What is the appropriate workup and management for a patient with an adrenal mass and associated uncontrolled hypertension (HTN)?

Workup for Adrenal Mass with Uncontrolled Hypertension

All patients with an adrenal mass and uncontrolled hypertension require comprehensive hormonal evaluation (cortisol, catecholamines, and aldosterone) regardless of imaging appearance, with subsequent management guided by hormonal status and imaging characteristics. 1

Initial Evaluation

Clinical Assessment

• Focused history targeting:
  • Symptoms of hormone excess:
    • Cortisol excess: weight gain, central obesity, facial rounding, purple striae, muscle weakness, easy bruising
    • Aldosterone excess: hypertension, hypokalemia, muscle weakness, headaches
    • Catecholamine excess: episodic hypertension, headaches, palpitations, sweating, anxiety
  • Symptoms suggesting malignancy: abdominal/flank pain, weight loss, early satiety

Imaging Evaluation

1. Non-contrast CT as initial imaging test:

   • HU ≤10: Benign (0% risk of adrenocortical carcinoma)
   • HU 10-20: Intermediate risk (0.5% risk of adrenocortical carcinoma)
   • HU >20: High risk (6.3% risk of adrenocortical carcinoma) 1

2. Second-line imaging for indeterminate lesions:

   • Contrast-enhanced CT washout study (>60% washout at 15 minutes suggests benign lesion)
   • Chemical-shift MRI (useful when CT contrast is contraindicated)
   • FDG-PET for suspected malignancy 1

Hormonal Evaluation

All patients with adrenal masses require complete hormonal evaluation regardless of imaging appearance 1, 2:

1. Cortisol evaluation:

   • 1mg overnight dexamethasone suppression test

2. Catecholamine evaluation:

   • Plasma-free or 24-hour urinary fractionated metanephrines
   • Consider plasma methoxytyramine if malignant pheochromocytoma suspected

3. Aldosterone evaluation:

   • Aldosterone-to-renin ratio (ARR)
   • If elevated ARR, confirmatory testing

Caution: Hormonal evaluation is frequently overlooked in clinical practice. One study found that 89.4% of patients with hypertension and adrenal masses did not undergo appropriate hormonal evaluation, potentially missing functional tumors. 2

Management Algorithm

For Hormonally Active Tumors:

1. Cortisol-secreting adenoma:

   • Adrenalectomy, especially with clinical Cushing's syndrome or progressive metabolic issues
   • Perioperative steroid coverage mandatory to prevent adrenal crisis

2. Aldosterone-secreting adenoma (likely in uncontrolled HTN):

   • Adrenalectomy recommended
   • Consider adrenal vein sampling prior to surgery to confirm laterality 1, 3
   • Expect improvement in hypertension post-surgery

3. Pheochromocytoma:

   • Adrenalectomy with preoperative alpha-blocker treatment
   • Critical to prevent dangerous intraoperative hypertensive crisis

For Non-functional Tumors:

Based on imaging characteristics:

• Low risk (HU ≤10, <3cm, homogeneous): Conservative management with repeat imaging in 6-12 months
• Intermediate risk: Repeat evaluation in 3-12 months
• High risk (>4cm, HU >20, inhomogeneous): Surgical removal due to malignancy risk 1

Multidisciplinary Approach

Involve endocrinologists, surgeons, and radiologists when:

• Imaging is not consistent with a benign lesion
• Evidence of hormone hypersecretion exists
• Tumor has grown significantly during follow-up
• Adrenal surgery is being considered 4, 1

Important Considerations

• Approximately 20% of adrenal incidentalomas are potential surgical lesions 4
• In patients with uncontrolled hypertension, primary aldosteronism should be strongly suspected, as it's a common cause of endocrine hypertension 5
• Adrenal vein sampling is crucial for localizing aldosterone-producing adenomas, as CT/MRI alone can be misleading 6, 3
• Laparoscopic approach is preferred when technically feasible for adrenalectomy 1

Pitfall: Relying solely on imaging without hormonal evaluation can miss functional tumors that require intervention regardless of appearance. Always complete the full hormonal workup, especially in patients with hypertension.