DIAGNOSIS AND MANAGEMENT OF ADRENAL INCIDENTALOMAS:

Spontaneous rupture of a benign giant adrenal adenoma

We report on a 50-year-old patient with a giant benign adenoma of the adrenal cortex, which ruptured spontaneously, leading to life-threatening retroperitoneal hemorrhage. Following emergency adrenalectomy with sparing of the ipsilateral kidney, an adenoma of the adrenal cortex with a diameter of 18 cm and a weight of 1400 g was found. A detailed literature search showed this to be the largest benign tumor of the adrenal cortex described so far. We discuss the diagnosis and treatment of this unusual tumor.

The utility of screening renal ultrasonography: identifying renal cell carcinoma in an elderly asymptomatic population

OBJECTIVE

To evaluate the efficacy and utility of screening renal ultrasonography (RUS) in older patients with a high prevalence of risk factors for renal cell carcinoma (RCC), as with the widespread use of advanced imaging techniques the identification of incidental RCC has increased, and although previous studies in low-risk groups reported little use for screening RUS, its utility in high-risk groups is unknown.

PATIENTS AND METHODS

From 1993 to 1997, screening RUS was completed for 6678 consecutive patients in conjunction with the Aneurysm Detection and Management study. Patient demographics, medical and social history were recorded for each patient. Screening RUS was completed by one ultrasonographer using a 3.5-MHz sector scanner. A urologist verified any abnormalities identified by RUS during consultation. Additional imaging tests were obtained selectively and intervention was recommended based on the results of the genitourinary evaluation.

RESULTS

From the screened population of 6678 patients, 817 (12.3%) renal anomalies were found, including a solid renal mass in 22 (0.32%), simple renal cysts in 627 (9.4%), hydronephrosis in 21 (0.31%), renal calculi in 121 (1.8%), or other abnormalities in 24 (0.36%). Treatment was completed for 15 renal cancers; 13 were organ-confined on pathological review. At a mean follow-up of >55 months, 12 of the 15 patients with RCC survived.

CONCLUSIONS

In this older cohort, retroperitoneal RUS was an effective tool for case-finding by detecting significant findings in an asymptomatic population. The prevalence of solid renal masses (0.32%) was higher than reported with other screening protocols. Although probably not the best method for generalized primary screening, the use of RUS may still be beneficial for 'secondary' screening in a more selected patient population.

Cascade effects of medical technology

Cascade effect refers to a process that proceeds in stepwise fashion from an initiating event to a seemingly inevitable conclusion. With regard to medical technology, the term refers to a chain of events initiated by an unnecessary test, an unexpected result, or patient or physician anxiety, which results in ill-advised tests or treatments that may cause avoidable adverse effects and/or morbidity. Examples include discovery of endocrine incidentalomas on head and body scans; irrelevant abnormalities on spinal imaging; tampering with random fluctuations in clinical measures; and unwanted aggressive care at the end of life. Common triggers include failing to understand the likelihood of false-positive results; errors in data interpretation; overestimating benefits or underestimating risks; and low tolerance of ambiguity. Excess capacity and perverse financial incentives may contribute to cascade effects as well. Preventing cascade effects may require better education of physicians and patients; research on the natural history of mild diagnostic abnormalities; achieving optimal capacity in health care systems; and awareness that more is not the same as better.