New recommendations for the diagnosis and treatment of adrenal incidentalomas

The appropriate clinical response to adrenal incidentaloma should depend on the likelihood of malignancy, according to new guidelines published today by the European Society of Endocrinology (ESE), in collaboration with the European Network for the Study of Adrenal Tumours (ENSAT) and first presented at ESE's annual European Congress of Endocrinology in May 2016.

An adrenal incidentaloma is a tumour of the adrenal glands discovered through imaging performed for reasons other than a suspected adrenal tumour. These incidentally discovered adrenal masses may be malignant or benign as well as functionally active (releasing hormones), or inactive. The majority found are benign, non-functioning masses.

Due to a rise in the number of imaging procedures available, the frequency of diagnosis of these tumours is increasing. Despite this, no international guidelines exist on the topic. In response, an interdisciplinary guideline working group made up of 10 international experts and led by Professors Martin Fassnacht (Germany) and Olaf Dekkers (The Netherlands) determined to establish the best response to adrenal incidentaloma.

The working group used GRADE (Grading of Recommendations, Assessment, Development and Evaluations) to define key clinical questions surrounding the disease. They then carried out extensive literature research to address these questions, providing recommendations based on quality of evidence as well as outcomes, patient preferences and feasibility of implementation.

"These guidelines are an important step in the handling of adrenal incidentaloma" says Martin Fassnacht. "We provide for the first time evidence-based recommendations to avoid over-diagnostics and over-treatment, without missing relevant disease, such as adrenocortical carcinomas."

Focusing on the assessment of malignancy, surgical intervention, follow-up recommendations and the definition and management of low-level autosomal cortisol secretion, the guidelines provide a comprehensive overview of disease assessment, treatment and follow-up. They state that the appropriateness of surgical intervention depends on the likelihood of malignancy, the presence and degree of hormone over-production as well as the age, general health and preference of the patient.

"The guidelines also provide recommendations on how to address bilateral incidentalomas (both adrenal glands) and tumours in patients with extra-adrenal malignancy (outside of the adrenal glands). They also clearly define that benign, non-functioning masses less than 4cm in size do not require follow-up imaging. Identification of this group is a major change to prior expert opinions."