What is the management approach for a 3.1 cm left adrenal nodule?

From the Guidelines

The management of a 3.1 cm left adrenal nodule should involve surgical removal (adrenalectomy) due to the increased risk of malignancy, even if non-functioning, as adrenocortical carcinoma risk increases with size. Initial steps should include hormonal testing, including a 1mg overnight dexamethasone suppression test, plasma metanephrines or 24-hour urinary catecholamines, plasma aldosterone to renin ratio, and sex hormone levels 1. Imaging characteristics are crucial, so a non-contrast CT scan should be performed to assess for lipid content (Hounsfield units <10 suggest a benign adenoma), followed by contrast-enhanced CT with washout calculations if needed.

• Laparoscopic adrenalectomy is the preferred surgical approach for most cases, with open surgery reserved for suspected malignancy 1.
• If the patient is not a surgical candidate or the nodule is determined to be benign and non-functioning, close surveillance with repeat imaging at 3-6 months initially and then annually for 1-2 years is appropriate 1.
• The size threshold of 3 cm is significant because adrenal incidentalomas smaller than this have a very low risk of malignancy, while those larger carry higher risk, justifying a more aggressive management approach 1. Key considerations in the management of adrenal nodules include:
• Multidisciplinary review by endocrinologists, surgeons, and radiologists when the imaging is not consistent with a benign lesion, there is evidence of hormone hypersecretion, the tumor has grown significantly during follow-up imaging, or adrenal surgery is being considered 1.
• Shared decision-making between patients and their clinicians should be used for the management of indeterminate non-functional adrenal lesions, with options including repeat imaging in 3-6 months versus surgical resection 1.

From the Research

Management Approach for a 3.1 cm Left Adrenal Nodule

The management approach for a 3.1 cm left adrenal nodule involves several steps, including:

• Diagnostic evaluation to determine the nature of the nodule
• Assessment of hormonal function to identify any excess hormone production
• Imaging studies to characterize the nodule and guide treatment decisions
• Consideration of surgical intervention, such as adrenalectomy, for nodules that are functional or large in size

Diagnostic Evaluation

Diagnostic evaluation for a 3.1 cm left adrenal nodule may include:

• Laboratory tests to assess hormonal function, such as plasma aldosterone concentration (PAC) and plasma renin activity (PRA) ratio 2
• Imaging studies, such as computed tomography (CT) or magnetic resonance imaging (MRI), to characterize the nodule and guide treatment decisions
• Adrenal venous sampling to determine the source of excess hormone production, if present 3, 4

Treatment Approach

The treatment approach for a 3.1 cm left adrenal nodule depends on the results of the diagnostic evaluation, including:

• Surgical intervention, such as adrenalectomy, for nodules that are functional or large in size 5, 3, 4
• Medical management, such as control of hypertension and hypokalemia, for nodules that are non-functional but require monitoring 2
• Consideration of genetic testing for patients with a family history of adrenal tumors or multiple endocrine neoplasia syndromes 6