We are writing to suggest a small, but important point of clarification regarding the CUA guidelines for management of incidentally discovered adrenal mass.1 (see Editor’s Note)
These are excellent and much-needed guidelines for what is a very common clinical scenario; however, we would like to discuss the followup recommendations in the guideline for adrenal incidentalomas (AI) with benign phenotype (computed tomograph [CT] density <10 HU, benign CT washout characteristics, or loss of signal on chemical shift magnetic resonance imaging [MRI]).
The authors suggest that these lesions should be considered for followup in 12 months. While a single followup study might be argued to be of limited inconvenience to the patient, AIs are common (estimated to be present in 4% of patients on imaging series2) and would be anticipated to result in a high number of unnecessary followup examinations and potential cost to the healthcare system. The authors’ justification for this recommendation is that, “The risk of progression is not well-defined” and that “...it should be considered non-negligible.” They quote the risk of developing malignancy as 0.1%. The data provided in Table 1 of their article (one lesion out of 1913 was malignant) may not be accurate. Specifically, if one examines the paper by Tsvetov et al, which reports this case of malignancy, the malignancy was identified in a patient with known renal cell cancer: “FNA carried out in three patients (two oncological), revealed metastasis in one patient with known renal cell carcinoma.”3 As such, we question whether this single case of malignancy should qualify as an AI by the definition provided in the guideline: “Adrenal incidentaloma is excluded in patients with known malignancy or high suspicion of malignant process.”
A rate of 0% malignancy in AI is also supported by an evaluation of over 1000 AIs with no malignancy identified.4 Given that the AI followup recommendation for benign phenotype is likely not justified by the evidence, and this recommendation, in our experience is driving a substantial number of unnecessary followup studies, we would like the CUA to consider aligning their recommendations with those of the American College of Radiology and European Society of Endocrinology, which state that masses with typical benign features of lipid-rich adenoma require no additional followup imaging.5,6
Footnotes
EDITOR’S NOTE: An update of the CUA guideline for the management of incidentally discovered adrenal mass is currently underway. The update is expected to be released by the end of 2021.
References
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