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 rethink?
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 computed tomography (CT) scan follow-up exposes each patient to 23 mSv of ionising 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 costs, 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.
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The higher prevalence in Song et al. may be because the study protocol included a dedicated radiological review of adrenal imaging in a significant percentage of cases, possibly resulting in diagnosis of more AI than in routine practice.
“However, the study protocol included a dedicated radiological review of adrenal imaging in a significant percentage of cases, thereby possibly resulting in the diagnosis of more AI than would have been encountered in routine radiological clinical practice (44,45).”
From Adrenal incidentaloma (2020) · cites this paper as [45]
Even at a cut-off concentration of 140 nmol/L, specificity of the 1-mg dexamethasone suppression test is only 95%, and a false positive result is far more likely than a true positive.
“Even at a cut-off concentration of 140 nmol/L specificity is only 95%; the investigator must consider that a false positive result is far more likely than a true positive (45).”
From Adrenal incidentaloma (2020) · cites this paper as [45]
Hyperaldosteronism in AI is relatively uncommon compared with cortisol hypersecretion or pheochromocytoma.
“The discovery of hyperaldosteronism in the context of an AI is relatively uncommon, compared with the detection of cortisol hypersecretion or pheochromocytoma (45,270).”
From Adrenal incidentaloma (2020) · cites this paper as [45]
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References 96 · Cited by 300
- Authors
- Cawood, T. J., Hunt, P. J., O'Shea, D., Cole, D., & Soule, S.
- Affiliations
- Christchurch Hospital (NZ)
- ORCID
- Cawood, T J
- Venue
- European Journal of Endocrinology
- Publisher
- Oxford University Press (OUP)
- Published
- 2009-10
- Volume
- 161
- Issue
- 4
- Pages
- 513-527
- ISSN
- 0804-4643 (ISSN-L)
- 1479-683X
- OpenAlex
- W2138275103
- Semantic Scholar
- 53014e87d2ba90c2b5dcbc33514c76265c2a52ef
- Cited by
- 300
- References
- 96
- Citations by year
- 2026: 7 · 2025: 15 · 2024: 14 · 2023: 14 · 2022: 12 · 2021: 21 · 2020: 20 · 2019: 14 · 2018: 23 · 2017: 24 · 2016: 25 · 2015: 22 · 2014: 21 · 2013: 18 · 2012: 18
- FWCI
- 16.86
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- European Journal of Endocrinology (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Surgery › Adrenal and Paraganglionic Tumors
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Adrenal Hormones and Disorders
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Pituitary Gland Disorders and Treatments
- Keywords
- adrenal incidentaloma, adrenocortical carcinoma, adrenal metastasis, false positive rate, CT follow-up, radiation-induced cancer risk, clinical guidelines
- MeSH terms
- Adrenal Gland Neoplasms, Cell Transformation, Neoplastic, Cushing Syndrome, False Positive Reactions, Follow-Up Studies, Humans, Hyperaldosteronism, Pheochromocytoma, Radiography, Guidelines as Topic, Disease Progression
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