Surgery for adrenal tumours: is operation for the small incidental tumour appropriate?

The last 15 years have seen a change in the indications for adrenalectomy. On the one hand there has been a decline in the number of operations for metastatic breast cancer due principally to the introduction of effective medical therapy. Moreover, the introduction of trans-sphenoidal techniques has reduced the number of adrenalectomies for Cushing's Disease. In contrast the introduction of CT scanning has seen an increase in the diagnosis of incidental adrenal masses, most of which turn out to be benign non-functioning adrenal cortical adenomas. During the period 1970-86, 124 adrenalectomies were performed at Royal North Shore Hospital. From 1970 to 1976 the primary indication for adrenalectomy was metastatic breast carcinoma (84%). Over the past three years one of the primary indications has been the discovery of an asymptomatic, non-functional adrenal mass on CT scan (26%) and, of these tumours, 95% have been less than 5 cm in size. Yet no incidentally discovered adrenal mass was an adrenocortical carcinoma and no adrenocortical carcinoma was smaller than 7 cm in diameter. We recommend that an asymptomatic adrenal mass less than 6 cm in size, with no evidence of function, should be managed conservatively.