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jye224
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+    "text": "n engl j med 384;16 nejm.org April 22, 2021 1544 The new england journal of medicine vertebral fractures, and death were higher among patients with mild autonomous cortisol excess than among those with nonfunctioning adrenal incidentaloma at baseline. These conditions were more likely to develop in patients with nonfunc - tioning tumors and to worsen during follow-up in those with mild autonomous cortisol excess. In retrospective studies involving patients with adrenal incidentaloma, the risks of cardiovascu - lar disease and death from any cause were higher Figure 1. Treatment Algorithm for Patients with an Adrenal Incidentaloma. Treatment should be individualized according to the patient’s coexisting conditions, preferences, and the clinical expertise available. Hormonal evaluations and imaging should be performed in parallel. Adrenalectomy is not warranted for all patients; the care plan should be discussed by a multidisciplinary team considering the patient’s coexisting conditions, response to medical treatment, and risk associ - ated with adrenalectomy. Most adrenalectomies can be performed with a minimally invasive approach, but for a tumor that arouses sus - picion for cancer, an open adrenalectomy is usually recommended. Adrenalectomy may be considered in patients with mild autonomous cortisol excess, depending on coexisting conditions and other factors, and it is generally recommended in patients who have cortisol levels higher than 5.0 μg per deciliter (>138 nmol per liter) after a 1-mg dexamethasone suppression test. Follow-up imaging at 6 months may be considered in patients younger than 40 years of age because adrenal incidentalomas are not common in this age group. 18 F-FDG PET-CT denotes 18 F-fluorodeoxyglucose positron-emission tomography–computed tomography, MRI magnetic resonance imaging, and SUV max maximum standardized uptake value. Comprehensive history taking and physical examination to assess for features of hormonal hypersecretion Imaging Tumor size and attenuation on unenhanced CT Additional imaging (enhanced CT, MRI, 18 F-FDG PET-CT) in some patients Hormonal evaluation Overnight 1-mg",
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+    "text": "n engl j med 384;16 nejm.org April 22, 2021 1545 Clinical Pr actice Table 1.",
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+    "text": "Biochemical Evaluation in Patients with Adrenal Incidentaloma.* Clinical Diagnosis Screening Test Additional or Confirmatory Test Common Causes of False Positive or False Negative Findings Special Considerations Mild autonomous cortisol excess Overnight dexamethasone (1 mg) suppression test; an abnormal result is a serum cortisol level >1.8 μg per deciliter (50 nmol per liter) with confirmation of serum dexamethasone level (to ensure adherence); a higher serum cor- tisol cutoff level (e.g., 3–5 μg per deciliter) can be used to reduce the risk of a false positive Measurement of levels of morn- ing serum corticotropin and cortisol levels, 24-hr urinary cortisol, late-night salivary cortisol, midnight serum cortisol, and DHEAS False positives may occur in patients receiving medica- tions that accelerate hepatic metabolism of dexamethasone and with nonadherence to dexa- methasone Consider a pseudo-Cushing’s syndrome state due to diabe- tes, obesity, pregnancy, alco- holism, psychiatric disorders, or stress Pheochromocytoma† Measurement of levels of plasma-free metanephrines or 24-hr urinary fractionated metanephrines Not applicable False positives may occur in pa- tients with stress and illness warranting hospitalization; with medications that increase levels of endogenous catecholamines; with excessive caffeine; and with recreational drug use (e.g., amphetamines) Biochemical testing may not be necessary if the adrenal mass has CT attenuation of ≤10 Hounsfield units; genetic testing for inherited syndrome should be performed, regard- less of family history, if screen- ing test is positive Primary hyperaldosteronism Measurement of mid-morning plasma aldosterone concentration and plasma renin activity; a ratio of plasma aldosterone concentration to plasma renin activity >20 con- firms diagnosis If the ratio of plasma aldoste- rone concentration to plasma renin activity <20, confirma- tory testing includes 24-hr urinary aldosterone excretion test with patient",
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+    "text": "receiving high-sodium diet, aldoste- rone suppression test, and testing with saline infusion while patient is sitting False positives can be caused by beta-blockers, methyldopa, clonidine, nonsteroidal anti- inflammatory drugs, and oral contraceptives and estrogen; false negatives can be caused by angiotensin-converting–en- zyme inhibitors, angiotensin II receptor blockers, and potas- sium-sparing diuretics (e.g., spironolactone, eplerenone, and amiloride) If patient is a candidate for adre- nalectomy and >35 yr of age, adrenal venous sampling is recommended to confirm later- alization of aldosterone to the side of the adrenal mass (some patients have bilateral aldo- sterone hypersecretion, or the contralateral adrenal gland may be the source of excess aldoste- rone and the tumor detected is nonfunctioning) * Reference ranges for specific assays based on age and sex should be used and may differ from the ranges shown here.",
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+    "text": "DHEAS denotes dehydroepiandrosterone sulfate. † Additional laboratory tests may include measurement of plasma chromogranin A levels, 24-hour urinary 3-methoxytyramine levels, or both, especially when a malignant pheochromocy- toma is suspected because of the presence of potential metastatic disease sites or local invasion.",
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+    "text": "The New England Journal of Medicine is produced by NEJM Group, a division of the Massachusetts Medical Society. Downloaded from nejm.org at Indiana University School of Medicine on December 29, 2025.",
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+    "text": "n engl j med 384;16 nejm.org April 22, 2021 1546 The new england journal of medicine among those with mild autonomous cortisol ex- cess (defined as a morning cortisol level >1.8 μg per deciliter after a 1-mg dexamethasone sup- pression test) than among those with nonfunc- tioning tumors, and the risks were greater with higher morning cortisol levels (>5.0 μg per deci- liter vs.",
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+    "text": ">1.8 to 5.0 μg per deciliter). 16-20 The care of patients with mild autonomous cortisol excess may involve active surveillance or adrenalectomy. Data comparing outcomes with the use of these strategies are limited.",
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+    "text": "One small randomized, controlled trial comparing adrenal- ectomy (in 23 patients) with surveillance (in 22 patients) for mild autonomous cortisol excess showed that after surgery, there was normaliza- tion or improvement in the condition of patients with type 2 diabetes mellitus (in 5 of 8 patients [62%]), hypertension (in 12 of 18 patients [67%]), and hyperlipidemia (in 3 of 8 patients [38%]), as compared with no normalization or no improve- ment in these conditions in patients in the sur- veillance group.",
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+    "text": "21 Three of 6 patients in the surgi- cal group were reported to have postoperative decreases in obesity, whereas no changes in bone measures were seen in 5 patients who had osteoporosis; comparative data were lacking for the control group.",
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+    "text": "In retrospective cohort stud- ies, patients who underwent adrenalectomy had lower glucose levels and less hypertension and dyslipidemia than those who were cared for with surveillance. 22,23 Pheochromocytoma Although pheochromocytoma may manifest as an adrenal incidentaloma, on careful history and physical examination, many patients are found to have classic symptoms or signs of pheochro- mocytoma, a family history of these masses, or both.",
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+    "text": "A total of 1.5 to 14.0% of adrenal inciden- talomas are found to be pheochromocytomas. 9 Imaging features on CT may be helpful in sug- gesting pheochromocytoma (Fig.",
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+    "text": "These fea- tures include an attenuation of more than 10 Hounsfield units on unenhanced CT, the pres- ence of areas of increased vascularity and necro- sis on enhanced CT, and delayed washout of contrast medium.",
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+    "text": "On magnetic resonance imag- ing (MRI), pheochromocytoma may have high T2-weighted intensity (Fig. Guidelines recommend that all patients with adrenal incidentaloma undergo biochemical screening for pheochromocytoma because these tumors may be clinically silent.",
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+    "text": "9,24-27 However, some investigators have suggested that biochem- ical screening for pheochromocytoma is not necessary in a patient who has a lipid-rich tumor with a CT attenuation of 10 Hounsfield units or less, because these tumors are rarely pheochro- mocytomas (<0.5% of cases).",
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+    "text": "28,29 The most accu- rate screening tests to detect pheochromocytoma are measurement of the levels of plasma-free metanephrines (sensitivity, 89 to 100%, and specificity, 79 to 98%) or 24-hour urinary frac- tionated metanephrine level (sensitivity, 86 to 97%, and specificity, 69 to 95%).",
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+    "text": "30 To minimize the risk of perioperative illness and death, pa- tients with a diagnosis of pheochromocytoma should undergo adrenalectomy only after suffi- cient alpha-blockade followed by beta-blockade, if necessary, is achieved (Fig.",
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+    "text": "Figure 2. Imaging Features of Adrenal Masses. Panel A (left image) shows an unenhanced CT scan that reveals a left adrenal mass (arrow) with high attenuation (>10 Hounsfield units). Panel A (right image) shows a left adrenal mass, presumed to be an adenoma (arrow), with low attenuation (≤10 Hounsfield units). Panel B shows a large heterogeneous left adrenal mass (arrows) with irregular borders and necrotic areas on enhanced CT.",
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+    "text": "The pathological find- ings were consistent with adrenocortical carcinoma. Panel C (left image) shows MRI of a right pheochromocytoma (arrow) that was hyper- intense on a T2-weighted image.",
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+    "text": "Panel C (right image) shows a right adrenocortical carcinoma (arrows) with local invasion. A B C The New England Journal of Medicine is produced by NEJM Group, a division of the Massachusetts Medical Society.",
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+    "text": "Downloaded from nejm.org at Indiana University School of Medicine on December 29, 2025. n engl j med 384;16 nejm.org April 22, 2021 1547 Clinical Pr actice Primary Hyperaldosteronism Among patients with adrenal incidentaloma, pri - mary hyperaldosteronism is less common than mild autonomous cortisol excess and pheochro - mocytoma; primary hyperaldosteronism accounts for 1.6 to 3.3% of incidentalomas.",
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+    "text": "9 However, any patient with adrenal incidentaloma and hyper - tension or hypokalemia should be screened for primary hyperaldosteronism with measurement of the mid-morning plasma aldosterone concen - tration and plasma renin activity; patients should not be taking medications that could cause false positive or false negative results (Table 1).",
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+    "text": "31 Although studies have used various cutoff values to identify hyperaldosteronism, a ratio of the plasma aldosterone concentration to plasma renin activity that is higher than 20 is consid - ered to be a reliable indicator of the diagnosis; if the ratio is high but below this level, confir - matory testing is recommended (Table 1).",
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+    "text": "31,32 Once the diagnosis is established, patient-specific factors guide decisions regarding medical versus surgical therapy (Fig. Additional Hormonal Secretion It is extremely rare for patients with adrenal in - cidentaloma to have sex hormone (estrogen or testosterone)–secreting tumors without appre - ciable clinical manifestations.",
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+    "text": "In women, excess testosterone is associated with features of viril - ization such as facial hair growth, acne, and deepening of the voice, and excess estrogen is associated with irregular uterine bleeding and breast tenderness.",
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+    "text": "In men, estrogen-secreting tu - mors can cause gynecomastia, testicular atrophy, and decreased libido. Assessment for Cancer An adrenal incidentaloma may be a primary malignant tumor that has arisen from the adrenal cortex (adrenocortical carcinoma) or medulla (pheochromocytoma), or, rarely, a metastatic tu - mor.",
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+    "text": "Adrenocortical carcinoma, which accounts for 1.2 to 11.0% of adrenal incidentalomas, 9 de - pending on the study population, may secrete excess hormones or be nonfunctioning.",
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+    "text": "Up to 21% of adrenal incidentalomas in patients with a history of or known current primary cancer indicate adrenal metastasis. 9,33 Cancers that are most likely to spread to the adrenal glands are lung cancer, gastrointestinal cancer, melanoma, and renal-cell carcinoma.",
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+    "text": "33 Tumor size and imag - ing features are key to determining the likeli - hood of cancer and guiding treatment (Table 2 and Figs. 1 and 2). Tumor Size Although many studies of the risks of cancer associated with tumor size are limited by small samples, retrospective design, and selection bias, data consistently support associations between tumors that are larger than 4 cm in greatest diameter and an increased risk of cancer among patients with a unilateral adrenal mass (Ta - ble 2).",
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+    "text": "35,36 The risk of adrenocortical carcinoma is less than 2% among patients with tumors smaller than 4 cm in diameter, 6% among those with tumors between 4 cm and 6 cm in diameter, and 25% or higher among those with tumors that are at least 6 cm in diameter.",
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+    "text": "35 However, patient age is an important factor in estimating cancer risk; because benign incidentalomas are uncommon in patients younger than 40 years of age, cancer is a concern even with smaller tu - mors (<4 cm in diameter) in this age group.",
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+    "text": "It is important to measure the adrenal tumor in three dimensions (the greatest length, width, and height) because two-dimensional (cross-sectional) measurements often underestimate size. Imaging Features Suggestive of Cancer On CT imaging, features other than tumor size can help to differentiate benign from malignant adrenal incidentalomas, although the ultimate diagnosis is based on histologic findings or clinical follow-up.",
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+    "text": "34,37 Irregular tumor margins, heterogeneity, necrosis, vascularity, and calcifi - cation are features that arouse suspicion for can - cer (Table 2). An attenuation of 10 Hounsfield units or less on unenhanced CT is consistent with a benign lesion; in a series of 1161 adrenal tumors with an attenuation of 10 Hounsfield units or less, no malignant tumors were ob - served.",
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+    "text": "38 In patients who have incidentalomas with an attenuation of more than 10 Hounsfield units, follow-up imaging may include contrast-enhanced CT (to measure the percentage of washout of contrast medium at various times), MRI with chemical-shift analysis, or positron-emission to - mography (PET)–CT with 18 F-f luorodeoxyglucose ( 18 F-FDG).",
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+    "text": "On contrast-enhanced CT, adenomas commonly enhance more rapidly and have faster washout of intravenous contrast medium when The New England Journal of Medicine is produced by NEJM Group, a division of the Massachusetts Medical Society.",
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+    "text": "Downloaded from nejm.org at Indiana University School of Medicine on December 29, 2025. n engl j med 384;16 nejm.org April 22, 2021 1548 The new england journal of medicine Table 2.",
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+    "text": "Imaging Features of Adrenal Incidentaloma.* Feature Adrenocortical Adenoma Pheochromocytoma† Adrenocortical Carcinoma Metastasis Size Usually small, <4 cm in diameter Variable, frequently large Large, usually >6 cm in diameter Variable Margins and shape Smooth margins, round or oval Smooth margins, round or oval Irregular margins and shape Irregular margins and shape Consistency Homogeneous Most are heterogeneous (but small ones can be homogeneous) Heterogeneous Heterogeneous Laterality Usually unilateral but can be bilateral (in 15% of cases) Usually unilateral but can be bilateral Usually unilateral Usually unilateral but can be bilateral Unenhanced CT attenuation — Hounsfield units ≤10 >10 >10 >10 Contrast-enhanced CT features Attenuation Low High High High Vascularity Low High High Usually high Washout‡ Fast Slow Slow Slow MRI features Isointense in relation to liver on T2- weighted image; signal drop on chemical-shift imaging Hyperintense in relation to liver on T2-weighted image; no signal drop on chemical-shift imaging Markedly hyperintense in relation to liver on T2-weighted image; no signal drop on chemical- shift imaging Hyperintense in relation to liver on T2-weighted image; no signal drop on chemical- shift imaging 18 F-FDG PET-CT features Avidity Not avid Avid Avid Avid SUV max <5 Usually ≥5§ Usually ≥5§ Usually ≥5§ Adrenal-to-spleen or adrenal-to liver signal-intensity ratio¶ <1.0 ≥1.0–1.5 ≥1.0–1.5 >≥1.0–1.5 but may vary based on primary origin of cancer Necrosis, calcification, and hemorrhage Uncommon Hemorrhagic, necrotic, and cystic areas more common in larger tumors Necrosis, calcification, and hem- orrhage are common Hemorrhagic, necrotic, and cystic areas more common in larger tumors * Myelolipoma and adrenal cysts have typical imaging features on CT",
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+    "text": "and or magnetic resonance imaging (MRI). 18 F-FDG PET-CT denotes positron-emission tomography (PET)–CT with 18 F-fluorodeoxyglucose, and SUV max maximum standardized uptake value.",
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+    "text": "† The presence of metastasis is the only way to determine whether a pheochromocytoma is malignant. Metastatic pheochromocytoma is associated with larger tumors (>6 cm in diam- eter) and irregular margins.",
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+    "text": "‡ Washout of contrast medium has been measured at various times (60 to 90 seconds [early] and 10 to 15 minutes [late]) with both relative and absolute values. Absolute washout is defined as the attenuation value in Hounsfield units on early enhanced CT minus Hounsfield units on delayed CT, divided by Hounsfield units on early enhanced CT minus Hounsfield units on unenhanced CT, multiplied by 100%, and relative washout is defined as Hounsfield units on early enhanced CT minus Hounsfield units on delayed CT, divided by Hounsfield units on enhanced CT, multiplied by 100%.",
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+    "text": "Absolute washout values greater than 60% and relative washout values greater than 40% suggest an adenoma. 34 § Some studies have used an SUV max cutoff value that is less than 5.",
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+    "text": "¶ The adrenal-to-spleen signal-intensity ratio (i.e., the signal intensity of the adrenal mass divided by the signal intensity of the spleen) and the adrenal-to-liver signal-intensity ratio (i.e., the signal intensity of the adrenal mass divided by the signal intensity of the liver) are based on meta-analyses and prospective studies.",
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+    "text": "34 Some studies have used adrenal-to-spleen or adrenal-to-liver SUV max ratios. The New England Journal of Medicine is produced by NEJM Group, a division of the Massachusetts Medical Society.",
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+    "text": "Downloaded from nejm.org at Indiana University School of Medicine on December 29, 2025. n engl j med 384;16 nejm.org April 22, 2021 1549 Clinical Pr actice measured at 60 to 90 seconds (early enhancement) and at 10 to 15 minutes (delayed enhancement) after the administration of contrast medium than adrenocortical carcinomas.",
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+    "text": "Absolute washout is defined as the attenuation value in Hounsfield units on early enhanced CT minus Hounsfield units on delayed CT, divided by Hounsfield units on early enhanced CT minus Hounsfield units on unenhanced CT, multiplied by 100%, and relative washout is defined as Hounsfield units on early enhanced CT minus Hounsfield units on delayed CT, divided by Hounsfield units on enhanced CT, multiplied by 100%.",
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+    "text": "Absolute washout of more than 60% of the contrast medium and relative washout of more than 40% of the contrast medi- um are suggestive of an adenoma, but the sensi - tivities and specificities of these cutoff values vary across studies owing to variations in tech - nique and timing of measurement of washout.",
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+    "text": "34 MRI with chemical-shift analysis, which as - sesses qualitative loss of signal intensity, quan - titative loss of signal intensity, or both between in-phase and out-of-phase imaging, is especially useful to avoid radiation exposure in pregnant women and children and in patients who are allergic to iodinated contrast medium.",
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+    "text": "In a sys - tematic review, qualitative (visual) analysis of the adrenal signal-intensity index and quantitative assessment of the adrenal-to-spleen ratio (i.e., the signal intensity of the adrenal mass divided by the signal intensity of the spleen) both had high accuracy (pooled sensitivities and specifici - ties, 94% and 95%, respectively) for identifying adenomas.",
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+    "text": "37 In a meta-analysis of 29 studies, findings on 18 F-FDG PET-CT adrenal imaging that determined the maximum standardized uptake value and the ratio of the maximum standard - ized uptake value in the adrenal tumor as com - pared with the spleen or liver effectively distin - guished benign from malignant tumors (pooled sensitivities, 85 to 91%, and pooled specificities, 89 to 91%).",
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+    "text": "39 Adrenal Biopsy Biopsy of an adrenal incidentaloma is rarely indi - cated, 33 since it has low accuracy for distinguish - ing benign from malignant adrenal tumors and may lead to tumor seeding if the mass is an adrenocortical carcinoma.",
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+    "text": "An exception is the rare case in which adrenal metastasis is strongly sus - pected and biopsy confirmation would change the treatment plan; in such cases, biochemical testing to exclude a pheochromocytoma should be performed first to avoid precipitation of a hyperadrenergic crisis by biopsy.",
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+    "text": "Assessment of Bilateral Adrenal Masses Approximately 15% of patients with adrenal in - cidentaloma have bilateral adrenal masses. 40 The differential diagnosis of bilateral adrenal masses includes primary bilateral macronodular adrenal hyperplasia and adenomas, bilateral pheochromo - cytomas, congenital adrenal hyperplasia, bilateral adrenal hyperplasia due to Cushing’s disease or ectopic corticotropin secretion, metastases or pri - mary cancers, myelolipomas, infections, hemor - rhage, and partial glucocorticoid resistance.",
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+    "text": "In addition to the hormonal assessments described for a solitary adrenal incidentaloma, measure - ment of the serum 17-hydroxyprogesterone level is indicated to rule out congenital adrenal hyper - plasia.",
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+    "text": "41 In addition, if bilateral adrenal masses appear on imaging to be hemorrhagic or infil - trative, the patient should undergo testing for adrenal insufficiency. In patients with bilateral adrenal masses, the imaging characteristics of each adrenal lesion should be evaluated indepen - dently in determining appropriate management.",
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+    "text": "Follow-up in Patients with Nonfunctioning Lesions Nonfunctioning adrenal incidentalomas with fea - tures that are consistent with an adenoma on imaging (≤10 Hounsfield units) and that are smaller than 4 cm in greatest diameter usually have a benign course and do not warrant addi - tional follow-up imaging.",
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+    "text": "In a meta-analysis in - volving 4121 patients with nonfunctioning adre - nal lesions, the mean tumor growth was 2 mm over a median of 52.8 months of follow-up; only 2.5% of the patients had tumor enlargement of 1 cm or more, and adrenocortical carcinoma did not develop in any of the patients.",
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+    "text": "15 Follow-up with imaging and biochemical tests is recommended for patients with nonfunction - ing tumors with indeterminate features on im - aging. However, the most appropriate time inter - vals for reassessment are unclear, and they vary among different guidelines.",
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+  {
+    "text": "Areas of Uncertainty The diagnostic criteria for and management of mild autonomous cortisol excess are uncertain. The New England Journal of Medicine is produced by NEJM Group, a division of the Massachusetts Medical Society.",
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+    "text": "n engl j med 384;16 nejm.org April 22, 2021 1550 The new england journal of medicine More data are needed to better identify patients with metabolic abnormalities that are most likely to be related to the adrenal lesion and to reverse the metabolic abnormalities with surgery. Stud - ies are lacking to compare outcomes of various follow-up strategies for patients who have a non - functioning adrenal incidentaloma with inter - mediate imaging features. Guidelines Guidelines for the management of adrenal inci - dentaloma have been published by several pro - fessional societies. 9,24-27 All recommend biochemi - cal testing to rule out functional tumors (mild autonomous cortisol excess, pheochromocytoma, and primary hyperaldosteronism) at the initial evaluation. However, guidelines vary in the cri - teria recommended to diagnose mild autono - mous cortisol excess and the need for additional biochemical testing, the other imaging recom - mended when further evaluation is needed, and the criteria for adrenal tumor size used to rec - ommend adrenalectomy for nonfunctioning tu - mors, although recent guidelines support a cut - off value of 4 cm in diameter. Guidelines also differ with respect to follow-up recommenda - tions for nonfunctioning tumors that are smaller than 4 cm in diameter with attenuation of 10 Hounsfield units or less, but the most recent guidelines recommend that no follow-up imag - ing is needed unless clinical manifestations de - velop. 9 The present recommendations are gener - ally concordant with most of these guidelines. 9 Conclusions and Recommendations The patient described in the vignette has an ad - renal incidentaloma that is 3.2 cm in diameter with an attenuation of less than 10 Hounsfield units on unenhanced CT. A comprehensive his - tory and physical examination should be per - formed to look for evidence of excess adrenal hormonal secretion. Biochemical testing is war - ranted to rule out mild autonomous cortisol ex - cess, pheochromocytoma, and — given that the patient has hypertension — primary hyperaldo - steronism. If the patient",
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+    "text": "has pheochromocytoma, she should undergo a unilateral minimally invasive adrenalectomy (open if imaging features arouse suspicion for cancer) after pretreatment. If bio - chemical testing shows mild autonomous corti - sol excess or primary hyperaldosteronism, im - aging features arouse suspicion for cancer, or both, involvement of a multidisciplinary team including an endocrinologist, a radiologist, and an endocrine surgeon is appropriate to guide management. If mild autonomous cortisol ex - cess is present in this patient who has obesity and hypertension, adrenalectomy might result in improvement in her blood pressure and weight, although data are limited. If biochemi - cal testing indicates that the tumor is nonfunc - tional, given that it is smaller than 4 cm in di - ameter and has an attenuation of less than 10 Hounsfield units on unenhanced CT, I would recommend no further testing, except in the un - likely case that clinical features of hormonal ex - cess develop. No potential conf lict of interest relevant to this article was reported. Disclosure forms provided by the author are available with the full text of this article at NEJM.org. I thank Ms. Rebecca Gaw (Stanford University) for her help with drafting and organizing an earlier version of the manu - script, Dr. Ryan L. Brunsing (Department of Radiology, Stanford University) for the analysis of the imaging features, and Drs. André Lacroix (Centre Hospitalier de l’Université de Montréal) and Quan-yang Duh (University of California, San Francisco) for their helpful comments on the initial draft of the manuscript. References 1. Young WF Jr. The incidentally discov - ered adrenal mass. N Engl J Med 2007; 356: 601-10. 2. Muth A, Hammarstedt L, Hellström M, Sigurjónsdóttir HÁ, Almqvist E, Wäng - berg B. Cohort study of patients with ad - renal lesions discovered incidentally. Br J Surg 2011; 98: 1383-91.",
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+    "text": "n engl j med 384;16 nejm.org April 22, 2021 1551 Clinical Pr actice with the European Network for the Study of Adrenal Tumors. Eur J Endocrinol 2016; 175: G1-G34.",
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+    "text": "Cardiovascular events and mortality in patients with adrenal incidentalomas that are either non-secreting or associated with intermediate phenotype or subclini - cal Cushing’s syndrome: a 15-year retro - spective study. Lancet Diabetes Endocri - nol 2014; 2: 396-405.",
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