What is the recommended management for a patient with non-specific lymph node uptake, bilateral adrenal adenomas, and a simple adnexal cyst?

Management of Non-Specific Lymph Node Uptake, Bilateral Adrenal Adenomas, and Simple Adnexal Cyst

For a patient with non-specific lymph node uptake, bilateral adrenal adenomas, and a simple adnexal cyst, dedicated imaging and hormonal evaluation of the adrenal adenomas should be prioritized, while the simple adnexal cyst and non-specific lymph nodes can be monitored with follow-up imaging. 1

Management of Bilateral Adrenal Adenomas

Diagnostic Evaluation

1. Dedicated Adrenal Imaging:

   • Non-contrast CT to determine Hounsfield Units (HU)
     • HU < 10 indicates benign adenoma (risk of adrenocortical carcinoma 0%) 1
     • If HU > 10, proceed with contrast-enhanced CT with 15-minute washout

       • 60% washout suggests benign lesion 1

   • Chemical-shift MRI as an alternative if CT contrast is contraindicated 1

2. Mandatory Hormonal Evaluation (regardless of imaging appearance):

   • 1-mg overnight dexamethasone suppression test (cortisol cutoff ≤50 nmol/L or ≤1.8 µg/dL) 1, 2
   • Plasma or 24-hour urinary metanephrines (for pheochromocytoma) 1, 2
   • Aldosterone-to-renin ratio (especially if hypertensive) 1, 2

Management Decision Algorithm

1. For Nonfunctioning Adenomas:

   • If <4 cm with benign imaging features (HU <10):
     • No further follow-up imaging required 1
   • If ≥4 cm or indeterminate features:
     • Repeat imaging in 6-12 months 1
     • Consider surgical evaluation if >4 cm with irregular margins or heterogeneous appearance 1

2. For Functioning Adenomas:

   • Cortisol-secreting: Laparoscopic adrenalectomy with perioperative steroid coverage 1
   • Aldosterone-secreting: Laparoscopic adrenalectomy 1
   • For Mild Autonomous Cortisol Secretion (MACS):
     • Consider adrenalectomy if progressive metabolic comorbidities attributable to cortisol excess 1, 2
     • If not managed surgically, annual clinical screening for new or worsening comorbidities 1

3. Growth Monitoring:

   • Growth >5 mm/year: Consider adrenalectomy after repeating functional work-up 1
   • Growth <3 mm/year: No further imaging or functional testing required 1

Management of Non-Specific Lymph Node Uptake

1. Evaluation:

   • FDG-PET is useful for distinguishing potentially malignant lesions from benign tumors in radiologically indeterminate cases 1
   • Mild tracer uptake in lymph nodes measuring up to 10-12mm may be reactive or represent lymphoproliferative disorder

2. Management:

   • Follow-up imaging in 3-6 months to assess for stability or progression
   • Consider biopsy if lymph nodes enlarge or demonstrate increased uptake on subsequent imaging

Management of Simple Adnexal Cyst

1. For simple cysts <5 cm:

   • Observation is typically sufficient
   • Follow-up ultrasound in 3-6 months to ensure stability

2. For 4 cm simple cyst (as in this case):

   • Follow-up ultrasound in 3-6 months
   • If stable and remaining simple in appearance, can extend follow-up intervals
   • Surgical intervention generally not indicated for asymptomatic simple cysts

Multidisciplinary Approach

The American Urological Association recommends a multidisciplinary approach involving endocrinologists, surgeons, and radiologists when evaluating adrenal masses, especially 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 1

Important Considerations and Pitfalls

• Pitfall #1: Failing to perform complete hormonal evaluation even for seemingly benign adrenal adenomas. Even radiologically benign-appearing adenomas can be hormonally active and require intervention. 1, 2

• Pitfall #2: Overlooking MACS (Mild Autonomous Cortisol Secretion). Patients with post-dexamethasone cortisol >50 nmol/L (>1.8 µg/dL) have increased risk of morbidity and mortality even without overt Cushing's syndrome. 2

• Pitfall #3: Assuming bilateral adrenal adenomas are always benign. While most are benign, they require thorough evaluation and may need adrenal vein sampling to determine if one or both glands are involved. 1

• Pitfall #4: Dismissing small adrenal masses without proper characterization. While most small adrenal masses are benign, proper imaging characterization (HU measurement, contrast washout) is essential. 1

• Caveat: For patients with bilateral adrenal adenomas who require surgery, careful consideration must be given to avoid bilateral adrenalectomy which would result in permanent adrenal insufficiency requiring lifelong steroid replacement. 3, 1