A panel convened by the National Institutes of Health issued recommendations to help physicians evaluate a particular class of tumors of the adrenal glands and determine which should be removed and which should be left alone. The tumors are known as "incidentalomas" because they are discovered by chance, as a result of testing for other conditions. Before the advent of sophisticated new imaging technologies, the tumors typically went undetected.
"Incidentalomas present a dilemma for physicians because while many of these masses are harmless, a few can progress into very serious conditions and cause a variety of complications," said panel chair Melvin Grumbach, M.D., Edwin B. Shaw Professor of Pediatrics Emeritus at the University of California in San Francisco. Noting that the prevalence of incidentalomas increases with age, Dr. Grumbach added that "the appropriate management of incidentalomas promises to be an increasingly common challenge for our aging society."
The adrenals are triangular glands that sit atop each kidney. They influence or regulate the body's metabolism, salt and water balance, response to stress, and other important functions by secreting a variety of hormones. Adrenal gland masses are among the most common tumors in humans, and although most cause no symptoms or health problems, a small proportion can lead to serious diseases, and approximately one out of every 4,000 adrenal masses is cancerous.
One type of adrenal tumor, known as a pheochromocytoma, releases hormones that can cause dangerously high blood pressure. Another type, known as an adrenal cortical cancer, has a high mortality rate. The panel recommends surgically removing both types when technically possible, regardless of size.
The panel members concurred with the prevailing view that incidentalomas should be surgically removed if they are greater than 6 cm, and that those under 4 cm, in some circumstances, may be followed to see if they grow or cause any symptoms. They regarded those tumors between 4 cm and 6 cm as falling into a gray zone. Decisions on whether to remove these tumors, they said, should be based on other factors, such as whether the tumor is producing abnormal levels of hormones.
The panel noted that minimally invasive laparoscopic surgery is an appropriate option for removing smaller, non-cancerous tumors. Open surgery involving a relatively long incision is usually appropriate for removing malignant tumors or large benign tumors.
Because managing incidentalomas may involve complex decisions, the panel recommended that patients be treated by a team of physicians with expertise in endocrinology, radiology, surgery, and pathology. Each member of the team can apply their unique expertise to dealing with a particular aspect of treatment.
The panel noted important gaps in knowledge about incidentalomas and therefore recommended that more research be conducted in several areas. Panel members said that studies should be conducted on the physical and mental health outcomes and quality of life of patients whose incidentalomas have not been surgically removed. They added that potential therapies for managing these patients should first be tested in prospective clinical studies. The panel also called for studies to find markers that could be used to identify adrenocortical carcinoma.
The 12-member panel included representation from medicine, surgery, endocrinology, pathology, biostatistics, epidemiology, radiology, oncology, and the general public. The panel issued its statement at the conclusion of a two-and-a-half-day NIH State-of-the-Science Conference on Management of the Clinically Inapparent Adrenal Mass (Incidentaloma). The conference brought together experts to present the latest research on adrenal masses, and the benefits and risks involved in their management. The panel reviewed an extensive collection of literature related to incidentaloma, including a systematic review of the available evidence prepared by the New England Medical Center, an Evidence-based Practice Center under the auspices of Agency for Healthcare Research and Quality (AHRQ).
The National Institute of Child Health and Human Development (NICHD) and the NIH Office of Medical Applications of Research (OMAR) sponsored the conference. Co-sponsors included the National Cancer Institute and the National Institute of Diabetes and Digestive and Kidney Diseases.
The panel's statement is an independent report and is not a policy statement of the NIH or the Federal Government. The NIH Consensus Development Program, of which this state-of-the-science conference was a part, was established in 1977 as a mechanism to judge in an unbiased, impartial manner controversial topics in medicine and public health. NIH has conducted 115 consensus development conferences, and 21 state-of-the-science (formerly "technology assessment") conferences, addressing a wide range of issues.
The full text of the panel's statement will be available in draft form following the conference at http://consensus.nih.gov. Statements from past conferences are available at the same Web site, or by calling 1-888-NIH-CONSENSUS (1-888-644-2667).
A summary of the evidence report prepared by the New England Medical Center Evidence-based Practice Center under contract with AHRQ is available online at https://archive.ahrq.gov/clinic/tp/adrentp.htm. Copies are also available from the AHRQ Publications Clearinghouse, by calling 1-800-358-9295.
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