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Original Investigation | Pacific Coast Surgical Association

Differences Between Bilateral Adrenal Incidentalomas and Unilateral Lesions

Jesse D. Pasternak, MD1; Carolyn D. Seib, MD, MSc1; Natalie Seiser, MD, PhD1; J. Blake Tyrell, MD2; Chienying Liu, MD2; Robin M. Cisco, MD3; Jessica E. Gosnell, MD1; Wen T. Shen, MD, MA1; Insoo Suh, MD1; Quan-Yang Duh, MD1
[+] Author Affiliations
1Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco
2Division of Endocrinology, Department of Medicine, University of California, San Francisco
3Department of Surgery, Good Samaritan Hospital, San Jose, California
JAMA Surg. 2015;150(10):974-978. doi:10.1001/jamasurg.2015.1683.
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Importance  Adrenal incidentalomas are found in 1% to 5% of abdominal cross-sectional imaging studies. Although the workup and management of unilateral lesions are well established, limited information exists for bilateral incidentalomas.

Objective  To compare the natural history of patients having bilateral incidentalomas with those having unilateral incidentalomas.

Design, Setting, and Participants  Retrospective analysis of a prospective database of consecutive patients referred to an academic multidisciplinary adrenal conference. The setting was a tertiary care university hospital among a cohort of 500 patients with adrenal lesions between July 1, 2009, and July 1, 2014.

Main Outcomes and Measures  Prevalence, age, imaging characteristics, biochemical workup, any intervention, and final diagnosis.

Results  Twenty-three patients with bilateral incidentalomas and 112 patients with unilateral incidentalomas were identified. The mean age at diagnosis of bilateral lesions was 58.7 years. The mean lesion size was 2.4 cm on the right side and 2.8 cm on the left side. Bilateral incidentalomas were associated with a significantly higher prevalence of subclinical Cushing syndrome (21.7% [5 of 23] vs 6.2% [7 of 112]) (P = .009) and a significantly lower prevalence of pheochromocytoma (4.3% [1 of 23] vs 19.6% [22 of 112]) (P = .003) compared with unilateral lesions, while rates of hyperaldosteronism were similar in both groups (4.3% [1 of 23] vs 5.4% [6 of 112]) (P > .99). Only one patient with bilateral incidentalomas underwent unilateral resection. The mean follow-up was 4 years (range, 1.2-13.0 years). There were no occult adrenocortical carcinomas.

Conclusions and Relevance  Bilateral incidentalomas are more likely to be associated with subclinical Cushing syndrome and less likely to be pheochromocytomas. Although patients with bilateral incidentalomas undergo a workup similar to that in patients with unilateral lesions, differences in their natural history warrant a greater index of suspicion for subclinical Cushing syndrome.

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Patient With Bilateral Incidentalomas and Left-Sided Pheochromocytoma

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