The adrenal glands are easilyoverlooked. Distinguishedanatomists from centuries agosuch as Aelius Galen, Leonardo daVinci, and Andreas Vesalius omittedthe adrenals in their early descriptionsof the retroperitoneum. The criticalimportance of the adrenal gland wasrecognized in the mid-19th centuryby Thomas Addison and CharlesÉdouardBrown-Séquard, who demonstratedthat bilateral adrenalectomyuniformly resulted in death. This ledto the discovery and isolation of adrenaline, cortisol and subsequentlyaldosterone in the 1930’s, 1940’s, and 1950’s, and a 1950 Nobel Prizefor Edward C. Kendall, Philip S. Hench, and Tadeus Reichstein.1

Today, specialists in the retroperitoneum too easily overlook the adrenalglands, perhaps because they are rarely the focal point of pathology.Oncologically, primary adrenal cortical carcinomas are rare (1 per millionor about 200 cases/year in the U.S.). While metastatic disease tothe adrenal gland is common, it only occasionally occurs in isolation,rendering it more suitable for systemic therapies.

Incidental adrenal abnormalities (“incidentalomas”) are quite common,however. Adrenal adenomas are found in up to 7% of adults aged 70years or more, with similar trends observed in historical autopsy series.While the overwhelming majority of adrenal incidentalomas display noevidence of metabolic activity, a small percentage of them can exhibitmetabolic activity representing “surgical” lesions.

When followed serially, about 9% of incidental adrenal lesions increasein size and 2% become metabolically active during follow-up, promptingrecommendations from a National Institute of Health panel for annualmetabolic hormonal screening for the first 3 to 4 years following diagnosis,especially for masses 3 cm or larger. Moreover, current guidelinesadvise surgical resection of adrenal masses regardless of radiographiccharacteristics if the lesion is 4 cm or larger, although the exact cutoffremains debated. 

In an era of routine imaging, incidental or bystander lesions offerinsights not only into biology and epidemiology of adrenal abnormalities,but, perhaps more importantly, into our interpretation of screening,disease, lead time bias, and the effectiveness of our therapeutic interventions.While over diagnosis may lead to over management, underdiagnosis sometimes represents a missed opportunity. In the case ofthe adrenal glands, the former may predominate. For the discriminatingurologist, however, the art of medicine is to discern the difference. 

Robert G. Uzzo, MD, FACSG.Willing “Wing” Pepper Chair in Cancer ResearchProfessor and Chairman, Department of SurgeryFox Chase Cancer CenterTemple University School of Medicine, Philadelphia 

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Reference

1. Kutikov A, Crispen PL, Uzzo RG: Chapter 65: Pathophysiology, Evaluation, and Medical Managementof Adrenal Disorders. In: Campbell-Walsh Urology. Edition 11. (Wein AJ, et al, eds). Elsevier, Philadelphia,PA, 2015