What is the management plan for a patient with a suspected adrenal adenoma, elevated cortisol levels, and symptoms of agitation?

Management of Adrenal Adenoma with Elevated Cortisol and Agitation

For a patient with suspected adrenal adenoma, elevated cortisol levels, and agitation, surgical removal of the adenoma through adrenalectomy is the recommended management approach, especially given the presence of symptomatic cortisol excess. 1

Diagnostic Evaluation

Initial Imaging Assessment

• Non-contrast CT is the first-line imaging modality for adrenal masses
  • Lesions with Hounsfield units (HU) ≤10 are likely benign adenomas
  • Lesions >4 cm, with HU >20, or inhomogeneous appearance suggest higher malignancy risk 1
• For indeterminate lesions:
  • Contrast-enhanced CT washout studies (>60% washout at 15 minutes suggests benign lesion)
  • Chemical shift MRI (signal intensity loss in opposed-phase images indicates benign adenoma) 1

Hormonal Evaluation

A complete hormonal assessment is essential for all adrenal masses, regardless of imaging appearance:

1. Cortisol Assessment:

   • 1mg overnight dexamethasone suppression test (DST)
   • Serum cortisol ≥1.8 μg/dL after DST suggests cortisol excess 1, 2
   • Assess diurnal rhythm of cortisol secretion (elevated late-night cortisol suggests Cushing's syndrome) 3

2. Catecholamine Assessment:

   • Plasma-free or 24-hour urinary fractionated metanephrines
   • Critical to rule out pheochromocytoma before any invasive procedure 1

3. Aldosterone Assessment:

   • Aldosterone-to-renin ratio to screen for primary aldosteronism 1

Management Algorithm for Adrenal Adenoma with Hypercortisolism

For Cortisol-Secreting Adenoma with Symptoms (as in this case):

1. Surgical Management:

   • Adrenalectomy is the treatment of choice for cortisol-secreting adenomas causing clinical symptoms 1
   • Perioperative steroid coverage is mandatory to prevent adrenal crisis 1
   • Laparoscopic approach is preferred when technically feasible

2. Preoperative Considerations:

   • Management of comorbid conditions (hypertension, diabetes, etc.)
   • Prophylactic antibiotics
   • Adequate steroid coverage to prevent adrenal insufficiency 4

3. Postoperative Management:

   • Monitor for temporary adrenal insufficiency, which occurs in approximately 50% of patients after removal of cortisol-producing adenomas 5
   • Gradual tapering of glucocorticoid replacement therapy
   • Follow-up cortisol testing to assess recovery of HPA axis function

For Subclinical Cushing's Syndrome (if symptoms were less pronounced):

• Shared decision-making between surgery vs. conservative management based on:
  • Patient preference
  • Severity of comorbidities
  • Risk of progression 4
• Consider surgery if there are metabolic complications (hypertension, diabetes, obesity) 5

Management of Associated Symptoms

For Agitation and Neuropsychiatric Symptoms:

• Recognize that cortisol excess commonly causes mood changes, anxiety, and agitation 1
• Address these symptoms through:
  • Treating the underlying cause (adrenalectomy)
  • Temporary symptomatic management while awaiting surgery
  • Monitor for improvement after normalization of cortisol levels

Important Clinical Considerations

Pitfalls to Avoid:

1. Do not delay diagnosis - subclinical Cushing's syndrome is the most common hormonal dysfunction caused by adrenal incidentalomas 4
2. Do not skip hormonal evaluation based on benign imaging appearance, as even radiologically benign-appearing lesions can be hormonally active 1
3. Do not perform biopsy of suspected adrenal masses, as biopsies are usually not informative and may trigger complications 1
4. Do not forget perioperative steroid coverage for patients undergoing surgery for cortisol-producing adenomas 4

Expected Outcomes:

After surgical removal of cortisol-producing adenomas, patients typically experience:

• Improvement in hypertension
• Weight loss in obese patients
• Better metabolic control of diabetes
• Resolution of neuropsychiatric symptoms including agitation 5

Long-term follow-up is mandatory to ensure complete resolution of hypercortisolism and associated symptoms 3.