Incidentaloma natural history, complications and prognosis

If left untreated, patients with adrenal incidentaloma may progress to develop dyslipidemia, osteoporosis, hyperglycemia, malignant hypertension, intracranial hemorrhage, acute coronary syndrome, aortic dissection, malignant transformation, and metastasis. Prognosis is usually good in benign adrenal incidentalomas, death is not directly related to the adrenal mass, but to cardiovascular accidents, malignancy, and chronic disorders, as observed in the general population. Adrenocortical carcinoma (ACC) carries a poor prognosis and is unlike most tumors of the adrenal cortex, which are benign (adenomas) and only occasionally cause Cushing’s syndrome.

• The symptoms of adrenal incidentaloma usually develop in the fifth decade of life, and start with symptoms such as weight loss, anorexia, diabetes, high incidence of vertebral fractures, dyslipidemia, impaired glucose tolerance or type 2 diabetes mellitus, and evidence of atherosclerosis, paroxysmal attacks of hypertension, palpitation, diaphoresis, headache, pallor, and tremor, hypertension and hypokalemia.
• If left untreated, patients with adrenal incidentaloma may progress to develop dyslipidemia, osteoporosis, hyperglycemia, malignant hypertension, intracranial hemorrhage, acute coronary syndrome, aortic dissection, malignant transformation, and metastasis.
• It seems that the majority of masses remain hormonally and morphologically unchanged. Some cases develop mass enlargement or adrenal hyperfunction.^[1][2]
• Nine precents of cases showed appearance of another mass in the contralateral adrenal gland. Mass enlargement was generally limited to 1–2 cm increase in diameter over a period of 1–3 years.^[3]
• Reduction or even disappearance of the adrenal mass have been reported in up to 40% of adrenal incidentalomas, most often in the case of cystic lesions, hematomas, or adrenal pseudotumors.

• Common complications of adrenal incidentaloma include:^[4]
  • Hypertension
  • Glucose intolerance
  • Diabetes mellitus
  • Obesity
  • Dyslipidemia
  • Osteoporosis
  • Hyperglycemia (due to opposition of insulin effect by high doses of adrenaline secreted by the tumor)
  • Malignant hypertension that may cause cerebrovascular accidents such as:
    • Intracranial hemorrhage
    • Acute coronary syndrome
    • Aortic dissection
    • Heart failure
  • Metastasis to:
    • Lymph nodes
    • Bones
    • Lungs
    • Liver

Adrenocortical carcinoma (ACC) carries a poor prognosis and is unlike most tumors of the adrenal cortex, which are benign (adenomas) and only occasionally cause Cushing’s syndrome. Adrenal mass size is important because the smaller the adrenocortical carcinoma is at the time of diagnosis, the better the overall prognosis.^[5]

• In the vast majority of patients with apparently benign adrenal incidentalomas, death is not directly related to the adrenal mass, but to cardiovascular accidents, malignancy, and chronic disorders, as observed in the general population.
• The most common causes of death are related to cardiovascular diseases (acute myocardial infarction, ventricular arrhythmia, cardiac failure, multi-infarct dementia, and acute cerebrovascular infarct).
• Mean age at death is 72.8 years.
• Five-year disease-free survival after a complete resection of a stage I–III ACC is 30%.
• The most important prognostic factors are:
  • Age of the patient
  • Stage of the tumor
  • Mitotic activity
  • Venous invasion, has worse prognosis.
  • Weight of more than 50g, has worse prognosis.
  • Diameter of 6.5 cm, has worse prognosis.

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