A 50-year-old man comes to the physician for follow-up of epigastric pain. He was evaluated in the emergency department 3 days ago. Abdominal CT scan with and without contrast showed a 2-cm left adrenal mass. The lesion was homogenous with well-defined margins and low x-ray attenuation (2 Hounsfield units measured on noncontrast images) . The abdominal pain resolved with antacids. The patient has no other medical problems and takes no medications. He denies weight gain, headache, flushing, sweating, muscle weakness, myalgias, or polyuria. He smokes 5 cigarettes a day but does not drink alcohol or use illicit drugs. Family history is unremarkable.
His blood pressure is 112/76 mm Hg and pulse is 67/min. His BMI is 25 kg/m². The physical examination is unremarkable.
Laboratory results are as follows:

What is the most appropriate next step in managing this patient?

Question

A 50-year-old man comes to the physician for follow-up of epigastric pain. He was evaluated in the emergency department 3 days ago. Abdominal CT scan with and without contrast showed a 2-cm left adrenal mass. The lesion was homogenous with well-defined margins and low x-ray attenuation (2 Hounsfield units measured on noncontrast images) . The abdominal pain resolved with antacids. The patient has no other medical problems and takes no medications. He denies weight gain, headache, flushing, sweating, muscle weakness, myalgias, or polyuria. He smokes 5 cigarettes a day but does not drink alcohol or use illicit drugs. Family history is unremarkable.
His blood pressure is 112/76 mm Hg and pulse is 67/min. His BMI is 25 kg/m². The physical examination is unremarkable.
Laboratory results are as follows:

What is the most appropriate next step in managing this patient?

Quizplus · Accepted Answer

11ec193a_97c2_666a_853d_dd6cecc1a7f7_MD0002_00 This patient has a small, incidentally discovered adrenal nodule on abdominal CT scan. Adrenal incidentalomas are commonly seen due to widespread use of abdominal imaging, with an overall frequency of nearly 6%. Patients with adrenal incidentalomas should be evaluated for excess adrenal hormone production and possible adrenal malignancy. A careful history and physical examination should focus on features of Cushing's syndrome, primary hyperaldosteronism, pheochromocytoma, and adrenal androgen excess in women. CT features suggesting malignancy include > 10 Hounsfield units, mass size > 4 cm, and > 50% contrast retention seen 10 minutes after contrast administration. This patient has no clinical features to suggest adrenal excess or CT findings worrisome for malignancy. The next step is biochemical testing (shown in the figure) with overnight dexamethasone test to evaluate for excess cortisol and urinary fractionated catecholamines and metanephrines (Choice D). Biochemical testing for pheochromocytoma and excess cortisol is required even in the absence of symptoms as these disorders can be clinically silent. Plasma aldosterone and plasma aldosterone to renin activity ratio are done only in hypertensive patients to evaluate for primary hyperaldosteronism, which can present with low or normal serum potassium. (Choice B) Adrenalectomy is considered for large tumors (generally > 4 cm in diameter) or for masses with positive biochemical testing. This patient should be evaluated for adrenalectomy if his biochemical testing indicates a secreting adrenal mass. (Choice C) MRI is preferred over CT for evaluating pheochromocytoma because iodinated contrast can precipitate hypertensive crisis in these patients. However, MRI would be considered only if biochemical testing showed elevated catecholamines and metanephrines. (Choice E) CT follow-up is required to monitor mass stability once adrenal hormonal excess is excluded. Educational objective: Patients with adrenal incidentaloma usually require evaluation for malignancy risk and biochemical testing (eg, overnight dexamethasone test, urinary fractionated catecholamines, and metanephrines) to document excess adrenal hormone production. Hypertensive patients also require renin and aldosterone measurements to evaluate for primary hyperaldosteronism, which can present with low or normal serum potassium. Patients with adrenal mass characteristics suggestive of malignancy or positive biochemical testing should be considered for surgery. __________ References: Adrenal incidentalomas. (http://www.ncbi.nlm.nih.gov/pubmed/22305453) Medical and surgical evaluation and treatment of adrenal incidentalomas. (http://www.ncbi.nlm.nih.gov/pubmed/21632813)

A 50-Year-Old Man Comes to the Physician for Follow-Up of Epigastric