Adrenal incidentaloma: A cautionary tale of three cases of adrenocortical carcinoma arising from apparently benign incidentalomas

Abstract

Unexpected incidental findings on cross-sectional imaging are becoming more commonplace in today's medical practice. These are likely due to ongoing improvements in the resolution of cross-sectional imaging and our increasing use of these tests combined with an aging population. In the case of the adrenal incidentalomas the majority of these represent benign nonfunctional adenomas and these are believed to have no malignant potential. On the contrary adrenocortical carcinoma (ACC) is an uncommon malignancy that carries a high mortality. Current biochemical and radiological follow-up investigations are expensive and are of limited benefit in the majority of cases of adrenal incidentalomas. This has created a dilemma for the proper diagnostic, clinical and radiologic follow-up as well as the triggers for surgical intervention. We present a series of three patients presenting with ACC that retrospectively arose from a small incidentally found adrenal lesion. Three patients were identified with ACC arising from an apparently benign adrenal incidentaloma. The average size of the original lesion was 1.6 cm whereas the average size of their adrenal tumor was 9.3 cm when they presented with ACC. Two of the three cases were found to develop functional tumors at the time of the diagnosis of ACC. Two of the three cases underwent surgical resection. The third patient was found to have metastatic disease at presentation and declined surgical intervention. We agree that current follow-up guidelines result in an increasing burden on our healthcare system; with expensive biochemical testing and imaging for what in most cases will prove to be a benign adenoma, these three cases have influenced our current strategies for follow-up. At the present time, we continue to follow the AAES/AACE guidelines. The development of improved methods of biochemical, radiologic and tissue diagnosis may help to improve our ability to recognize an ACC in this population at an earlier and potentially curable stage. © Jaypee Brothers Medical Publishers (P) Ltd.