Incidentaloma

Question 1

Definition of adrenal incidentaloma

Answer 1

Incidental finding of adrenal mass > 1cm on cross sectional imaging

Question 2

DDX of adrenal incidentaloma

Answer 2

• Functional
  
  • Phaechromocytoma
  • Cushing syndrome
  • Primary hyperaldosteronism
• Non-functional
  
  • Benign: Adenoma/ Myelilipoma/ Cyst/ Hematoma/ Calcification
  • Malignant: Adrenocortical Cancer / Metastasis

Question 3

Hormonal workup for incidentaloma

Answer 3

1 mg ONDST

24 hour urine metanephrine

RFT + spot ARR

Sex hormone levels (if suspicious for ACC)

Question 4

Suspicious CT features for adrenal incidentaloma

Answer 4

Size > 4cm

Irregular border

Heterogenous

HU >20 on non-contrast CT

Absolute washout <60%, relative washout < 40%

Question 5

Benign CT features

Answer 5

size < 4cm

Regular border

Homogenous

HU <10 on non-contrast CT

Absolute washout > 60%, relative washout > 40%

Question 6

Indications for adrenalectomy

Answer 6

Functional adrenal lesion

Suspected of malignancy

Suspicious imaging

Size > 4 cm

Interval growth > 1 cm on 6-12 month CT

Question 7

Surveillance for benign adenoma

Answer 7

Repeat ONDST annually

Routine CT (5 years)

Question 8

Further preop management for phaechromocytoma with suspicious CT features

Answer 8

MIBG +/- DOPA PETCT exclude synchronous

Check chromogranin A

Question 9

Further pre-op management for suspected ACC after CT

Answer 9

PETCT to rule out metastasis

Consult endocrine + anaes

Urgent open radical adrenalectomy