February is National Cancer Prevention Month.

To prevent adrenal cancer, knowing about adrenal incidentalomas is very important.

Preventing a disease like cancer is obviously advantageous over treating it when it already has developed, or even worse, spread (metastasis). There are many great ways we can prevent cancer, such as modifying lifestyle choices, e.g., not smoking prevents lung cancer.

Early detection is another way to ensure a better outcome for cancer patients. Screening programs such as colonoscopy and mammography are such programs to ensure that cancers are detected early when effective treatment (most commonly surgery) is still possible and effective. Again, to prevent adrenal cancer, knowing about adrenal incidentalomas are very important. The definition of an adrenal incidentaloma (sometimes termed adrenal mass, or nodule) is an adrenal lesion that is discovered when a radiological (X-ray) study (often CT or MRI) is performed for indications other than for adrenal disease (e.g., belly pain, car accident, etc.). That means it was discovered incidentally, or by accident.

If you ever have had such a CT or MRI of your abdomen or chest, it is a great screening test to look for an adrenal incidentaloma which can prevent adrenal cancer. It can also help diagnose other benign adrenal tumors, producing toxic amounts of adrenal hormones making you sick.

You can read about those disease here:

• Too much cortisol: Cushing’s syndrome
• Too much aldosterone: primary hyperaldosteronism (aka Conn’s syndrome)
• Too much adrenaline: https://www.adrenal.com/pheochromocytoma/overview

If you ever have had a CT or MRI of your abdomen or chest, track it down, and have your doctor and radiologist double check that there are no adrenal tumors! Trust me it is worth it. I did this myself, and fortunately I have no adrenal tumors.

When clinicians face an adrenal incidentaloma, there are mainly three questions that need to be answered:

1) Is it truly arising from the adrenal? This is usually easy to tell based on the CT or MRI scan. However, there are some rare retroperitoneal lesions that may be adjacent but not arising from the adrenal gland, per se.

2) Is the tumor a cancer (malignant), and if so, is it a primary or a metastatic tumor?

3) Is it functional (overproducing hormones)? Patients with an adrenal incidentaloma should undergo a thorough clinical evaluation. The history and physical exam and laboratory test should be aimed at excluding a functional tumor or an underlying malignant disease.

Unfortunately, many patients who have an adrenal incidentaloma do not know about it, even if they had a CT or MRI of your abdomen or chest. The 3 main reasons adrenal incidentaloma are not used more appropriately as screening test to prevent adrenal cancer and other adrenal tumor disease are:

1. The adrenal incidentaloma is missed by the radiology doctor looking at the X-ray (CT or MRI) scan.
2. The adrenal incidentaloma is seen and described in the radiology report, but the doctor does not realize its importance, or blows it off.
3. The adrenal incidentaloma is seen and described in the radiology report, the doctor does realize its importance, but fails to order the correct laboratory test to evaluate for hormone production.

Figure 1. The arrow displays a right adrenal incidentaloma. The patient underwent an uncomplicated Mini Back Scope Adrenalectomy (MBSA) and the pathology proved that it was an early-stage adrenal cancer. The fact that this patient had this incidentaloma taken seriously by her doctor, and a perfect operation saved her life.

1) The adrenal incidentaloma is missed by the radiology doctor looking at the X-ray (CT or MRI) scan.

As I have stated elsewhere, I love radiologists. In fact, my younger brother and my best friend from medical school are both radiologists. But radiologists sometimes miss things, and this is especially true when it comes to adrenal tumors. In particular, small aldosterone-producing adrenal adenomas can easily be missed. These small adrenal adenomas that overproduce aldosterone cause primary hyperaldosteronism (aka Conn’s syndrome).

Often these aldosterone-producing adrenal tumors are quite small, less than half an inch or about one centimeter. The is the size of a pea or a small grape.

Why do radiologists miss adrenal tumors on CT scans? Radiologists look at dozens to hundreds of CT scans in a single day. They look at many different organs in your body. When a radiologist looks at the CT scan of the chest and abdomen, they review the lungs, heart, liver, kidneys, spleen, pancreas, bowels, and all sorts of different organs. A small adrenal tumor can easily be missed. Again, if you ever have had a CT or MRI of your abdomen or chest, track it down, and have your doctor and radiologist double check that there are no adrenal tumors!

2) The adrenal incidentaloma is seen and described in the radiology report, but the doctor does not realize its importance, or blows it off.

This drives my bananas! Unfortunately, every single week I see multiple patients who have been told by their doctor that “Ahh, adrenal masses are common, we don’t need to worry about it”. Approximately, 60% of the patient I see with adrenal cancer (many of them with stage 4 cancer, when surgery is no longer possible and they will die within months), have had a previous CT or MRI scan that showed an adrenal incidentaloma, but nothing was done about it. Again, about 60% could have had surgery at an early stage when surgery would likely have cured and prevented the cancer. How can this be, you may ask?

The problem is that adrenal incidentalomas are common and most of these masses are 1) not cancerous and 2) not overproducing hormones. In such a case the mass can be safely watched without surgery. However, about 20% are potentially cancerous, cancerous, or hormone overproducing. Identifying these patients is the pinnacle of preventive medicine and cancer prevention.

In autopsy studies about 6 % of all individuals have an adrenal mass. Using CT scanning, one may identify adrenal masses in about 4 % of patients. Again, most of these masses are 1) not cancerous and 2) not overproducing hormones. In such a case the mass can be safely watched without surgery. The rate of adrenal incidentalomas increases with age; it is less than 1% in patients younger than 30 yr. of age and up to 7% in patients over age 70.

But just because most are not cancerous, and not overproducing hormones do not mean we can ignore all adrenal incidentalomas.

This is why all national and international guidelines state that all patients with adrenal incidentalomas have to be checked for hormone overproduction and need follow up scans to make sure they do not grow.

To learn more about adrenal incidentalomas and how they should be managed go here:

https://www.adrenal.com/adrenal-tumors/adrenal-incidentaloma

3) The adrenal incidentaloma is seen and described in the radiology report, the doctor does realize its importance, but fails to order the correct laboratory test to evaluate for hormone production.

Many doctors are not very knowledgeable about how to correctly order laboratory tests and interpret these tests for adrenal tumors. Part of the reason is that many doctors during their training see no or very few adrenal tumor patients. Even many endocrinologists who specialize on adrenal diseases struggle with interpretation of laboratory tests. Probably the one that confuse doctors the most are diagnosing Cushing’s syndrome.

Go here to read about the Top myths about Cushing’s syndrome.

https://www.adrenal.com/blog/top-5-myths-about-adrenal-cushing-s-syndrome

However, don’t be confused! The laboratory tests are done to figure out if there is:

• Too much cortisol: Cushing’s syndrome
• Too much aldosterone: primary hyperaldosteronism (aka Conn’s syndrome)
• Too much adrenaline: https://www.adrenal.com/pheochromocytoma/overview

Also, for adrenal cancer, sex-steroid hormones such as estrogen, estradiol, testosterone, and DHEA-S also have to be measured.

Read more here: https://www.adrenal.com/adrenal-cancer/overview

To read about laboratory testing for adrenal incidentaloma go here:

https://www.adrenal.com/adrenal-tumors/lab-testing

The best way to ensure that you have the correct hormones measured for your adrenal incidentaloma is to print that page out and bring it to your doctor. Print this PDF out and bring to your doctor. 

Figure 2. February is National Cancer Prevention Month. If you have ever had an CT or MRI of your abdomen or chest have your doctor check if you have an adrenal incidentaloma which can help prevent adrenal cancer and other adrenal tumor diseases.

Additional Resources: 

• Learn more about the Carling Adrenal Center
• Learn more about Dr. Tobias Carling
• Learn more about our sister surgeons at the Norman Parathyroid Center, Clayman Thyroid Center and Scarless Thyroid Surgery Center
• Learn more about the Hospital for Endocrine Surgery