Should a computed tomography (CT) scan of the adrenal glands be considered in a patient with elevated Dehydroepiandrosterone sulfate (DHEAS)?

CT Imaging for Elevated DHEAS Levels

Yes, a CT scan of the adrenal glands should be performed in patients with elevated DHEAS levels, as this finding may indicate adrenal pathology including possible adrenocortical carcinoma.

Rationale for CT Imaging with Elevated DHEAS

Elevated DHEAS (Dehydroepiandrosterone sulfate) is an important marker that warrants further investigation through adrenal imaging for several reasons:

1. Marker for Possible Malignancy: Elevated DHEAS levels can indicate adrenocortical carcinoma (ACC), which requires prompt diagnosis and treatment 1.

2. Differential Diagnosis: While some adrenal adenomas may produce elevated DHEAS, this pattern is more commonly associated with malignant adrenal tumors 2.

3. Clinical Significance: The NCCN guidelines recommend serum DHEA-S testing as part of the functional evaluation for adrenal tumors, particularly when clinical signs of virilization are present 1.

Imaging Protocol for Adrenal Assessment

When evaluating a patient with elevated DHEAS, the following imaging approach is recommended:

• First-line imaging: Non-contrast CT scan of the adrenal glands 1

  • Evaluates adrenal morphology, size, heterogeneity, and lipid content
  • Hounsfield units (HU) < 10 on unenhanced CT strongly suggests benign adenoma 1, 3

• Second-line imaging (if initial CT is indeterminate):

  • Contrast-enhanced CT with washout protocol (>60% washout at 15 minutes suggests benign lesion) 1
  • Chemical-shift MRI (signal intensity loss in opposed-phase images indicates benign adenoma) 1, 3

Interpretation of Imaging Findings

When interpreting adrenal imaging in the context of elevated DHEAS:

• Features suggesting malignancy:

  • Size >4 cm (high suspicion if >6 cm) 3
  • Irregular margins or heterogeneous appearance 1
  • HU >10 on unenhanced CT 3
  • Poor contrast washout (<60% at 15 minutes) 3
  • Local invasion or metastases 1

• Features suggesting benign lesions:

  • Size <3 cm 3
  • Homogeneous appearance with smooth borders 3
  • HU <10 on unenhanced CT 3
  • Rapid contrast washout (>60% at 15 minutes) 3

Additional Workup Considerations

In addition to imaging, patients with elevated DHEAS should undergo:

1. Complete hormonal evaluation:

   • Cortisol studies (dexamethasone suppression test, 24-hour urinary cortisol) 1
   • Sex hormones and steroid precursors (17-OH-progesterone, androstenedione, testosterone) 1
   • Aldosterone/renin ratio (if hypertensive or hypokalemic) 1
   • Plasma or urinary metanephrines (to rule out pheochromocytoma) 1

2. Follow-up recommendations:

   • For indeterminate lesions 4-6 cm: repeat imaging in 3-6 months 1
   • For lesions growing >5 mm/year: consider adrenalectomy 1
   • For stable lesions <3 mm growth/year: no further imaging required 1

Clinical Pitfalls to Avoid

• Don't rely solely on DHEAS levels: While elevated DHEAS is concerning, there is some overlap between benign and malignant lesions 2.

• Don't delay imaging: Adrenocortical carcinoma has poor prognosis when diagnosed late, so prompt imaging is essential 1.

• Avoid needle biopsy: Fine needle aspiration of suspected adrenal carcinoma is contraindicated due to risk of tumor seeding 1.

• Don't miss functioning tumors: Even if imaging suggests benign features, hormonal evaluation is crucial as some functional tumors may require intervention regardless of appearance 4.

By following this systematic approach to elevated DHEAS levels, clinicians can appropriately identify patients who require surgical intervention versus those who can be safely monitored.