Adrenal incidentaloma

　　1. Etiology

　　The frequency of non-functional adrenal cortical adenomas is the highest, accounting for 36% to 94%, while the proportion of adrenal adenomas that can secrete hormones, including cortisol-secreting adenomas, aldosterone-secreting adenomas, and pheochromocytomas, is very low. Primary adrenal cortical adenocarcinoma accounts for 0 to 25%. The proportion of adrenal metastatic tumors is very high, among which the frequency of adrenal metastatic carcinoma in patients with known malignant tumors is 32% to 73%, while in patients without known malignant tumors, adrenal metastatic carcinoma only accounts for 0 to 21%, and adrenal tumors with other causes are less common.

　　2. Pathogenesis

　　The pathogenesis of adrenal incidentalomas is not well understood at present. Some literature reports suggest that it may be related to long-term stimulation by adrenocorticotropic hormone (ACTH), or secondary changes caused by long-term hypertension leading to adrenal arteriosclerosis. Many scholars have tried to explore the etiology of incidentalomas from the perspective of molecular genetics. At present, certain molecular studies on adrenal incidentalomas associated with genetic syndromes have made certain progress.

　　Most adrenal incidentalomas are benign adenomas without hypersecretory function. Both clinical and laboratory examinations show no signs of increased hormone secretion. The disease is mainly characterized by increased secretion of cortisol, androgens, estrogens, salt-losing corticosteroids, or catecholamines, with clinical manifestations mainly caused by the increase of corresponding hormones. For example, an increase in cortisol often leads to central obesity, hypertension, abnormal glucose tolerance, and osteoporosis.

　　Most adrenal incidentalomas are benign adenomas without hypersecretory function. Both clinical and laboratory examinations show no signs of increased hormone secretion. Hyperfunctional adrenal incidentalomas mainly secrete cortisol, androgens, estrogens, salt-losing corticosteroids, or catecholamines, with clinical manifestations mainly caused by the increase of corresponding hormones. For example, an increase in cortisol often leads to central obesity, hypertension, abnormal glucose tolerance, and osteoporosis. Some adrenal incidentalomas with hypersecretory function have no obvious clinical symptoms and are called silent hyperfunctional adenomas, including cortisol-secreting adenomas, aldosterone-secreting adenomas, and pheochromocytomas. For such cortisol-secreting adenomas, some people refer to them as subclinical Cushing's syndrome.

　　1. Pay attention to the patient's medical history and accompanying symptoms: Once an adrenal incidentaloma is found in clinical practice, it is first necessary to comprehensively understand the patient's medical records, including whether there are any suspicious clinical symptoms and past medical history, especially for tumors and primary hypertension.

　　2. It is important to quickly determine the exact location of the tumor: the localization of an incidentally discovered mass is crucial, that is, it should be determined whether the mass is located in the adrenal glands. Our hospital once investigated a patient with an adrenal mass suggested by imaging and found that the mass was a corpus luteum hematoma.

　　3. For patients diagnosed with an adrenal incidentaloma, a further comprehensive evaluation of the tumor's hormone secretion function should be conducted, including adrenal cortex and medulla hormones. For patients suspected of having pheochromocytoma, pharmacological stimulation or suppression tests can be performed when necessary. In addition, the use of 131I-metaiodobenzylguanidine (MIBG) radionuclide imaging for the qualitative and locational diagnosis of pheochromocytoma is of certain value.

　　4. The discovery of an adrenal incidentaloma in patients with tumors is a relatively complex clinical issue. Autopsy findings show that 36% of such patients have adrenal metastases, and it is rare for adrenal incidentalomas to be malignant when found incidentally in patients without malignant tumors.

　　5, Imaging examinations have a certain guiding role in the judgment of the nature of adrenal incidentaloma, especially CT, including the location, size, CT value of the mass, and whether the enhancement examination can be enhanced, etc.

　　6, It should be noted that some functional adrenal cortical tumors may not cause changes in hormone levels at the time of detection. Dynamic observation should be made, or iodinated cholesterol scanning should be performed to clarify whether they have function.

　　7, It should be noted that it is not reliable to judge the benign or malignant nature of tumors solely based on their size. It should be determined by integrating clinical data.

　　It should be noted that it is not reliable to judge the benign or malignant nature of tumors solely based on their size. It should be determined by integrating clinical data.

　　Due to the uncertainty of the nature of adrenal incidentaloma, there is currently no absolute clinical, biochemical, and pathological diagnostic standard.

　　For patients diagnosed with adrenal incidentaloma, a further comprehensive evaluation should be made on whether the mass has hormone secretion function, including adrenal cortex and medulla hormones. For patients clinically suspected of having pheochromocytoma, pharmacological stimulation or suppression tests can be performed when necessary. In addition, the use of 131I-metaiodobenzylguanidine radionuclide imaging has certain value for the qualitative and locational diagnosis of pheochromocytoma.

　　Imaging examinations have a certain guiding role in the judgment of the nature of adrenal incidentaloma, especially CT, including the location, size, CT value of the mass, and whether the enhancement examination can be enhanced, etc.

　　1, Lotus leaf porridge:Fresh lotus leaf one, glutinous rice 100 grams, a little rock sugar. ① Rinse the glutinous rice clean, wash the fresh lotus leaf clean, and cut it into pieces of one inch square. ② Place the fresh lotus leaf in a pot, add an appropriate amount of water, boil with high heat, then simmer for 10 to 15 minutes, remove the residue and keep the juice. ③ Put the glutinous rice and lotus leaf juice in a pot, add rock sugar and an appropriate amount of water, boil with high heat, then simmer until the rice is soft and the porridge is done. Take twice daily, for breakfast and dinner.

　　2, Red bean porridge:Red bean 30 grams, glutinous rice 50 grams. Wash the red beans and glutinous rice, put them in a pot, and cook with water until the rice is soft and the porridge is done. Take twice daily, for breakfast and dinner. Long-term consumption can help with diuresis, invigorating the spleen, and weight loss.

　　3, Oat flakes porridge:Oat flakes 50 grams. Place the oat flakes in a pot, add water, and stir while boiling until soft. Alternatively, you can cook oat flakes with 250 milliliters of milk to make porridge. Take once daily, during breakfast. It has the effects of lowering blood fat and weight loss, suitable for the obese, patients with hyperlipidemia, coronary heart disease, and for daily health care of healthy individuals.

　　4, Poria cocos cake:Poria cocos 200 grams, flour 100 grams. Grind the Poria cocos into powder and mix it with flour and water to make a cake, then bake until done. Regular consumption has the effects of invigorating the spleen and eliminating dampness, nourishing the stomach, and is suitable for long-term use.

　　5. Fresh Mixed Three Skins:Watermelon rind 200 grams, cucumber skin 200 grams, winter melon skin 200 grams. Peel the wax-like outer skin of the watermelon rind, peel the downy outer skin of the winter melon rind, and mix with the cucumber skin. Boil in boiling water, cool, cut into strips, add a little salt and monosodium glutamate, and serve. It can be eaten regularly, with the effects of clearing heat and dampness, and weight loss.

　　I. Treatment

　　1. Treatment Principles of Adrenal Incidentalomas

　　(1) Those with hormone secretion function should be surgically removed.

　　(2) Tumors with a diameter ≥ 4 cm should be surgically removed.

　　(3) If it is confirmed to be a metastatic tumor, it only affects one adrenal gland, and no metastatic tumor is found in the other adrenal gland and other parts, the adrenal metastatic tumor can also be surgically removed.

　　(4) Diameter

　　(5) There is no need for surgery for adrenal cysts, hematomas, adrenal tuberculosis, congenital adrenal cortical hyperplasia, and other conditions. The classic surgical method is open surgery via a lumbar incision. There are reports of laparoscopic surgery in China and abroad. Laparoscopic surgery can be performed through the peritoneum or retroperitoneally. This endoscopic surgery has less trauma, less bleeding, and faster recovery, but requires higher technical skills. It is better to choose open surgery for larger tumors or those suspected to be malignant tumors.

　　2. Currently, the management of adrenal incidentalomas abroad tends to adopt proactive measures. Surgical resection is performed for tumors with hormone secretion function, fine needle aspiration biopsy is performed for tumors without hormone secretion function, and surgical resection or treatment of the primary cancer is performed if it is malignant or metastatic cancer; surgical resection is also performed for tumors larger than 5 cm and patients with suspected cancer in imaging, while follow-up observation and regular re-examination are performed for tumors smaller than 5 cm.

　　3. It is necessary to monitor the dynamic changes of imaging and hormone levels in patients undergoing conservative treatment, generally re-examine CT every 6 months. If there is a tendency for the tumor to increase, it should be surgically removed. For adrenal cortical cancer that cannot be surgically removed, O, P'-DDD and other chemotherapeutic drugs can be used.

　　II. Prognosis

　　The management of adrenal incidentalomas is a very challenging problem for clinical physicians. Proper management is conducive to improving the quality of life of patients and improving the prognosis.