"A young patient who has undergone a CT scan to the abdomen for blunt abdominal trauma was found to have a 3.5cm mass in the left adrenal gland". What would you do?"
Start always by taking a good endocrine history, keeping in mind the possibilities (pheo, Cushing, Conn's and rarely, sexual hormones secreting tumor, mets). Ask for HTN, headaches, diabetes, fatigue and polyuria and sexual history (loss of libido, amenorrhea, etc.). Ask for family history related to MEN II (thyroid CA...). If the patient is totally asymptomatic, you are obligated to prove the adrenal mass is truly a non-functioning mass and you should order the chemical work-up:
-Blood (Aldosterone/renin ratio), K, Na.
-Urine (Catecholamine, cortisol, 17 Ketosteroids)
(In older patients when you suspect mets, may need to do Colonoscopy, mammogram...etc.)
If you have an elevation of one of the hormones, you direct your investigation to the syndrome involved. If your chemical work-up is completely negative, you're left with 3 possibilities.
1. Non-functioning benign adrenal mass.
2. Adrenal malignancy.
3. Metastasis to the adrenal gland.
The possibility of metastasis should be thoroughly investigated, especially in older patients (breast, lung, prostate, colon and thyroid). Otherwise order MRI, T2 weighed study to the abdomen with comparing the liver substance signal intensity to the adrenal mass signal intensity. The following guidelines have been found in several studies to be very accurate:
Adrenal mass/Liver ratio | Diagnosis |
>3 | Pheochromocytoma |
1.4-3 | Carcinoma |
<1.4 | Adenoma |
Now, after MRI, chemical studies and history and physical, and after you have ruled out the possibility of metastasis, a safe guideline to treatment plan is presented here:
All functioning adrenal masses have to be excised.
All adrenal masses >5cm in size have to be excised.
Any adrenal mass >3cm and non-functioning with low mass/liver ratio (lower than 1.4) can be observed with frequent CT scans (Q2-4 months because adrenal malignancy grows rapidly).
Adrenal mass 3-5cm in size and non-functioning with low mass/liver ratio in a poor risk patient could be considered for FNA under CT guidance (not very reliable) and observed.
Adrenal cysts should be aspirated under CT guidance (FNA). If you get clear fluid, observe. If you get bloody fluid, treat as adrenal solid mass.
Recently, laparoscopic adrenalectomy has rapidly replaced open adrenalectomy for small benign adrenal tumors, even for pheochromocytoma.
They are slightly more difficult on the right (short adrenal vein). You should mention this option to the patient and refer him if you don't do laparoscopic adrenalectomy yourself.