How to manage a patient with a 1 cm adrenal lesion, mild autonomous cortisol secretion, elevated aldosterone-to-renin (ARR) ratio, diabetes mellitus, and hypertension?

Management of a 1 cm Adrenal Lesion with Mild Autonomous Cortisol Secretion and Elevated Aldosterone-Renin Ratio

For this patient with a 1 cm adrenal lesion showing mild autonomous cortisol secretion, elevated aldosterone-renin ratio, and metabolic comorbidities (diabetes and hypertension), adrenalectomy should be considered after adrenal vein sampling confirms unilateral aldosterone production. 1

Evaluation of Current Findings

• The patient presents with a 1 cm adrenal lesion with concerning radiological features (30 HU, poor washout on CT), suggesting this is not a typical benign adenoma 1
• Hormonal evaluation shows:
  • Mild autonomous cortisol secretion (MACS) 1
  • Elevated aldosterone-renin ratio (ARR) of 20, suggesting possible primary aldosteronism 1
• The patient has metabolic comorbidities (diabetes mellitus and hypertension) that could be exacerbated by both cortisol and aldosterone excess 1, 2

Recommended Management Algorithm

Step 1: Complete Hormonal Evaluation

• Confirm primary aldosteronism with confirmatory testing (saline suppression test or salt loading test) 1
• Measure serum electrolytes to assess for hypokalemia related to aldosterone excess 1
• Screen for pheochromocytoma with plasma or 24-hour urinary metanephrines (required due to HU >10) 1

Step 2: Adrenal Vein Sampling

• Perform adrenal vein sampling to determine if aldosterone production is unilateral or bilateral 1
• This is critical before considering surgery as CT imaging alone is not reliable for lateralization 1

Step 3: Surgical Decision

• If unilateral aldosterone production is confirmed:
  • Proceed with laparoscopic adrenalectomy of the affected gland 1, 3
  • This approach addresses both the aldosterone excess and MACS 1, 4
• If bilateral aldosterone production is found:
  • Medical management with mineralocorticoid receptor antagonists (spironolactone) 1, 3
  • Initial dose of 25-100 mg daily, titrated based on blood pressure response 3

Rationale for Surgical Approach

• The patient has two indications for considering surgery:
  1. Elevated ARR suggesting primary aldosteronism (if confirmed unilateral) 1, 3
  2. MACS with metabolic comorbidities (diabetes and hypertension) 1, 2
• Current guidelines recommend adrenalectomy for unilateral aldosterone-secreting adrenal masses 1
• For patients with MACS and progressive metabolic comorbidities, adrenalectomy should be considered after shared decision-making 1, 2

Perioperative Considerations

• Prepare for potential postoperative adrenal insufficiency due to MACS 4, 5
• Measure morning cortisol on postoperative day 1 to determine need for glucocorticoid replacement 4
• If surgery is performed, minimally invasive laparoscopic approach is recommended 1, 4

Medical Management (if surgery is not performed or bilateral disease)

• For primary aldosteronism: Spironolactone 25-100 mg daily, titrated based on blood pressure response and potassium levels 3
• For MACS: Annual screening for worsening of metabolic comorbidities 1, 6
• Aggressive management of diabetes and hypertension 2, 6

Follow-up Recommendations

• If not surgically managed:
  • Annual clinical screening for worsening of metabolic comorbidities 1, 2
  • Repeat imaging in 6-12 months to assess for growth 1
• If surgically managed:
  • Monitor for adrenal insufficiency in immediate postoperative period 4, 5
  • Assess resolution of hypertension and improvement in glycemic control 5, 7

Common Pitfalls to Avoid

• Failing to perform adrenal vein sampling before surgery for primary aldosteronism, which could lead to removal of the wrong adrenal gland 1
• Underestimating the risk of postoperative adrenal insufficiency in patients with MACS 4, 5
• Overlooking the possibility of bilateral disease or co-secreting tumors 5, 7
• Neglecting to address both hormonal abnormalities (cortisol and aldosterone excess) in management planning 5, 7