What is the initial approach to managing a patient with an adenoma?

Initial Management of Adenoma

The initial approach to managing a patient with an adenoma depends critically on the anatomic location and tissue type, with adrenal adenomas requiring immediate hormonal screening and imaging characterization, while gastric and colonic adenomas necessitate endoscopic assessment with histologic confirmation, and pituitary adenomas demand both hormonal evaluation and dedicated MRI imaging. 1

Adrenal Adenomas

Immediate Imaging Characterization

• Obtain unenhanced CT scan as the first-line imaging study to measure Hounsfield units (HU), as homogeneous lesions with ≤10 HU are definitively benign and require no further imaging regardless of size. 1, 2
• For lesions with HU >10 on initial non-contrast CT, proceed to second-line imaging with either washout CT or chemical shift MRI to distinguish adenomas from other masses. 1
• Be aware that approximately one-third of adenomas do not washout in the typical adenoma range, and one-third of pheochromocytomas may falsely appear as adenomas on washout studies. 1

Mandatory Hormonal Screening

• Every patient with an adrenal incidentaloma requires comprehensive hormonal evaluation including: 1, 2
  • 1-mg overnight dexamethasone suppression test (cortisol >50 nmol/L or >1.8 µg/dL indicates mild autonomous cortisol secretion)
  • Plasma or urinary fractionated metanephrines (to exclude pheochromocytoma)
  • Aldosterone-to-renin ratio if hypertension or unexplained hypokalemia is present

Size-Based Management Algorithm

• Benign non-functional adenomas <4 cm with <10 HU require no further follow-up imaging or functional testing. 1
• Non-functional lesions that are radiologically benign (<10 HU) but ≥4 cm should undergo repeat imaging in 6-12 months. 1
• Consider adrenalectomy for lesions growing >5 mm/year after repeating functional work-up. 1
• Lesions >4 cm that are inhomogeneous or have HU >20 should be discussed in multidisciplinary meeting as they carry sufficient malignancy risk to warrant surgical consideration. 2

Functional Adenoma Management

• Aldosterone-secreting adenomas require laparoscopic adrenalectomy after confirmation with saline suppression testing and consideration of adrenal vein sampling for lateralization. 1
• Patients with mild autonomous cortisol secretion and progressive metabolic comorbidities (hypertension, type 2 diabetes) attributable to cortisol excess should be considered for adrenalectomy after shared decision-making. 1
• Those not managed surgically require annual clinical screening for new or worsening comorbidities. 1

Gastric Adenomas

Endoscopic Assessment and Biopsy

• All gastric adenomas carry significant cancer risk and should be resected where appropriate, with diagnosis and degree of dysplasia confirmed histologically before treatment. 1
• Perform careful evaluation of the entire stomach to identify synchronous neoplasia (present in up to 30% of cases), gastric atrophy, and intestinal metaplasia. 1
• Test for Helicobacter pylori status in all cases. 1

Resection Strategy

• En bloc excision with endoscopic submucosal dissection (ESD) is advisable for sessile polyps >15 mm due to high possibility of invasive neoplasia and reduced recurrence compared to endoscopic mucosal resection (EMR). 1
• Approximately 50% of adenomatous polyps >2 cm contain foci of adenocarcinoma, mandating complete resection. 1

Surveillance Protocol

• Follow-up gastroscopy should be performed at 6-12 months after endoscopic resection. 1
• Continue surveillance gastroscopy at yearly intervals depending on number of polyps, size, and highest grade of dysplasia. 1

Pituitary Adenomas

Imaging Requirements

• MRI of the sella with both pre-contrast (T1 and T2) and post-contrast-enhanced (T1) thin-sliced sequences is mandatory for evaluation of pituitary adenomas. 3
• High-resolution, focused field-of-view sequences targeted for sellar and parasellar assessment should be used. 3
• MRI is significantly more sensitive than CT for detecting pituitary pathology and better demonstrates cavernous sinus invasion critical for surgical planning. 3

Comprehensive Hormonal Evaluation

• All patients require evaluation for gonadal, thyroid, and adrenal function as well as prolactin and growth hormone secretion. 4
• Visual assessment is essential and should include visual acuity testing, visual field assessment, and fundoscopy for any macroadenoma. 3

Age-Specific Considerations

• In children and young people under 19 years, consider genetic assessment due to increased potential for familial or syndromic disease (McCune-Albright syndrome, Carney complex, X-linked acrogigantism). 1, 5
• Pituitary adenomas in young patients are more aggressive, present as larger masses, and have higher rates of genetic causes compared to adults. 1, 5

Multidisciplinary Discussion

• Management decisions should involve multidisciplinary discussion at both local and national levels, particularly for complex cases or in younger patients. 1
• Surgery should be performed in specialist centers with experienced pituitary surgeons. 1

Critical Pitfalls to Avoid

• Never biopsy an adrenal mass before excluding pheochromocytoma, as this can precipitate hypertensive crisis. 1
• Do not assume all adrenal lesions with washout characteristics are benign—malignant masses can also washout in the adenoma range. 1
• Avoid delaying surgical referral for gastric adenomas >2 cm due to high cancer risk. 1
• Do not use CT as first-line imaging for pituitary adenomas—MRI is mandatory for adequate evaluation. 3