What is the best management approach for a patient with a splenunculus, left adrenal nodule, mild incomplete bladder emptying, and a complex left adnexal lesion?

Management of Multiple Incidental Findings: Splenunculus, Adrenal Nodule, Incomplete Bladder Emptying, and Adnexal Lesion

The most appropriate management approach is to prioritize the left adrenal nodule with dedicated CT or MRI for further characterization, followed by a dedicated pelvic ultrasound for the complex left adnexal lesion, while the splenunculus requires no further evaluation or intervention. 1

Management of Splenunculus (Accessory Spleen)

• The 18 x 15 x 15 mm solid lesion between the spleen and left kidney is most likely a splenunculus (accessory spleen) as noted on previous imaging
• No further evaluation or intervention is required for the splenunculus as this is a normal anatomical variant
• Stability on serial imaging (noted from February 2024 to present) confirms benign nature

Management of Left Adrenal Nodule

Initial Evaluation

• CT with non-contrast phase is the primary imaging modality for adrenal nodule characterization 1, 2
• Key parameters to assess:
  • Hounsfield Units (HU) < 10 on non-contrast CT indicates benign adenoma 1, 3
  • Size measurement (lesions ≥4 cm have higher risk of malignancy) 2

Recommended Imaging Approach

1. Dedicated adrenal protocol CT with non-contrast and contrast-enhanced phases with washout calculations

   • 60% washout at 15 minutes suggests benign lesion 1, 3

   • If non-contrast CT shows HU > 10, proceed with contrast washout assessment 1

2. Chemical-shift MRI if CT is equivocal or contraindicated

   • Signal intensity loss in opposed-phase images indicates benign adenoma 1
   • Particularly useful for adrenal masses discovered incidentally 1

Hormonal Evaluation

• Complete hormonal workup is essential regardless of symptoms 1, 2:
  • 1mg overnight dexamethasone suppression test (for subclinical Cushing's)
  • Plasma or 24-hour urinary metanephrines (for pheochromocytoma)
  • Aldosterone-to-renin ratio if hypertension or hypokalemia present

Follow-up Recommendations

• If radiologically benign (<10 HU) and <4 cm: no further follow-up required 2, 1
• If radiologically benign but ≥4 cm: repeat imaging in 6-12 months 2
• If indeterminate: repeat imaging in 3-6 months or consider surgical evaluation 2

Management of Complex Left Adnexal Lesion

Recommended Imaging

• Dedicated transvaginal and transabdominal ultrasound is the first-line modality 2
  • Transvaginal US has >90% sensitivity for adnexal pathology 2
  • Combined approach allows for detailed evaluation of morphologic features and vascularity 2

Evaluation Parameters

• Assessment should include:
  • Grayscale morphologic features (septations, solid components, wall thickness)
  • Color Doppler evaluation for vascularity within solid areas 2
  • Size and growth compared to previous imaging from April 2025

Risk Stratification

• Use standardized reporting systems such as O-RADS or IOTA simple rules 2
• Features suggesting higher risk:
  • Irregular thick septations
  • Papillary projections
  • Mural nodules
  • Strong internal vascularity 2

Follow-up Recommendations

• Follow-up interval should be based on risk stratification from dedicated ultrasound
• MRI pelvis without and with IV contrast is appropriate if ultrasound is inconclusive 2

Management of Incomplete Bladder Emptying

• Mild incomplete bladder emptying noted on ultrasound requires clinical correlation
• Consider:
  • Post-void residual measurement
  • Urinalysis to rule out infection
  • Assessment for symptoms of lower urinary tract dysfunction

Important Considerations and Pitfalls

Adrenal Nodule Pitfalls

• Never perform adrenal biopsy without excluding pheochromocytoma first 2, 1
• Avoid overdiagnosis and unnecessary follow-up for small lipid-rich nodules 1
• Remember that adrenal masses in younger patients have higher risk of malignancy 2, 1

Adnexal Lesion Pitfalls

• CT is suboptimal for adnexal mass characterization 2
• Avoid unnecessary follow-up of clearly benign adnexal cysts 4
• Patient discomfort during examination may limit complete evaluation; dedicated follow-up is essential 2

Integrated Approach

• Prioritize evaluation based on risk of malignancy and clinical significance
• Coordinate timing of follow-up studies to minimize patient burden
• Consider patient factors (age, comorbidities, symptoms) in determining urgency of evaluation

By following this structured approach, you can systematically evaluate and manage these incidental findings while prioritizing the conditions that pose the greatest potential risk to the patient's health.