|
Management of the Clinically
Inapparent
Adrenal Mass (Incidentaloma)
National Institutes of
Health
State-of-the-Science Conference Statement
February 4-6,
2002
NIH Consensus and
State-of-the-Science statements are prepared by independent panels of
health professionals and public representatives on the basis of (1) the
results of a systematic literature review prepared under contract with
the Agency for Healthcare Research and Quality (AHRQ), (2) presentations
by investigators working in areas relevant to the conference questions
during a 2-day public session, (3) questions and statements from
conference attendees during open discussion periods that are part of the
public session, and (4) closed deliberations by the panel during the
remainder of the second day and morning of the third. This statement is
an independent report of the panel and is not a policy statement of the
NIH or the Federal Government.
The statement reflects the
panel's assessment of medical knowledge available at the time the
statement was written. Thus, it provides a "snapshot in time" of the
state of knowledge on the conference topic. When reading the statement,
keep in mind that new knowledge is inevitably accumulating through
medical research.
Introduction
The adrenals are
triangular glands that sit atop each kidney. They influence or regulate
the body's metabolism, salt and water balance, and response to stress by
secreting a variety of hormones. Based on autopsy studies, adrenal
masses are among the most common tumors in humans: at autopsy, an
adrenal mass occurs in at least 3 percent of persons over age 50. Most
adrenal masses cause no health problems. A small proportion, however,
can lead to a number of serious hormonal diseases; approximately 1 out
of every 4,000 adrenal tumors is malignant.
Clinically inapparent adrenal masses are
discovered inadvertently in the course of diagnostic testing or
treatment for other clinical conditions that are not related to
suspicion of adrenal disease and, thus, are commonly known as
incidentalomas. The definition of incidentaloma excludes patients
undergoing imaging procedures as a part of staging and workup for
cancer. Improvements in abdominal imaging techniques and technologies
have resulted in the detection of an increasing number of adrenal
incidentalomas. Increasing clinical and scientific interest is reflected
in a twentyfold increase in publications about this condition over the
past three decades.
When detected, clinically inapparent adrenal
masses raise challenging questions for physicians and their patients.
Diagnostic evaluation is performed to determine whether the lesion is
hormonally active or nonfunctioning and whether it is malignant or
benign. The results from these tests will influence whether the mass is
removed surgically or treated nonsurgically. Because the prevalence of
these masses increases with age, appropriate management of adrenal
tumors will be a growing challenge in our aging society.
Over the past three decades, new information
has become available regarding the epidemiology, biology, screening,
treatment, and followup of adrenal tumors. For example, recent
refinements in the field of minimally invasive surgery have made
laparoscopic adrenalectomy a more frequently used method for removing
adrenal masses. Recent reports suggest that up to 20 percent of patients
with adrenal incidentalomas have some form of subclinical hormonal
dysfunction and may represent a population at higher risk for metabolic
disorders and cardiovascular disease. It is important to determine
whether groups of patients with subclinical disease benefit from
treatment. The psychological impact on the patient of knowing that he or
she harbors an adrenal incidentaloma, an incompletely understood
clinical problem, merits investigation.
This two-and-a-half-day state-of-the-science
conference on Management of the Clinically Inapparent Adrenal Mass
("Incidentaloma") was convened on February 4&emdash;6, 2002, to
explore and assess the current knowledge regarding adrenal
incidentalomas, so that health care providers and the general public can
make informed decisions about this important public health
issue.
After a day-and-a-half of expert
presentations and questions and public discussion by members of the
panel and the audience of interested attendees on incidental adrenal
masses, an independent, non-Federal panel weighed the evidence and
drafted a statement that was presented on the third day of the
conference. Expert presentations and the panel's statement addressed the
following questions:
1. What are the causes,
prevalence, and natural history of clinically inapparent adrenal
masses?
2. Based on available scientific evidence,
what is the appropriate evaluation of a clinically inapparent adrenal
mass?
3. What criteria should guide the decision
on surgical versus nonsurgical management of these masses?
4. If surgery is indicated, what is the
appropriate procedure?
5. What is the appropriate followup for
patients for each management approach?
6. What additional research is needed to
guide practice?
The panel's draft statement was posted to the
Consensus Program Web
site&endash;http://consensus.nih.gov&endash;on Wednesday,
February 6, 2002.
The primary sponsors of this meeting were the
National Institute of Child Health and Human Development and the NIH
Office of Medical Applications of Research. Cosponsors included the
National Cancer Institute and the National Institute of Diabetes and
Digestive and Kidney Diseases.
1. What are the causes, prevalence, and
natural history of clinically inapparent adrenal masses?
Clinically inapparent adrenal masses are
detected incidentally with imaging studies conducted for other reasons.
They may be clinically important because some are caused by adrenal
cortical carcinomas (estimated prevalence of 4&emdash;12 per
million), which have a high mortality rate. The other clinical concern
is hormone overproduction from pheochromocytomas, aldosteronomas, and
subclinical hypercortisolism, which may be associated with morbidity if
untreated.
Prevalence of Clinically Inapparent
Adrenal Masses
In autopsy series, the prevalence of
clinically inapparent adrenal masses is about 2.1 percent. Because of
increased use of noninvasive high-resolution imaging technology,
clinically inapparent adrenal masses are being recognized more often.
Estimates range from 0.1 percent for general health screening with
ultrasound to 0.42 percent among patients evaluated for
nonendocrinologic complaints to 4.3 percent among patients who have a
previous diagnosis of cancer.
In addition to the source of data (autopsy
versus clinical series) and reasons for imaging (cancer workup,
nonendocrinologic complaints, general health screening), the prevalence
of clinically inapparent adrenal masses varies with age. The prevalence
of clinically inapparent adrenal masses detected at autopsy is less than
1 percent for ages younger than 30 years and increases to 7 percent in
those 70 years of age or older. Many of these lesions detected at
autopsy are very small. Among patients with clinically inapparent
adrenal masses, more are women. This probably reflects the sex
distribution of the population undergoing imaging procedures. There is
no evidence of a sex difference in prevalence from autopsy studies or
general health exams. There is insufficient information to determine
whether the prevalence of clinically inapparent adrenal masses differs
by the initial diagnostic test.
Causes of Clinically Inapparent Adrenal
Masses
Clinically inapparent
adrenal masses can be either benign or malignant. These include
adenomas, pheochromocytomas, myelolipomas, ganglioneuromas, adrenal
cysts, hematomas, adrenal cortical carcinomas, metastases from other
cancers, and other rare entities.
The distributions of the pathologic origins
of clinically inapparent adrenal masses vary with several clinically
important factors, including cancer history and mass size. Among cancer
patients, three-fourths of clinically inapparent adrenal masses are
metastases. In contrast, in populations with no history of cancer,
two-thirds of clinically inapparent adrenal masses are benign tumors.
The prevalence of primary adrenal cortical carcinoma is clearly related
to the size of the tumor. Adrenal cortical carcinoma accounts for 2
percent of tumors less than or equal to 4 cm, 6 percent of tumors
4.1&emdash;6 cm, and 25 percent of tumors greater than 6
cm.
Among unselected patients and those with
nonendocrinologic complaints, clinically inapparent adrenal masses are
most often nonfunctioning tumors (approximately 70 percent). Among
patients being evaluated for nonendocrinologic complaints, approximately
5&emdash;10 percent have subclinical hypercortisolism (sometimes
called "subclinical Cushing syndrome "). The percentage of patients with
subclinical hypercortisolism depends on the testing methods and cortisol
levels achieved after dexamethasone suppression.
The distribution of clinically inapparent
adrenal mass pathologies derived from surgical series will overestimate
the prevalence of adrenal cortical carcinoma, since suspicion of adrenal
cortical carcinoma is an indication for surgery. Moreover, the reported
frequency of adrenal cortical carcinomas is derived from highly selected
patient populations and does not reflect the prevalence rates seen in
population-based studies. The age and sex of the patient do not appear
to be helpful in predicting the presence of adrenal cortical carcinoma.
Distribution estimates from autopsy studies are not biased by surgical
indications but may not reflect the risk of adrenal cortical carcinoma
among the subset of people undergoing abdominal imaging studies. A
precise estimate of the risk of adrenal cortical carcinoma that could
guide clinical decisionmaking may not be possible. Almost all the
reported large studies used imaging equipment that would now be
considered obsolete. The use of contemporary equipment may increase the
prevalence of detected clinically inapparent adrenal masses and may
enhance our ability to differentiate adrenal cortical carcinomas from
adenomas. In addition, the literature comprises mainly small,
retrospective studies with variable definitions of clinically inapparent
adrenal masses, which cause variation in the relative proportions of
adrenal pathological classifications.
Natural History of
Clinically Inapparent Adrenal Masses
The observed natural history of clinically
inapparent adrenal masses varies, depending on the composition of the
study population and the size and pathological classification of the
adrenal mass. Patients with or without a previous cancer diagnosis found
to have adrenal gland metastases will have a clinical course defined by
the stage, grade, and site of the primary tumor. Usually, large
clinically inapparent adrenal masses (greater than 6 cm) are treated
surgically. Approximately 25 percent of masses greater than 6 cm in
diameter are adrenal cortical carcinomas, and these patients have very
poor clinical outcomes. The overwhelming majority of studies report less
than 50 percent 5-year overall survival for adrenal cortical carcinoma,
and several report less than 50 percent 2-year overall survival.
Inconclusive evidence suggests that adrenalectomy at stage 1 or 2 may
improve the survival rate.
Followup of patients with nonfunctioning
adrenal masses suggests that 5&emdash;25 percent of masses increase
in size by at least 1 cm. The threshold for a clinically significant
increase in size is unknown. The risk of malignancy is about 1/1,000. Up
to 20 percent of patients develop hormone overproduction. Masses greater
than or equal to 3 cm are more likely to develop hyperfunction compared
to smaller tumors. The interpretation of these followup studies is
affected by variable length of followup and variable followup
strategies.
Most studies indicate
that the transformation rate of small (less than 3 cm) nonfunctioning
nodules to functional tumors is low. This may suggest that only limited
followup is necessary to detect the clinically inapparent adrenal masses
that become biochemically active. Similarly, the high growth rate (or
short doubling time) and extremely low incidence of adrenal cortical
carcinomas suggest that a judicious followup strategy is sufficient to
reassure concerned patients.
2. Based on available scientific
evidence, what is the appropriate evaluation of a clinically inapparent
adrenal mass?
The patient with a clinically inapparent
adrenal mass revealed by an imaging study requires a complete history
and physical examination, a biochemical evaluation for hormone excess,
and possible additional radiologic studies. The goal is to determine
whether the patient has pheochromocytoma, subtle glucocorticoid excess,
primary aldosteronism (Conn syndrome), or virilizing or feminizing
tumors.
Hormonal Evaluation
Available evidence
suggests that an overnight (1-mg) dexamethasone suppression test and
determination of fractionated urinary and/or plasma metanephrines should
be performed. Exceptions will include patients with imaging
characteristics of myelolipoma or an adrenal cyst. In patients with
hypertension, serum potassium and a plasma aldosterone
concentration/plasma renin activity ratio should be determined to
evaluate for primary aldosteronism. A plasma aldosterone
concentration/plasma renin activity ratio greater than 30 and a plasma
aldosterone concentration of greater than 20 ng/dL are highly suggestive
of autonomous aldosterone production. The sensitivity and specificity of
24-hour urine catecholamines for the diagnosis of pheochromocytoma are
high, but this test is less sensitive than the determination of free
metanephrines, a test now available in commercial laboratories in the
United States. Plasma-free metanephrines (normetanephrine, metanephrine)
can be measured with high diagnostic sensitivity (99 percent) and good
specificity (~ 89 percent) and are recommended, on the basis of a
multicenter study of biochemical tests for the detection of a
pheochromocytoma, as the test of choice for excluding or confirming the
diagnosis of pheochromocytoma. The rationale for the 1-mg dexamethasone
suppression test is to detect subclinical hypercortisolism. After
dexamethasone administration, the vast majority of normal individuals
suppress their serum cortisol concentration to less than 5 µg/dL. Some
experts, however, propose further testing of individuals with serum
cortisol values between 1.8&emdash;5 µg/dL, in addition to patients
with the more traditional cutoff of greater than 5 µg/dL, to increase
the detection of subclinical hypercortisolism. However, when lower
cutpoints are used, specificity decreases, which results in more false
positive test results. Unfortunately, this subclinical syndrome has not
been adequately characterized, and its natural history is unknown. A
better term for this condition may be subclinical autonomous
glucocorticoid hypersecretion. It is controversial whether this disorder
is associated with long-term morbidity and whether treatment to reverse
subtle glucocorticoid excess is beneficial.
Radiologic
Evaluation
The size and appearance of an adrenal mass on
the computed tomography (CT) or magnetic resonance imaging (MRI) may
help distinguish between benign and malignant lesions. The available
data suggest that nearly all lesions smaller than 4 cm are benign. A
standardized measure of X-ray absorption known as CT attenuation value,
conventionally expressed in Hounsfield units (HU), may differentiate
between benign and malignant lesions. A homogeneous mass with a smooth
border and an attenuation value of less than 10 HU on an unenhanced CT
study strongly suggests the diagnosis of a benign adrenal adenoma. The
optimal diagnostic evaluation has not been established for adrenal
masses between 4&emdash;6 cm. If these lesions are hormonally
inactive and exhibit a benign imaging appearance as described above,
they can be monitored. Lesions greater than 6 cm are more likely to be
malignant; therefore, surgery should be considered.
MRI is equally effective as CT in
distinguishing benign from malignant lesions. A benign adenoma exhibits
a signal drop on chemical shift imaging and has an intensity similar to
that of the liver on a T2-weighted image. Although chemical shift MRI is
commonly performed, it does not provide additional information beyond
that which is already available on unenhanced CT. The following tests
are not widely available, and there are insufficient data regarding
their clinical usefulness: radionuclide scintigraphy using
iodocholesterol (NP59) for evaluating adrenocortical lesions, I-131
metaiodobenzyl guanidine (MIBG) for evaluating pheochromocytoma, and
positron emission tomography (PET).
Fine Needle
Aspiration
CT-guided fine needle aspiration may be
helpful in the diagnostic evaluation of patients with a history of
cancer (particularly lung, breast, and kidney), with no other signs of
metastases, and a heterogenous adrenal mass with a high attenuation
value (greater than 20 HU). Pheochromocytoma should always be excluded
before attempting fine needle aspiration biopsy of an adrenal mass, in
order to avoid the potential for hypertensive crisis. A benign cytologic
diagnosis on fine needle aspiration does not, of course, exclude
malignancy because of the high false negative rate of this
procedure.
There are few data regarding the utility of
fine needle aspiration in patients without a history of malignancy who
have an incidentally found adrenal mass.
3. What criteria should guide the
decision on surgical versus nonsurgical management of these
masses?
The major issues to
be addressed in formulating a therapeutic plan are whether the lesion is
clinically or biochemically active (functional) and whether the lesion
is likely to be benign or malignant.
If a patient with a unilateral incidentaloma is found
on history or physical examination to have the signs and symptoms
suggestive of glucocorticoid, mineralocorticoid, adrenal sex hormone, or
catecholamine excess that is confirmed biochemically, adrenalectomy is
often considered the treatment of choice. However, medical therapy may
be appropriate in several situations. For instance, the use of
inhibitors of adrenal cortical steroid hormone biosynthesis may be
useful when patients with Cushing syndrome are poor surgical candidates.
Similarly, aldosterone antagonists may be used to treat an
aldosterone-secreting tumor.
In the absence of clinical
symptoms, treatment decisions for those patients with biochemical
evidence of adrenal hormone excess are not always straightforward.
Patients with "silent" pheochromocytomas are at risk for a hypertensive
crisis and should undergo adrenalectomy. Adrenalectomy is an option for
an individual with hypertension and aldosterone excess. Patients with
subclinical autonomous glucocorticoid hypersecretion present a vexing
problem. Data exist that indicate that some patients with subtle
glucocorticoid excess may develop metabolic derangements, including
insulin resistance, that could be attributable to autonomous cortisol
hypersecretion or, rarely, may progress to overt Cushing syndrome. The
long-term effects of these derangements on the patient are unknown.
Adrenalectomy or careful observation has been suggested as a treatment
option. However, while adrenalectomy has been demonstrated to correct
the biochemical abnormalities, its effect on long-term outcome and
quality of life is unknown.
In
patients with nonfunctioning incidentalomas, distinguishing between
malignant and benign primary adrenal tumors guides subsequent
management. Variables to consider are the size of the lesion, its
imaging characteristics, and its growth rate. Traditionally, the size of
the lesion has been considered to be the major determinant of the
potential presence of a malignant tumor. More than 60 percent of
incidentalomas less than 4 cm are benign adenomas, while less than 2
percent represent primary adrenal carcinomas. In contrast, the risk of
adrenal carcinoma increases to 25 percent in lesions that are greater
than 6 cm, while benign adrenal adenomas account for less than 15
percent. Therefore, the generally accepted recommendation is to excise
lesions that are larger than 6 cm. Lesions that are less than 4 cm and
appear to be defined as low risk by imaging criteria are unlikely to
have malignant potential and are generally not resected. The need and
strategy for routine followup in this group are unclear. For lesions
between 4 and 6 cm, either close followup or adrenalectomy is considered
a reasonable approach. Adrenalectomy should be strongly considered if
the imaging findings, including rapid growth rate, decreased lipid
content, and other features described previously, suggest that the
lesion is not an adenoma. It is important to recognize that the size
criteria discussed above are to some degree arbitrary, and treatment
recommendations are based upon data derived from highly selected series
of patients. Data from several small series of patients indicate that
less than 30 percent of incidentalomas increase in size and less than 20
percent develop biochemical abnormalities when followed for up to 10
years. It is reassuring to note that in studies in which patients were
monitored for many years, the risk of the lesion being an adrenal
cortical carcinoma was extremely low. The clinical condition and
personal concerns of an individual patient should be taken into account
when making treatment recommendations. Future efforts should be directed
toward defining the true natural history of adrenal incidentalomas as a
function of size based upon properly designed prospective clinical
studies.
Finally, there is no known benefit from adrenalectomy
for patients who, during their workup for a clinically inapparent
adrenal mass, are diagnosed with metastasis from a known or unknown
primary neoplasm.
4. If surgery is
needed, what is the appropriate procedure?
Either open or laparoscopic adrenalectomy is an
acceptable procedure for the resection of an adrenal mass. There are no
prospective, randomized trials comparing open with laparoscopic
adrenalectomy. Operative mortality associated with adrenalectomy is less
than 2 percent. However, the laparoscopic approach may have advantages
over the open approach when performed by a surgical team experienced in
advanced laparoscopic techniques. These advantages include decreased
postoperative pain, reduced time to return of bowel function, decreased
length of hospital stay, and the potential for earlier return to work.
At present, relative contraindications to laparoscopic adrenalectomy are
a definitive or presumed diagnosis of invasive adrenal cortical
carcinoma or circumstances that make a minimally invasive approach
technically difficult, for example, large tumors. There are no studies
that demonstrate a consistent benefit of one laparoscopic approach
(transabdominal or retroperitoneal) over another.
5. What is the
appropriate followup for patients for each management
approach?
Recommendations for
followup are designed to detect interval changes in tumor size or the
development of hormone overproduction. Long-term followup studies
suggest that the vast majority of adrenal lesions remain stable, whereas
5&emdash;25 percent enlarge and 3&emdash;4 percent decrease in
size. However, the limited and incomplete evidence available precludes
making specific recommendations regarding serial imaging and biochemical
evaluation. In patients whose lesions have not been excised, a CT study
repeated 6&emdash;12 months after the initial study is reasonable.
For lesions that do not increase in size, there are no data to support
continued radiologic evaluation. This observation is based on
longitudinal studies of up to 10 years reporting that the risk of
developing adrenal cortical carcinoma is extremely low.
Hormone excess may develop
in up to 20 percent of patients during followup but is unlikely in a
patient with a lesion less than 3 cm. Cortisol hypersecretion is the
most likely disorder that may ensue and is subclinical in two-thirds of
cases. The onset of catecholamine overproduction or hyperaldosteronism
during long-term followup is rare. There are few data that would guide
recommendations for periodic hormonal testing. One current approach
would be to perform an overnight 1-mg dexamethasone suppression test and
urine catecholamines/
metabolites at yearly
intervals or earlier if clinically indicated. The risk of tumor
hyperfunction appears to plateau after 3&emdash;4 years; however,
these data are based on a small number of patients with variable
followup.
Patients with subclinical
hypercortisolism should receive perioperative glucocorticoids because
they are at risk for hypoadrenalism following the removal of the
functioning mass. They should be monitored for subsequent
hypothalamic-pituitary-adrenal axis recovery and clinical improvement.
Guidelines for followup of other patients who have undergone resection
have not been defined.
6. What additional
research is needed to guide practice?
Additional research needed
to guide practice should be led by the establishment of an international
collaborative study group whose charge would be to develop a database of
patients with clinically inapparent adrenal masses. The database would
need to have clearly defined entry criteria, variables to be collected,
guidelines for followup, and so forth.
The purpose would be to
provide longitudinal data to help address several important questions.
These include:
- What is the natural history of clinically
silent adrenal masses?
- Can we identify patients who are at high
risk for developing adrenal cortical carcinoma?
- How long should patients be monitored
before concluding that they are not at risk for adrenal cortical
carcinoma or emergence of endocrine hyperfunction?
- What is the optimal followup strategy for
patients with incidentally discovered adrenal masses?
Proposed studies
are:
1. A study of perioperative and
postoperative outcomes designed to define the risks and benefits of
the various surgical procedures
2. Studies of physical
and mental health outcomes and quality of life among patients with
conservatively managed clinically inapparent adrenal masses
3. A study of the effect
of surgical removal of tumors on the evolution of common chronic
diseases, such as obesity, diabetes, osteoporosis, hypertension, and
psychiatric conditions
4. A prospective study at
centers conducting screening whole body scans to learn more about the
prevalence and natural history of incidentalomas and the psychosocial
effect on the patient
5. A prospective study to
characterize subclinical hypercortisolism, including the evaluation of
diagnostic tests, possible associated morbidity, and the benefits of
treatment
6. A study to validate
the reproducibility of size measurements in serial imaging exams for
ultrasound, CT, and MRI and to determine what constitutes a
significant change
Additionally, markers
sensitive and specific for adrenal cortical carcinoma need to be
identified.
There is a need to better
define the various diagnostic tests that have been advocated for
evaluating adrenal masses and their translation to clinical practice.
These include:
- Positron emission tomography
- Delayed enhanced computed tomography for
distinguishing between benign and malignant adrenal neoplasms
- Adrenal biopsies with immunostaining for
tumor markers
- 3-mg dexamethasone suppression test versus
the 1-mg overnight dexamethasone suppression test
- Utility of plasma free metanephrines
measurements for the diagnosis of an adrenal incidentaloma that is a
pheochromocytoma
- Finally, the appropriate specialty and
surgical societies should develop minimal criteria that define
proficiency in the performance of laparoscopic adrenalectomy.
Conclusions
- The management of clinically inapparent
adrenal masses is complicated by limited studies of incidence,
prevalence, and natural history, including the psychologic impact on
the patient who is informed of the diagnosis. Improvements in the
resolution of abdominal imaging techniques combined with increased use
of abdominal imaging suggest that the prevalence of clinically
inapparent adrenal masses will continue to escalate. The low
prevalence of adrenal cortical carcinomas and the relatively low
incidence of progression to hyperfunction call into question the
advisability of the current practice of intense, long-term clinical
followup of this common condition.
- All patients with an incidentaloma should
have a 1-mg dexamethasone suppression test and a measurement of
plasma-free metanephrines.
- Patients with hypertension should also
undergo measurement of serum potassium and plasma aldosterone
concentration/plasma renin activity ratio.
- A homogeneous mass with a low attenuation
value (less than 10 HU) on CT scan is likely a benign adenoma.
- Surgery should be considered in all
patients with functional adrenal cortical tumors that are clinically
apparent.
- All patients with biochemical evidence of
pheochromocytoma should undergo surgery.
- Data are insufficient to indicate the
superiority of a surgical or nonsurgical approach to manage patients
with subclinical hyperfunctioning adrenal cortical adenomas.
- Recommendations for surgery based upon
tumor size are derived from studies not standardized for inclusion
criteria, length of followup, or methods of estimating the risk of
carcinoma. Nevertheless, patients with tumors greater than 6 cm
usually are treated surgically, while those with tumors less than 4 cm
are generally monitored. In patients with tumors between 4 and 6 cm,
criteria in addition to size should be considered in making the
decision to monitor or proceed to adrenalectomy.
- The literature on adrenal incidentaloma
has proliferated in the last several years. Unfortunately, the lack of
controlled studies makes formulating diagnostic and treatment
strategies difficult. Because of the complexity of the problem, the
management of patients with adrenal incidentalomas will be optimized
by a multidisciplinary team approach involving physicians with
expertise in endocrinology, radiology, surgery, and pathology. The
paucity of evidence-based data highlights the need for well-designed
prospective studies.
- Either open or laparoscopic adrenalectomy
is an acceptable procedure for resection of an adrenal mass. The
choice of procedure will depend upon the likelihood of an invasive
adrenal cortical carcinoma, technical issues, and the experience of
the surgical team.
- In patients with tumors that remain stable
on two imaging studies carried out at least 6 months apart and do not
exhibit hormonal hypersecretion over 4 years, further followup may not
be warranted.
State-of-the-Science
Panel
Melvin M. Grumbach, M.D.
Panel and
Conference Chairperson
Edward B. Shaw Professor of Pediatrics
Emeritus
Department of Pediatrics
University of California, San
Francisco
San Francisco, California
Beverly M.K.
Biller, M.D.
Associate Professor of Medicine,
Harvard Medical
School
Associate Physician in Medicine,
Massachusetts General
Hospital
Neuroendocrine Unit
Massachusetts General
Hospital
Boston, Massachusetts
Glenn D. Braunstein,
M.D.
Professor and Chairman
Department of
Medicine
Cedars-Sinai Medical Center
University of California, Los
Angeles
School of Medicine
Los Angeles,
California
Karen K. Campbell
Cushing's Support
and Research Foundation
Pleasanton, California
J.
Aidan Carney, M.D., Ph.D.
Emeritus Professor of
Pathology
Emeritus Consultant
Department of Laboratory
Medicine
and Pathology
Mayo Clinic
Rochester,
Minnesota
Paul A. Godley, M.D., Ph.D.,
M.P.P.
Associate Professor of Medicine,
Adjunct Associate
Professor, Biostatistics
Adjunct Associate Professor,
Epidemiology
Division of Hematology/Oncology
University of North
Carolina School of
Medicine
Chapel Hill, North
Carolina
Emily L. Harris, Ph.D., M.P.H.
Senior
Investigator
Kaiser Permanente Center for
Health
Research
Portland, Oregon
Joseph K.T. Lee, M.D.,
F.A.C.R.
Professor and Chair of Radiology
Department of
Radiology
University of North Carolina School
of
Medicine
Chapel Hill, North Carolina
Yolanda C.
Oertel, M.D.
Professor Emerita of Pathology
George Washington
University
School of Medicine and Health Sciences
Adjunct
Professor of Pathology
and Laboratory Medicine
MCP Hahnemann
University School
of Medicine
Senior Staff
Pathologist
Director, Fine Needle Aspiration Service
Pathology
Department
Washington Hospital Center
Washington,
DC
Mitchell C. Posner, M.D.
Associate Professor
of Surgery
Chief, Surgical Oncology
University of
Chicago
Chicago, Illinois
Janet A. Schlechte,
M.D.
Professor of Medicine
Department of Internal
Medicine
University of Iowa Hospitals and Clinics
Iowa City, Iowa
H. Samuel Wieand,
Ph.D.
Director
Biostatistics Center
University of
Pittsburgh Cancer Institute
Pittsburgh, Pennsylvania
Speakers
Alberto Angeli,
M.D.
Full Professor of Internal Medicine
University of
Turin
Head
Division of Internal Medicine I
Dipartimento di
Scienze Cliniche e Biologiche
San Luigi Hospital
Orbassano (TO),
Italy
David C. Aron, M.D., M.S.
Associate Chief
of Staff/Education
Education Office
Louis Stokes Cleveland
VA
Medical Center 111-W
Cleveland, Ohio
Ethan M.
Balk, M.D., M.P.H.
Assistant Director
New England Medical
Center
Evidence-Based Practice Center
Tufts University School of
Medicine
Boston, Massachusetts
Luisa Barzon,
M.D.
Research Associate
Department of Histology,
Microbiology
and Medical Biotechnologies
University of
Padova
Padova, Italy
Stefan R. Bornstein, M.D.,
Ph.D.
Professor of Medicine
Associate Director
Department
of Endocrinology
University of Düsseldorf
Düsseldorf,
Germany
Clara S. Heffess, M.D.
Chief
Endocrine
Division
Armed Forces Institute of Pathology
Washington,
DC
Anna A. Kasperlik-Zaluska, M.D.,
Ph.D.
Professor of Medicine
Department of
Endocrinology
Centre for Postgraduate Medical Education
Warsaw,
Poland
Job Kievit, M.D.,
Ph.D.
Director
Department of Medical Decision Making
Leiden
University Medical Center
Leiden, The
Netherlands
Melvyn Korobkin, M.D.
Professor of
Radiology
Director of Abdominal Imaging
Department of
Radiology
University of Michigan Medical School
Ann Arbor,
Michigan
Ernest E. Lack, M.D.
Professor of
Anatomic Pathology
Department of Pathology
Washington Hospital
Center
Washington, DC
Joseph Lau,
M.D.
Director
New England Medical Center
Evidence-Based
Practice Center
Tufts University School of Medicine
Boston,
Massachusetts
Franco Mantero, M.D.
Professor of
Endocrinology
Department of Endocrinology
University of
Padova
Padova, Italy
Sandra Ann Murray,
Ph.D.
Professor
Department of Cell Biology and
Physiology
University of Pittsburgh School of Medicine
Pittsburgh,
Pennsylvania
Karel Pacak, M.D., Ph.D.,
D.Sc.
Tenure-Track Investigator
Pediatric and
Reproductive
Endocrinology Branch
National Institute of Child
Health
and Human Development
National Institutes of
Health
Bethesda, Maryland
Martin Reincke,
M.D.
Professor of Medicine
University of Freiburg
Freiburg,
Germany
Michael Rothberg, M.D.,
M.P.H.
Consultant
New England Medical Center
Evidence-Based
Practice Center
Tufts University School of Medicine
Boston,
Massachusetts
Hironobu Sasano, M.D.,
Ph.D.
Director, Department of Pathology
Tohoku University
Hospital
Professor, Department of Pathology
Tohoku University
School of Medicine
Sendai, Japan
David E.
Schteingart, M.D.
Professor
Department of Internal
Medicine
University of Michigan Medical School
Ann Arbor,
Michigan
Allan E. Siperstein, M.D.
Head, Section
of Endoscopic Surgery
Department of General Surgery
Cleveland
Clinic Foundation
Cleveland, Ohio
Robert Udelsman,
M.D., M.S.B., M.B.A.,
F.A.C.S.
Lampman Professor of Surgery
and Oncology
Chairman
Department of Surgery
Yale University
School of Medicine
New Haven, Connecticut
William F.
Young, Jr., M.D.
Consultant
Department of Endocrinology
and
Metabolism
Mayo Clinic and Foundation
Rochester,
Minnesota
Planning
Committee
Duane Alexander,
M.D.
Director
National Institute of Child Health and Human
Development
National Institutes of Health
Bethesda,
Maryland
Jacqueline S. Besteman, J.D.,
M.A.
Director, EPC Program
Center for Practice
and
Technology Assessment
Agency for Healthcare Research and
Quality
U.S. Department of Health and Human Services
Rockville,
Maryland
Stefan R. Bornstein, M.D.,
Ph.D.
Professor of Medicine
Associate Director
Department
of Endocrinology
University of Düsseldorf
Düsseldorf,
Germany
John A. Bowersox
Communications
Specialist
Office of Medical Applications of Research
Office of
the Director
National Institutes of Health
Bethesda,
Maryland
Elsa A. Bray
Senior
Analyst
Office of Medical Applications of Research
Office of the
Director
National Institutes of Health
Bethesda,
Maryland
Antonio Fojo, M.D., Ph.D.
Chief,
Experimental Therapeutics Section
Division of Clinical
Sciences
National Cancer Institute
National Institutes of
Health
Bethesda, Maryland
Henrietta D. Hyatt-Knorr,
M.A.
Acting Director
Office of Rare Diseases
Office of the
Director
National Institutes of Health
Bethesda,
Maryland
Melvyn Korobkin, M.D.
Professor of
Radiology
Director of Abdominal Imaging
Department of
Radiology
University of Michigan Medical School
Ann Arbor,
Michigan
Barnett S. Kramer, M.D.,
M.P.H.
Director
Office of Medical Applications of
Research
Office of the Director
National Institutes of
Health
Bethesda, Maryland
Ernest E. Lack,
M.D.
Professor of Anatomic Pathology
Department of
Pathology
Washington Hospital Center
Washington,
DC
D. Lynn Loriaux, M.D., Ph.D.
Chairman,
Department of Medicine
Chief, Division of Endocrinology, Diabetes,
and Clinical Nutrition
Oregon Health Sciences University
Portland,
Oregon
Stephen J. Marx, M.D.
Branch
Chief
Metabolic Diseases Branch
National Institute of Diabetes and
Digestive and Kidney Diseases
National Institutes of
Health
Bethesda, Maryland
Lynnette K. Nieman,
M.D.
Senior Investigator
Pediatric and Reproductive
Endocrinology Branch
National Institute of Child Health and Human
Development
National Institutes of Health
Bethesda,
Maryland
Karen Patrias, M.L.S.
Senior Resource
Specialist
Public Services Division
National Library of
Medicine
National Institutes of Health
Bethesda,
Maryland
Cynthia A. Rooney
Program
Analyst
Office of Medical Applications of Research
Office of the
Director
National Institutes of Health
Bethesda,
Maryland
Susan Rossi, Ph.D., M.P.H.
Deputy
Director
Office of Medical Applications of Research
Office of the
Director
National Institutes of Health
Bethesda,
Maryland
David E. Schteingart,
M.D.
Professor
Department of Internal Medicine
University
of Michigan Medical School
Ann Arbor, Michigan
Robert
Udelsman, M.D., M.S.B., M.B.A., F.A.C.S.
Lampman Professor of
Surgery and
Oncology
Chairman
Department of Surgery
Yale
University School of Medicine
New Haven,
Connecticut
Judith M. Whalen,
M.P.A.
Associate Director for Science Policy,
Analysis, and
Communication
National Institute of Child Health and Human
Development
National Institutes of Health
Bethesda,
Maryland
Conference
Sponsors
National Institute of Child Health and
Human Development
Duane Alexander,
M.D.
Director
Office of Medical Applications
of Research
Barnett S. Kramer, M.D.,
M.P.H.
Director
Conference
Cosponsors
National
Cancer Institute
Andrew C. von Eschenbach,
M.D.
Director
National Institute of Diabetes and
Digestive and Kidney Diseases
Allen M. Spiegel,
M.D.
Director |