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James A. Lee, MD; Rasa Zarnegar, MD; Wen T. Shen, MD; Electron Kebebew, MD; Orlo H. Clark, MD; Quan-Yang Duh, MD

Arch Surg. 2007;142:870-874.

Objective  To assess the risk of pheochromocytoma in patients with borderline-elevated urine or plasma metanephrine levels.

Design  Retrospective review.

Setting  University tertiary care center.

Patients  Forty-two consecutive patients with adrenal incidentalomas (defined as adrenal tumors identified during routine imaging for another condition) who were treated at the UCSF (University of California, San Francisco) Medical Center between January 1, 1995, and July 31, 2005. Patients with genetic syndromes were excluded.

Intervention  Laparoscopic adrenalectomy for adrenal incidentaloma based on size criteria and preoperative hormonal test results.

Main Outcomes Measures  Urine or plasma metanephrine and catecholamine levels, tumor size, and presence of pheochromocytoma.

Results  Of 42 patients, 14 (33%) had a pheochromocytoma (11 of whom had clear-cut elevations in urine or plasma metanephrine levels defined as greater than 2 times the upper limit of normal) and 28 did not. Ten of the 42 patients (24%) had borderline elevations in urine or plasma metanephrine levels (defined as 1-2 times the upper limit of normal), 3 of whom had a pheochromocytoma (30%). Of patients with borderline elevations, mean ± SD tumor size was 5.4 ± 3.1 and 4.8 ± 1.9 cm for patients with and without pheochromocytoma, respectively (P = .37). In these 10 patients, no clinical factors (age, sex, hypertension, presence of symptoms, number of antihypertensive medications, preoperative hemodynamics, or size of tumor on computed tomographic scan) allowed differentiation between those with and without pheochromocytoma.

Conclusions  Thirty percent of patients with adrenal incidentaloma and borderline-elevated urine or plasma metanephrine levels had a pheochromocytoma. Clinical factors cannot distinguish between those with and without pheochromocytoma. In this group of patients, we advocate either routine alpha-blockade preoperatively or further diagnostic tests to better characterize the tumor.

Author Affiliations: Division of Gastrointestinal/Endocrine Surgery, Columbia University Medical Center, New York, New York (Dr Lee); Department of Surgery, University of California, San Francisco (Drs Zarnegar, Shen, Kebebew, Clark, and Duh); and Surgical Service, Veterans Affairs Medical Center, San Francisco (Dr Duh).