A 56-year-old woman comes to the physician for evaluation of a right adrenal mass found 2 weeks ago on an abdominal CT scan performed for renal colic. The lesion is 2 cm in diameter, round, and has low x-ray attenuation (8 Hounsfield units) on non-contrast slices. Her other medical problems include hypertension treated with amlodipine. Family history is unremarkable.
Her blood pressure is 144/96 mm Hg, pulse is 66/min, and BMI is 26 kg/m². The remainder of the examination is within normal limits.
Laboratory results are as follows:

Which of the following is the most appropriate next step in managing this patient?

Question

A 56-year-old woman comes to the physician for evaluation of a right adrenal mass found 2 weeks ago on an abdominal CT scan performed for renal colic. The lesion is 2 cm in diameter, round, and has low x-ray attenuation (8 Hounsfield units) on non-contrast slices. Her other medical problems include hypertension treated with amlodipine. Family history is unremarkable.
Her blood pressure is 144/96 mm Hg, pulse is 66/min, and BMI is 26 kg/m². The remainder of the examination is within normal limits.
Laboratory results are as follows:

Which of the following is the most appropriate next step in managing this patient?

Quizplus · Accepted Answer

11ec193a_97b6_314b_853d_cddea0a39d89_MD0002_00 Incidental adrenal masses are found in up to 10% of routine imaging studies. The evaluation of these patients focuses on two major things: 1) Identifying clinical and/or biochemical adrenal hormonal excess; and 2) Determining the risk of malignancy. Patients with hypertension (such as this patient) and incidental adrenal masses require evaluation for Cushing's syndrome, primary hyperaldosteronism, pheochromocytoma, and excess adrenal androgen (in females). Primary hyperaldosteronism may present with hypertension and hypokalemia, but the majority of patients do not develop hypokalemia. However, hypokalemia may be provoked very easily with diuretics. This patient has suboptimal control of her hypertension as well as mild metabolic alkalosis in the absence of diuretic use, which suggests possible primary hyperaldosteronism. The most appropriate next step in this patient would be to perform an aldosterone to renin ratio to evaluate for primary hyperaldosteronism. If positive, surgery with unilateral adrenalectomy should be considered. If negative, follow-up imaging is appropriate in 6 months to monitor growth. (Choice A) Adding diuretic therapy in this patient may result in severe hypokalemia and worsening metabolic alkalosis. Instead, an aldosterone antagonist is preferred for blood pressure control. (Choice C) Fine needle aspiration is typically performed for masses with CT features suggestive of infection or malignancy such as irregular shape, higher density (Hounsfield units > 10), larger size (> 4 cm), and retention of contrast agent (> 50% after 10 minutes). Pheochromocytoma should be ruled out before manipulating the patient's adrenal mass. (Choice D) Repeat CT scan in 6 months is performed in patients with negative hormonal excess studies, no evidence of malignancy, and tumor size < 4 cm. This patient first needs a work-up for hormonal excess. (Choice E) Unilateral adrenalectomy is performed for suspected malignancy and/or confirmed functional unilateral adrenal mass. Educational objective: Patients with hypertension and incidental adrenal masses require evaluation for Cushing's syndrome, primary hyperaldosteronism, pheochromocytoma, and excess adrenal androgen (in females). Primary hyperaldosteronism can present with hypertension and without spontaneous hypokalemia. __________ References: Adrenal incidentaloma (http://www.ncbi.nlm.nih.gov/pubmed/22305453) Medical and surgical management of adrenal incidentaloma (http://www.ncbi.nlm.nih.gov/pubmed/21632813)

A 56-Year-Old Woman Comes to the Physician for Evaluation of a Right