What is the management approach for a 92-year-old female with an incidentally found 1.3 cm left adrenal adenoma?

From the Guidelines

For a 92-year-old female with an incidentally found 1.3 cm left adrenal adenoma, the recommended management approach is observation without intervention. Given the patient's advanced age, the small size of the adenoma (less than 4 cm), and its incidental discovery, active surveillance is appropriate rather than surgical removal or extensive workup. Initial evaluation should include a basic hormonal assessment to rule out functionality, including a 1 mg overnight dexamethasone suppression test, plasma metanephrines or 24-hour urinary catecholamines, and serum potassium and aldosterone-renin ratio if the patient has hypertension, as suggested by the guidelines 1. If the adenoma is non-functional (which most incidental adrenal adenomas are), follow-up imaging can be considered in 6-12 months to ensure stability, though even this may be unnecessary given the patient's age and the small size of the lesion, as indicated in the guidelines 1. The rationale for this conservative approach is that small, non-functional adrenal adenomas carry a very low risk of malignant transformation or becoming hormonally active, especially in elderly patients, and this approach is supported by recent studies 1. The risks of surgical intervention would far outweigh any potential benefits in this age group, and the patient's limited life expectancy makes the clinical significance of this finding minimal. Some studies suggest that the management of adrenal incidentalomas should be individualized, taking into account the patient's preferences, comorbidities, and the presence of hormonal dysfunction 1. However, for a small, non-functional adenoma in an elderly patient, the most recent and highest quality guidelines support a conservative approach 1. Key points to consider in the management of this patient include:

• The small size of the adenoma and its incidental discovery
• The patient's advanced age and limited life expectancy
• The low risk of malignant transformation or hormonal dysfunction in small, non-functional adrenal adenomas
• The potential risks and benefits of surgical intervention versus observation
• The importance of individualizing management based on patient-specific factors, as suggested by recent studies 1.

From the Research

Management Approach for Incidental Adrenal Adenoma

• The management approach for a 92-year-old female with an incidentally found 1.3 cm left adrenal adenoma depends on various factors, including the patient's clinical history, physical examination, and imaging characteristics of the lesion 2.
• According to the study by 3, multidetector CT scan with the combination of unenhanced and dynamic scans represents the single most accurate modality for the detection and characterization of adrenal adenomas.
• The study by 4 suggests that cortisol-producing adrenal adenomas predominantly composed of lipid-poor compact cells can present with atypical imaging findings, highlighting the importance of considering the proportion of compact cells in the differential diagnosis.
• For patients with primary aldosteronism and unilateral adenomas, adrenal venous sampling may be selectively performed in appropriate patients with clearly visualized unilateral adenomas without affecting outcomes 5.
• In cases of bilateral adrenal masses, including bilateral cortisol-secreting adrenal adenomas, adrenal venous sampling adjusted by plasma aldosterone can be a useful technique in diagnosing ACTH-independent Cushing's syndrome prior to surgery 6.
• The evaluation and management of bilateral adrenal masses require a comprehensive systematic approach, including the assessment and interpretation of the patient's clinical history, physical examination, dynamic hormone evaluation, and imaging modalities to determine the key radiographic features of each adrenal nodule 2.

Considerations for Treatment

• Treatment options for adrenal adenomas depend on the presence of hormone excess, malignancy, or familial syndrome 2.
• Medical therapy may be considered for patients with hormone-excess disorders, while surgical therapy may be necessary for patients with malignant or potentially malignant lesions 2.
• Surveillance is also an important consideration, particularly for patients with bilateral adrenal masses or those with a history of familial syndromes 2.

Imaging Modalities

• CT and MR imaging are commonly used modalities for the evaluation of adrenal masses 3, 4.
• The choice of imaging modality depends on the patient's clinical history, physical examination, and the characteristics of the lesion 2.
• Additional imaging modalities, such as ¹⁸F-fluoro-2-deoxyglucose (FDG)-positron emission tomography (PET)/CT, may be useful in certain cases, particularly for detecting malignancy or confirming adrenal metastases 3.