Introduction

The adrenal gland is an endocrine organ located in the retroperitoneum. It has two main components: medulla and cortex, the former is responsible for the synthesis of catecholamines and the latter for the production of mineralocorticoids, glucocorticoids and androgens (1).

The incidence and prevalence of adrenal masses have increased between the last 15 and 20 years, probably secondary to the development of more advanced imaging techniques and their frequent use, which allow for early visualization (2-4). It is extremely important to know the etiology, frequency, location and malignancy of these diseases in order to facilitate their diagnosis and treatment.

Adrenal masses can be classified according to their origin, behavior, location, function and manner of diagnosis. In most cases they are found incidentally, so they are called incidentalomas; defined as adrenal masses larger than one centimeter and characterized by being found during imaging studies in pathologies of non-adrenal etiology (1,2,5).

It is important to emphasize that the frequency of incidentalomas increases with age. It is rare to find them in people under 30 years of age and reaches a frequency of up to 7% in adults over 50 years of age (1,3,6). In addition to this, it is related to pathologies such as obesity, diabetes mellitus and high blood pressure (7,8).

International epidemiology is available, including the 2016 European Society of Endocrinology guidelines, which establish the histopathological prevalence of incidentaloma-type adrenal masses. It is evident that the most frequent mass is the non-functioning adenoma in up to 80% of the cases, followed by functioning adenomas, the most frequent being the cortisol-secreting in up to 12%. Additionally, there is pheochromocytoma 7%, adrenocortical carcinoma 8% and metastatic lesions 5% (9-11). In turn, a cross-sectional study carried out in a hospital in Brazil found that the prevalence of adrenal masses was 2.5%, being more frequent in men than in women and with a significant increase in prevalence at advanced ages (12) and found unilaterally in most cases, which is in agreement with the Argentinean clinical guidelines for the diagnostic and therapeutic evaluation of adrenal masses (8).

In Colombia and Latin America there are few studies describing the global distribution of the etiology of adrenal masses, the histopathological characteristics and the relationship with malignancy, which limits their diagnosis and effective clinical approach. Considering the clinical impact and the honest increase in the incidence of these masses, it is considered important to describe the main histopathological and malignancy findings of adrenal masses, determining the frequency of masses according to multiple variables such as sex and different age groups. It is essential to initiate and promote the study of adrenal masses in the Colombian population in order to obtain local epidemiology, which will improve diagnosis, treatment and prognosis.

Methodology

A descriptive and retrospective study was carried out, in which pathological studies of patients of all ages with adrenal gland pathologies performed at the Mega Pathology and Cytology center in Bucaramanga between 2007 and 2019 were reviewed. Cases were identified through a search of the institution’s database using the term “adrenal gland”. After reviewing the pathologies, a total of 79 pathologies were included in the study, of which 40 showed no alterations and 39 showed pathological changes of the adrenal gland. A data collection database was prepared, which took into account the diagnosis made by the pathologist, size and weight of the gland, location of the lesion, malignancy, and whether it was of primary or metastatic origin; likewise, sociodemographic variables such as sex and age were taken into account. The data obtained from the pathologies were collected in an Excel database and then grouped by age (over or under 65) and the length of the mass (over or under 4 cm). The statistical analysis was performed on Stata 15.0. Measures of central tendency and dispersion were used for quantitative measures, and qualitative measures were described by absolute and relative frequencies. Subsequently, a bivariate analysis was performed to determine whether there are associations between malignancy and other variables.

Results

For the study 79 adrenal gland pathologies were used, collected from January 2007 to October 2019, 39 (49.3%) of these reported histopathological findings and 40 (50.7%) were reported as normal. Men accounted for 62.3% of the pathologies performed at the institution. The rest of the results were analyzed taking into account only the 39 pathologies that had histopathological findings. With respect to age, it was evident that only 19.5% were patients older than 65 years, and the mean age was 55.2 years, with a range between 4 and 82 years. No significant age-related differences were found between men (55.4 years) and women (55 years). The most frequent location was in the right gland (61.2%), and it was observed that at a global level benign lesions are more frequent (58.9%) among which are pheochromocytoma (15.3%), cortical adenoma (12.8%), myelolipoma (7.6%) and adrenal hyperplasia (5.1%). However, it should be noted that the most frequent diagnosis is metastatic lesions (28.2%). A description of the demographic characteristics is included in Table 1.

Regarding the characteristics of the masses, the average length was 8.15 cm (with a range between 2-23 cm), the average height was 6.05 cm (with a range between 0.6- 29 cm), and the average width was 3.9 cm (with a range between 0.5-10 cm). The mean lesion weight was 423.66 g (range 11-2,025 g). These characteristics are summarized in Table 2. It was also observed that in tumors of primary origin the vast majority are non-malignant (82.1%), and in those tumors of metastatic origin the primary cancer is usually clear cell renal cancer (55.5%), followed by collecting duct renal cancer (22.2%); the rest of the distribution is depicted in Figure 1. Regarding malignancy according to sex, malignant masses in women were 36.8% and in men they accounted for 45%; this distribution is shown in Figure 2.

Table 1.Demographic characteristics of the population.

Table 1
Demographic characteristics of the population.

Source: own preparation.

Lesion	Frequency (n=39)	Percentage (%)
Sex
Men	48	62.3
Women	29	37.66
Age
Under 65	29	80.5
Over 65	10	19.5
Location
Right	23	62.16
Left	14	37.84
Malignancy
No	23	58.97
Yes	16	41.03
Metastasis
No	3	21.43
Yes	11	78.57
Diagnosis
Metastasis	11	28.2
Pheochromocytoma	6	15.3
Cortical adenoma	5	12.8
Adrenocortical Carcinoma	4	10.2
Myelolipoma	3	7.6
Adrenal Hyperplasia	2	5.1
Paracoccidioidomycosis	2	5.1
Unclear diagnosis	2	2.5
Necrosis	1	2.5
Hemorrhage	1	2.5
Thrombosed Adenomatoid Tumor	1	2.5
Ganglioneuroma	1	2.5
Length
Bigger than 4 cm	70	90.9
Smaller than 4 cm	7	9.09

Table 2. General characteristics of the masses

Table 2
General characteristics of the masses

Source: own preparation.

Variable	Mean	SD
Length (cm)	8.15	5.15
Height (cm)	6.05	5.2
Width (cm)	3.9	2.43
Weight (gr)	423.66	2.43

Figure 1. Distribution of tumors of primary origin in neoplasms of metastatic origin.

Figure 1.
Distribution of tumors of primary origin in neoplasms of metastatic origin.

Source: own preparation.

When performing the bivariate analysis, associations were sought between the size of the mass (>4 centimeters) and its malignancy, without finding statistically significant relationships (p=0.339). When the association between age and malignancy was determined, it was found that patients older than 65 years had a significant association with malignancy (p=0.04). Regarding the association between malignancy and sex, no statistically significant differences were found (p=0.650).

Figure 2.Relationship between the malignancy of masses and sex.

Figure 2
Relationship between the malignancy of masses and sex
Source: own preparation.

Discussion

In this retrospective study, the characteristics of a group of 39 pathologies of the adrenal gland were evaluated, which made it possible to compare the results obtained with the international literature. These pathologies were performed in patients with suspected cancer; therefore, they are considered high-risk masses. Similarities were found in the epidemiology such as age, in international studies the incidence increases with age, presenting a peak after 50 years of age, which is consistent with the average age found in the study, which is 55.2 years. This is also found in studies conducted in Europe and Argentina (8,9). Additionally, the study also corroborates that the right adrenal gland is the most affected and that the presence of the mass is more frequent in men than in women, although the study did not present statistically significant associations, worldwide there are studies that demonstrate this (13,14).

Regarding histopathological diagnoses, it is important to highlight the significant frequency of metastatic lesions found in the study, as well as the primary origin of the tumor, which in this case was mostly of renal origin, clear cell. This is a relevant difference, since, internationally, the organ with the highest frequency of metastasis to the adrenal gland in most studies is the lung (16,17). However, melanoma has also been described as the main primary (18). It should be noted that metastases can also be of the breast, gastric, renal, colon and pancreas (17,19,20). This study presents data that reveal the distribution and behavior of adrenal gland lesions in the Colombian population, which is useful in clinical practice for differential diagnosis and therapeutic decisions.

Additionally, it was possible to evaluate the need for standardization in terms of pathology readings, since some of these samples lacked fundamental data, from the age and sex of the patient to the detailed microscopic description and relevant immunohistochemical markers of each pathology, as for example in a study of urological pathologies developed in the United States of America, where they unified criteria for the description of the samples, which would be useful in clinical practice (15). Similarly, more studies with prospective follow-up data and integrating clinical variants are required for a deeper understanding of the pathology at the level of the adrenal gland specific to this region.

Conclusion

When describing the histopathological findings and the malignancy of the adrenal glands, it was found that variants such as age, sex and laterality of adrenal gland involvement, have similar frequencies with the epidemiology described worldwide. Although no statistically significant associations were found, new studies with prospective monitoring and integrate clinical data are considered necessary to better understand the behavior of these lesions and, in turn, continue with the generation of local epidemiology that allows improving the diagnosis, treatment and prognosis of these lesions.

Disclosure of sources of financing and potential conflicts of interest

No funding required.

No conflict of interest found.

Ethical Considerations

This is a descriptive observational study, conducted under the criteria and parameters established by Resolution 8430 of 1990. The study used medical and histopathological registry data collected at an institution in Bucaramanga between 2007 and 2019 and has the endorsement of the technical committee.

References

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Notas de autor

Gustavo Adolfo Parra-Serrano. Calle 158 # 20 -55 consultorio 408 Floridablanca, Santander. Telephone: +57 3112306707. Email. gparra_serrano@hotmail.com

Información adicional

Citation. : Parra-Serrano GA, Torres-Langhammer MP, Castillo-Díaz AM, García-Ardila ME, Serrano-Gómez S. Histopathological findings and malignancy of adrenal masses in a pathology and cytology center in Bucaramanga, Santander between 2007 and 2019. MedUNAB. 2021;24(2):162- 168 doi: https://doi.org/10.29375/01237047.4054

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