endocrinology, Christchurch Hospital, Christchurch, 8001, New Zealand
P Hunt, Endocrinology, Christchurch Hospital, Christchurch, New Zealand
D O'Shea, Endocrinology, St. Vincent's University Hospital, Dublin, Ireland
D Cole, Endocrinology, Christchurch Hospital, Christchurch, New Zealand
S Soule, Endocrinology, Christchurch Hospital, Christchurch, New Zealand

Correspondence: Tom Cawood, Email: tom.cawood{at}cdhb.govt.nz

Abstract

Objective: To assess the performance of current clinical recommendations for the evaluation of an adrenal incidentaloma.

Design and methods: Literature review. Electronic databases (Pubmed, Ovid and citation searches from key articles) from 1980 to 2008 were searched. Eligible studies were those deemed most applicable to the clinical scenario of a patient referred to an endocrinologist for assessment of an incidentally detected adrenal mass. Surgical series, histopathological series and oncological series were reviewed and most were excluded.

Results: The prevalence of functional and malignant lesions presenting as adrenal incidentaloma was similar to that quoted in most reviews, other than a lower incidence of adrenal carcinoma (1.9% vs 4.7%) and metastases (0.7% vs 2.3%). The development of functionality or malignancy during follow-up was rare (<1% becoming functional and 0.2% becoming malignant). During follow-up, false-positive rates of the recommended investigations are typically 50 times greater than true positive rates. The average recommended CT scan follow-up exposes each patient to 23mSv of ionizing radiation, equating to a 1 in 430 to 2170 chance of causing fatal cancer. This is similar to the chance of developing adrenal malignancy during 3 year follow-up of adrenal incidentaloma.

Conclusion: Current recommendations for evaluation of adrenal incidentaloma are likely to result in significant cost, both financial and emotional, due to high false-positive rates. The dose of radiation involved in currently recommended CT scan follow-up confers a risk of fatal cancer that is similar to the risk of the adrenal becoming malignant. This argues for a review of current guidelines.