Vol 72, No 5 (2021)
Original paper
Published online: 2021-07-12

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Adrenal “nonadenoma” — clinical characteristics and risk of malignancy

Radosław Samsel1, Lucyna Papierska2, Karolina Nowak2, Agnieszka Kolasińska-Ćwikla1, Agnieszka Łebek-Szatańska2, Dorota Leszczyńska2, Kamil Jakubowicz1, Ewa Komorowska1, Michal Rabijewski2, Katarzyna Roszkowska-Purska3, Andrzej Cichocki1
Pubmed: 34292568
Endokrynol Pol 2021;72(5):492-497.


Introduction: There is an increasing number of adrenal tumours discovered incidentally during imaging examinations performed for many different indications. Based on imaging results, it is possible to differentiate benign from malignant adrenal masses, although there is still a number of equivocal imaging findings. Our study presents 77 cases of adrenal tumours in which imaging was inconclusive and the final diagnosis was stated only after surgery and histopathological examination. 

Material and methods: Retrospective data analysis: 77 cases of indeterminate adrenal tumours with a presumptive diagnosis of “nonadenoma” in patients operated within a 16-year period (2004–2019). None of the patients had a history of malignancy, and all tumours were hormonally inactive. On contrast-enhanced computed tomography (CT), the native density of all tumours was higher than 10 Hounsfield Units (HU), and the absolute percentage washout (APW) and relative percentage washout (RPW) were lower than 60% and 40%, respectively.

Results: The most common findings were adrenal adenoma (25.9%), macronodular adrenal hyperplasia (16.9%), ganglioneuroma (15.6%), and haemorrhage with posthaemorrhagic changes (13%). In total, there were 12 various histopathological diagnoses in this group. There were only 2 (2.6%) malignant (adrenal cancer and leiomyosarcoma) and 3 (3.9%) potentially malignant (pheochromocytoma) lesions in this group.

Conclusions: It is often impossible to make a correct diagnosis in a clinical setting until it is histologically verified. “Nonadenoma” adrenal tumours constitute a heterogeneous group including very rare pathologies. The risk of malignancy in indeterminate adrenal tumours is relatively low. 

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  1. Young WF. Clinical practice. The incidentally discovered adrenal mass. N Engl J Med. 2007; 356(6): 601–610.
  2. Blake MA, Cronin CG, Boland GW. Adrenal imaging. AJR Am J Roentgenol. 2010; 194(6): 1450–1460.
  3. Lattin GE, Sturgill ED, Tujo CA, et al. From the radiologic pathology archives: Adrenal tumors and tumor-like conditions in the adult: radiologic-pathologic correlation. Radiographics. 2014; 34(3): 805–829.
  4. Grossman A, Koren R, Tirosh A, et al. Prevalence and clinical characteristics of adrenal incidentalomas in potential kidney donors. Endocr Res. 2016; 41(2): 98–102.
  5. Androulakis II, Kaltsas G, Piaditis G, et al. The clinical significance of adrenal incidentalomas. Eur J Clin Invest. 2011; 41(5): 552–560.
  6. Davenport C, Liew A, Doherty B, et al. The prevalence of adrenal incidentaloma in routine clinical practice. Endocrine. 2011; 40(1): 80–83.
  7. Bittner JG, Brunt LM. Evaluation and management of adrenal incidentaloma. J Surg Oncol. 2012; 106(5): 557–564.
  8. Barzon L, Sonino N, Fallo F, et al. Prevalence and natural history of adrenal incidentalomas. Eur J Endocrinol. 2003; 149(4): 273–285.
  9. Birsen O, Akyuz M, Dural C, et al. A new risk stratification algorithm for the management of patients with adrenal incidentalomas. Surgery. 2014; 156(4): 959–965.
  10. Blake MA, Krishnamoorthy SK, Boland GW, et al. Low-density pheochromocytoma on CT: a mimicker of adrenal adenoma. AJR Am J Roentgenol. 2003; 181(6): 1663–1668.
  11. Peña CS, Boland GW, Hahn PF, et al. Characterization of indeterminate (lipid-poor) adrenal masses: use of washout characteristics at contrast-enhanced CT. Radiology. 2000; 217(3): 798–802.
  12. Ilias I, Sahdev A, Reznek RH, et al. The optimal imaging of adrenal tumours: a comparison of different methods. Endocr Relat Cancer. 2007; 14(3): 587–599.
  13. Szolar DH, Kammerhuber FH. Adrenal adenomas and nonadenomas: assessment of washout at delayed contrast-enhanced CT. Radiology. 1998; 207(2): 369–375.
  14. Peña CS, Boland GW, Hahn PF, et al. Characterization of indeterminate (lipid-poor) adrenal masses: use of washout characteristics at contrast-enhanced CT. Radiology. 2000; 217(3): 798–802.
  15. Taskin HE, Berber E. Retroperitoneal tumors that may be confused as adrenal pathologies. J Surg Oncol. 2012; 106(5): 600–603.
  16. NIH Consens State Sci Statements NIH state-of-the-science statement on management of the clinically inapparent adrenal mass ("incidentaloma") 2002, Feb 4–6; 19(2):1–25. https://consensus.nih.gov/2002/2002AdrenalIncidentalomasos021Program.pdf.
  17. Bittner JG, Brunt LM. Evaluation and management of adrenal incidentaloma. J Surg Oncol. 2012; 106(5): 557–564.
  18. Sahdev A, Willatt J, Francis IR, et al. The indeterminate adrenal lesion. Cancer Imaging. 2010; 10: 102–113.
  19. Choyke PL. ACR Committee on Appropriateness Criteria. ACR Appropriateness Criteria on incidentally discovered adrenal mass. J Am Coll Radiol. 2006; 3(7): 498–504.
  20. Terzolo M, Stigliano A, Chiodini I, et al. Italian Association of Clinical Endocrinologists. AME position statement on adrenal incidentaloma. Eur J Endocrinol. 2011; 164(6): 851–870.
  21. Haider MA, Ghai S, Jhaveri K, et al. Chemical shift MR imaging of hyperattenuating (>10 HU) adrenal masses: does it still have a role? Radiology. 2004; 231(3): 711–716.
  22. Outwater EK, Siegelman ES, Huang AB, et al. Adrenal masses: correlation between CT attenuation value and chemical shift ratio at MR imaging with in-phase and opposed-phase sequences. Radiology. 1996; 200(3): 749–752.
  23. Mayo-Smith WW, Song JH, Boland GL, et al. Management of Incidental Adrenal Masses: A White Paper of the ACR Incidental Findings Committee. J Am Coll Radiol. 2017; 14(8): 1038–1044.
  24. Park BK, Kim CK, Kim B, et al. Comparison of delayed enhanced CT and chemical shift MR for evaluating hyperattenuating incidental adrenal masses. Radiology. 2007; 243(3): 760–765.
  25. Bednarczuk T, Bolanowski M, Sworczak K, et al. Adrenal incidentaloma in adults — management recommendations by the Polish Society of Endocrinology. Endokrynol Pol. 2016; 67(2): 234–258.
  26. Fassnacht M, Arlt W, Bancos I, et al. Management of adrenal incidentalomas: European Society of Endocrinology Clinical Practice Guideline in collaboration with the European Network for the Study of Adrenal Tumors. Eur J Endocrinol. 2016; 175(2): G1–G34.
  27. Lenders JWM, Duh QY, Eisenhofer G, et al. Endocrine Society. Pheochromocytoma and paraganglioma: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2014; 99(6): 1915–1942.
  28. Lam AKY. Update on Adrenal Tumours in 2017 World Health Organization (WHO) of Endocrine Tumours. Endocr Pathol. 2017; 28(3): 213–227.
  29. Song JH, Chaudhry FS, Mayo-Smith WW. The incidental adrenal mass on CT: prevalence of adrenal disease in 1,049 consecutive adrenal masses in patients with no known malignancy. AJR Am J Roentgenol. 2008; 190(5): 1163–1168.
  30. Song JH, Chaudhry FS, Mayo-Smith WW. The incidental indeterminate adrenal mass on CT (> 10 H) in patients without cancer: is further imaging necessary? Follow-up of 321 consecutive indeterminate adrenal masses. AJR Am J Roentgenol. 2007; 189(5): 1119–1123.
  31. Wright L, Nordenström E, Almquist M. Determinants for malignancy in surgically treated adrenal lesions. Langenbecks Arch Surg. 2012; 397(2): 217–223.
  32. Cichocki A, Samsel R, Papierska L, et al. Adrenal tumour bigger than 5 cm - what could it be? An analysis of 139 cases. Endokrynol Pol. 2017; 68(4): 411–415.
  33. Cyranska-Chyrek E, Szczepanek-Parulska E, Olejarz M, et al. Malignancy Risk and Hormonal Activity of Adrenal Incidentalomas in a Large Cohort of Patients from a Single Tertiary Reference Center. Int J Environ Res Public Health. 2019; 16(10).
  34. Shawa H, Elsayes KM, Javadi S, et al. Adrenal ganglioneuroma: features and outcomes of 27 cases at a referral cancer centre. Clin Endocrinol (Oxf). 2014; 80(3): 342–347.
  35. Samsel R, Cichocki A, Papierska L, et al. [Adrenal gangliuoneuroma — features of 10 cases in own material]. Pol Merkur Lekarski. 2018; 44(263): 233–235.
  36. Guerrisi A, Marin D, Baski M, et al. Adrenal lesions: spectrum of imaging findings with emphasis on multi-detector computed tomography and magnetic resonance imaging. J Clin Imaging Sci. 2013; 3: 61.
  37. Zhou Y, Tang Y, Tang J, et al. Primary adrenal leiomyosarcoma: a case report and review of literature. Int J Clin Exp Pathol. 2015; 8(4): 4258–4263.
  38. Henry JF, Peix JL, Kraimps JL. Positional statement of the European Society of Endocrine Surgeons (ESES) on malignant adrenal tumors. Langenbecks Arch Surg. 2012; 397(2): 145–146.
  39. Welch HG, Black WC. Overdiagnosis in cancer. J Natl Cancer Inst. 2010; 102(9): 605–613.
  40. Corwin MT, Mitchell AS, Wilson M, et al. Accuracy of focal cystic appearance within adrenal nodules on contrast-enhanced CT to distinguish pheochromocytoma and malignant adrenal tumors from adenomas. Abdom Radiol (NY). 2021; 46(6): 2683–2689.
  41. Akbulut S, Erten O, Kahremangi B, et al. A Critical Analysis of Computed Tomography Washout in Lipid-Poor Adrenal Incidentalomas. Ann Surg Oncol. 2021; 28: 2756–2762.
  42. Patel N, Egan RJ, Carter BR, et al. Outcomes of surgery for benign and malignant adrenal disease from the British Association of Endocrine and Thyroid Surgeons' national registry. Br J Surg. 2019; 106(11): 1495–1503.
  43. Harrison B. The indeterminate adrenal mass. Langenbecks Arch Surg. 2012; 397(2): 147–154.