What is the recommended management for a 2.8 cm hypodense left adrenal gland nodule with 42% washout, previously measuring 1.1 cm, in a patient with left flank pain and normal hormonal workup for aldosterone, cortisol, and catecholamines?

From the Guidelines

The recommended management for this 2.8 cm left adrenal nodule with 42% washout and significant growth from 1.1 cm is surgical resection, specifically laparoscopic adrenalectomy. This recommendation is based on several concerning features: the significant growth in size, the indeterminate washout value (42% is below the 60% threshold typically used to confidently classify a lesion as benign) [ 1 ], and the presence of symptoms (left flank pain). While the normal hormonal workup is reassuring that this is not a functioning adrenal tumor, the growth pattern and washout characteristics raise concern for potential malignancy.

Key Considerations

• The size of the nodule (2.8 cm) and its significant growth from 1.1 cm are concerning features that warrant further investigation [ 1 ].
• The washout value of 42% is below the threshold typically used to classify a lesion as benign, suggesting the need for surgical intervention [ 1 ].
• The presence of symptoms, such as left flank pain, also supports the recommendation for surgical resection.

Preoperative Evaluation

Prior to surgery, a complete preoperative evaluation including chest imaging to rule out metastatic disease would be appropriate. The patient should be counseled about the risks of surgery, including bleeding, infection, and the small possibility of adrenal insufficiency, though this is unlikely with a unilateral adrenalectomy and normal contralateral adrenal gland.

Postoperative Management

Postoperatively, the patient should be monitored for signs of adrenal insufficiency, though routine steroid replacement is not typically necessary. The surgical specimen should undergo comprehensive pathological examination to determine the final diagnosis, which will guide any further management or surveillance needed.

Additional Considerations

It is also important to consider the patient's overall health and medical history when making treatment decisions. However, based on the provided information, surgical resection remains the recommended course of action [ 1 ].

From the Research

Management of Adrenal Gland Nodule

• The patient has a 2.8 cm hypodense left adrenal gland nodule with 42% washout, which previously measured 1.1 cm, and is experiencing left flank pain with normal hormonal workup for aldosterone, cortisol, and catecholamines.
• According to the study 2, patients with an adrenal incidentaloma 1 cm or larger should undergo biochemical testing and further imaging characterization.
• The study 3 suggests that a size cut-off of 4 cm would have led to resection of all primary malignant adrenal tumors, however, the current nodule size is 2.8 cm.
• The American Association of Endocrine Surgeons Guidelines for Adrenalectomy 2 recommend that adrenal protocol computed tomography (CT) should be used to stratify malignancy risk and concern for pheochromocytoma.
• Minimally invasive adrenalectomy is recommended for patients with primary aldosteronism or autonomous cortisol secretion, however, this patient's hormonal workup is normal 2.
• The study 4 suggests that adrenalectomy following metastatic disease to the adrenals should be performed when the lesion is isolated in the gland and the site of primary cancer has or can be resected, but there is no indication of metastatic disease in this case.
• Adrenal biopsy can be considered for further diagnostic workup in select cases, particularly in patients with an active or previously diagnosed extra-adrenal malignancy 5.
• The patient's left flank pain and the nodule's significant growth from 1.1 cm to 2.8 cm may indicate the need for further evaluation and possible surgical intervention.

Diagnostic Considerations

• The study 6 recommends native computed tomography (CT) as the diagnostic standard, with supplementary radiological modalities such as magnetic resonance imaging (MRI), contrast CT, and 18F-fluorodeoxyglucose positron emission tomography (18F-FDG-PET) for larger tumors or those that cannot be clearly classified as benign.
• The patient's nodule size and washout characteristics may indicate the need for further imaging characterization to determine the risk of malignancy 2.

Treatment Options

• The study 2 recommends minimally invasive adrenalectomy over open adrenalectomy due to improved perioperative morbidity, but the decision to operate should be based on the patient's individual characteristics and the results of further evaluation.
• The patient's normal hormonal workup and lack of indication of metastatic disease may influence the treatment options, and a multidisciplinary approach should be considered to determine the best course of action 4, 2.