Incidental Adrenal Mass

Question 1

What is the first step in screening for hormone excess in an adrenal mass?

Answer 1

1. Plasma metanephrines or 24-h urine for metanephrine excretion.
2. Dexamethasone 1mg overnight test
3. Plasma aldosterone and plasma renin
4. If tumore > 4cm, 17-hydroxyprogesterone and androstenedione and DHEAs

Question 2

What test is performed if the dexamethasone 1 mg overnight test is positive?

Answer 2

Also perform plasma ACTH, midnight salivary cortisol (≥2x), and 24-h urine for free cortisol excretion (≥2x).

Question 3

What tests are indicated for patients with hypertension and/or hypokalemia?

Answer 3

Plasma aldosterone and plasma renin.

Question 4

What additional tests are required if the tumor is greater than 4 cm?

Answer 4

Serum 17-hydroxyprogesterone, androstenedione, and DHEAS.

Question 5

What imaging is recommended if not already done as the index scan?

Answer 5

Unenhanced CT adrenals or MRI adrenals with chemical shift analysis.

Question 6

What is the management for a positive mild autonomous corticol excess or MACE?

Answer 6

Follow up or Surgery.

Question 7

If no evidence of hormone excess, What indicates adrenal cancer is likely after imaging?

Answer 7

Tumor ≥4 cm and >20 HU.

Question 8

What indicates adrenal cancer is highly unlikely?

Answer 8

Tumor <4 cm and >20 HU.
Do additional test: fdg pet, biopsy, in particular if with hx of extra adrenal ca

Question 9

What is the management for a benign adrenal mass?

Answer 9

Tumor ≤20 HU; discharge.

Question 10

What should be considered for follow-up if there is a history of extra-adrenal cancer?

Answer 10

Consider additional tests (FDG-PET, biopsy).

Question 11

If tumor more than or equal to 4cm and > 20HU?

Answer 11

Adrenal Cancer likely
Do urine steroid metabolites (if available), if negative, consider fdg pet, biopsy

Question 12

If there is evidence of hormone excess and positive confirmatory test? If negative?

Answer 12

+ Surgery
- discharge