What is the recommended management for a patient with a 1.6 cm left adrenal cortical adenoma and fatty hepatomegaly?

Management of 1.6 cm Left Adrenal Cortical Adenoma with Fatty Hepatomegaly

For a 1.6 cm left adrenal cortical adenoma with benign imaging features confirmed by chemical shift imaging, no further follow-up imaging or intervention is required as the lesion is clearly benign. 1 The management should focus on addressing the fatty hepatomegaly, which requires lifestyle modifications and metabolic evaluation.

Adrenal Adenoma Management

Imaging Characteristics and Risk Assessment

• The 1.6 cm left adrenal lesion shows signal dropout on out-of-phase chemical shift imaging, which is highly specific for a benign adrenal adenoma
• Chemical-shift MRI is highly sensitive and specific for differentiating benign from malignant adrenal tumors, as benign tumors contain fat while malignant tumors typically do not 2
• The adenoma's small size (1.6 cm) and benign imaging features indicate extremely low risk of malignancy
• Adrenal carcinoma should only be suspected in:
  • Tumors larger than 4 cm
  • Lesions with irregular margins
  • Internally heterogeneous masses
  • Tumors with poor contrast washout 2, 1

Hormonal Evaluation

Despite the benign appearance, all adrenal incidentalomas require hormonal evaluation:

1. Cortisol assessment:

   • 1mg overnight dexamethasone suppression test (values >138 nmol/L indicate hypersecretion) 1

2. Catecholamine assessment:

   • Plasma free metanephrines or 24-hour urinary fractionated metanephrines 1, 3

3. Aldosterone assessment (if hypertensive):

   • Aldosterone-to-renin ratio (ARR >20 ng/dL per ng/mL/hr has >90% sensitivity/specificity for hyperaldosteronism) 1

Follow-up Recommendations

• For this clearly benign adenoma (<4 cm with definitive benign features on chemical shift imaging):
  • No further follow-up imaging is required 1, 4
  • If hormonal evaluation is negative, no additional hormonal testing is needed 1

Fatty Hepatomegaly Management

The 18 cm hepatomegaly with fatty infiltration requires separate management:

1. Lifestyle modifications:

   • Weight loss (5-10% of body weight)
   • Regular physical activity (150+ minutes/week)
   • Mediterranean or DASH diet pattern

2. Metabolic evaluation:

   • Assess for metabolic syndrome components (diabetes, hypertension, dyslipidemia)
   • Liver function tests
   • Consider FibroScan or other non-invasive fibrosis assessment

3. Medical therapy if metabolic abnormalities present:

   • Management of diabetes (consider GLP-1 receptor agonists or pioglitazone)
   • Control of dyslipidemia
   • Treatment of hypertension

Important Caveats

• If hormonal evaluation reveals subclinical hypercortisolism (mild autonomous cortisol secretion), additional follow-up may be warranted, especially if metabolic comorbidities are present 1, 4
• The fatty hepatomegaly may be related to metabolic syndrome, which can be exacerbated by even mild cortisol excess
• If the patient develops symptoms specifically related to the adrenal adenoma in the future (hypertension, hypokalemia, cushingoid features), re-evaluation is indicated

The combination of a small adrenal adenoma with definitive benign features and fatty hepatomegaly suggests metabolic syndrome as the unifying diagnosis, with management focused primarily on addressing metabolic health rather than the incidental adrenal finding.