What is the diagnosis and treatment for an adrenal adenoma?

From the Guidelines

Adrenalectomy should be performed for patients with unilateral aldosterone-secreting adrenal masses and pheochromocytomas, with minimally-invasive surgery (MIS) being the preferred approach when feasible. This recommendation is based on the most recent and highest quality study available, which emphasizes the importance of surgical intervention for these specific types of adrenal adenomas 1.

Key Considerations

• The management of adrenal adenomas depends on their size and functionality, with non-functioning adenomas smaller than 4 cm typically requiring only regular monitoring with imaging every 6-12 months.
• For functioning adenomas or those larger than 4 cm, surgical removal is often advised due to the increased risk of malignancy in larger tumors.
• Laparoscopic adrenalectomy is the preferred surgical approach when indicated, as it minimizes the risk of complications and promotes faster recovery.
• For hormone-producing tumors, specific medications may be prescribed to manage symptoms until surgery can be performed, highlighting the importance of a multidisciplinary approach to patient care.

Diagnostic Approach

• The work-up for an adrenal incidentaloma should include a focused history and physical examination, along with screening for autonomous cortisol secretion and primary aldosteronism when clinically appropriate 1.
• Adrenal vein sampling is recommended prior to offering adrenalectomy in patients with primary aldosteronism, to distinguish between unilateral and bilateral disease.
• Non-contrast CT and chemical-shift MRI are useful imaging modalities for characterizing adrenal masses and guiding further management.

Treatment Outcomes

• Surgical removal of unilateral aldosterone-secreting adrenal masses and pheochromocytomas can lead to significant improvements in patient outcomes, including resolution of hyperfunction and reduction of morbidity associated with excess hormone production 1.
• The choice of surgical approach, whether open or minimally-invasive, should be individualized based on patient factors and tumor characteristics, with the goal of minimizing complications and promoting optimal recovery.

From the FDA Drug Label

Long-term maintenance therapy for patients with discrete aldosterone-producing adrenal adenomas who are not candidates for surgery Long-term maintenance therapy for patients with bilateral micro or macronodular adrenal hyperplasia (idiopathic hyperaldosteronism). Spironolactone tablets are indicated for long-term maintenance therapy in patients with discrete aldosterone-producing adrenal adenomas who are not candidates for surgery 2.

• The dosage for this condition can range from 100 mg to 400 mg daily 2.
• Spironolactone can be used to treat patients with adrenal adenomas who are not suitable for surgery.

From the Research

Adrenal Adenoma Overview

• Adrenal adenomas are a type of tumor that can be found in the adrenal glands, and they are often discovered incidentally during imaging tests for other conditions 3, 4, 5, 6.
• The majority of adrenal incidentalomas are benign, but it is essential to evaluate them carefully to rule out primary adrenocortical carcinoma and functional adenomas 6.

Diagnosis and Evaluation

• The diagnostic approach for adrenal incidentalomas should focus on determining whether the lesion is malignant and whether it is hormonally active 4, 6.
• Radiological evaluation, including noncontrast and contrast computed tomography attenuation values, is the best tool to differentiate between benign and malignant adrenal masses 6.
• Hormonal evaluation, including tests for subclinical Cushing's syndrome and pheochromocytoma, is necessary for all patients with adrenal incidentalomas 4, 6.

Management and Treatment

• The management of adrenal incidentalomas varies based on the etiology, associated comorbidities, and patient preference 5.
• Surgical excision is recommended for adrenal tumors with suspicious radiological findings, functional tumors, and tumors larger than 4 cm in size that lack characteristic benign imaging features 6.
• Medical treatment, such as metyrapone, can be effective in normalizing biochemical and clinical parameters in patients with Cushing's syndrome due to adrenal adenoma before surgical intervention 7.

Follow-up and Monitoring

• Annual biochemical follow-up of patients with adrenal incidentalomas, especially those with tumors larger than 3 cm in size, is recommended for up to 5 years 6.
• Repeat computed tomography studies are recommended for patients with adrenal masses less than 4 cm in size and a noncontrast attenuation value of more than 10 Hounsfield units 6.