A 42-year-old female complains of occasional nagging midabdominal pain. She describes the pain as crampy in quality and states that it is relieved by bowel movements. Sometimes the pain wakes her from sleep. She denies any associated nausea, vomiting, chest pain, fever or weight loss. She is otherwise healthy. Her blood pressure is 130/80 mmHg and her heart rate is 85/min. Physical examination is essentially unremarkable. Abdominal CT scan shows a right-sided adrenal mass measuring 2 cm in diameter. Which of the following is the best next step in managing this patient?

Question

A 42-year-old female complains of occasional nagging midabdominal pain.  She describes the pain as crampy in quality and states that it is relieved by bowel movements.  Sometimes the pain wakes her from sleep.  She denies any associated nausea, vomiting, chest pain, fever or weight loss.  She is otherwise healthy.  Her blood pressure is 130/80 mmHg and her heart rate is 85/min.  Physical examination is essentially unremarkable.  Abdominal CT scan shows a right-sided adrenal mass measuring 2 cm in diameter.  Which of the following is the best next step in managing this patient?

Quizplus · Accepted Answer

Explanation: Based on her history, this patient's abdominal pain is most likely functional, as in irritable bowel syndrome. Still, she has undergone abdominal CT scanning to rule out an organic cause, and this investigation has incidentally revealed an adrenal mass, or "incidentaloma." Incidentally discovered (as part of the work-up for an unrelated problem) adrenal masses are common, present in up to 8% of autopsies and 4% of abdominal CT studies. Although this patient has no symptoms to suggest adrenal pathology, all adrenal masses require workup for hormone hypersecretion or malignancy. In any patient with an adrenal mass, essential laboratory studies include serum electrolytes, dexamethasone suppression testing, and 24-hour urine catecholamine, metanephrine, vanillylmandelic acid and 17-ketosteroid measurement. Surgical excision is recommended for all functional tumors, all malignant tumors (which demonstrate a characteristic heterogenous appearance on imaging), and all tumors greater than 4 cm. All other masses can be managed conservatively with serial abdominal imaging, and removed if they increase in size. (Choice A) Observation and repeat evaluation is indicated for non-functional tumors less than 4 cm in diameter with a benign appearance on CT scan. Functional studies must first be performed before deciding on observation. (Choice B)Fluorodeoxyglucose (FDG) PET scanning can identify tumors with moderate to high proliferative activity as well as other tissues with increased metabolic activity. False-positive and false-negative results are common, thus, this modality is not commonly used in the initial assessment of adrenal masses. (Choice C)17-hydroxyprogesterone is an intermediate in adrenal cortical cortisol and androstenedione production. It is elevated in congenital adrenal hyperplasia (CAH) due to 21-hydroxylase and 11b-hydroxylase deficiency, and depressed in CAH due to 17a-hydroxylase deficiency. An intermediate product, its levels would not be elevated in an incidentally discovered unilateral adrenal mass in an adult. (Choice E)A pituitary MRI would be of little immediate relevance in this patient. The MEN IIa and IIb syndromes include pheochromocytoma but not pituitary adenomas, and MEN I includes pituitary tumors but not adrenal tumors. Educational objective: Before deciding to medically, surgically, or conservatively manage an incidentally detected unilateral adrenal mass, evaluation for hormone production should first be completed. All functional masses, masses with radiographic evidence of malignancy, or masses greater than 4 cm in size should be removed.

A 42-Year-Old Female Complains of Occasional Nagging Midabdominal Pain