Is further workup or referral needed for a 1.12 cm left adrenal nodule, likely a benign adenoma?

From the Guidelines

For a 1.12 cm left adrenal nodule that is likely a benign adenoma, no immediate referral or intervention is typically needed, and follow-up imaging in 6-12 months with a non-contrast CT scan is recommended to ensure stability in size, as suggested by the most recent guidelines 1. These small adrenal nodules (less than 4 cm) are often incidental findings and are usually benign. However, basic laboratory tests to rule out functionality may include checking blood pressure, serum potassium, and possibly screening for excess cortisol (overnight dexamethasone suppression test) or catecholamines (plasma metanephrines) if there are any concerning symptoms like hypertension, unexplained weight gain, or palpitations, as recommended by the guidelines 1. Some key points to consider in the management of adrenal incidentalomas include:

• A focused history and physical examination aimed at identifying signs/symptoms of adrenal hormone excess, adrenal malignancy, and/or extra-adrenal malignancy should be performed 1.
• Patients found to have an indeterminate incidental adrenal mass should undergo a non-contrast CT as first-line imaging to distinguish benign lesions from those which require further radiologic investigation 1.
• Adrenal mass biopsy should not be performed routinely for the work-up of an adrenal incidentaloma, and should be reserved for cases in which the results of noninvasive techniques are equivocal 1.
• All patients with adrenal incidentalomas should be screened for autonomous cortisol secretion, and 1 mg dexamethasone suppression testing is the preferred screening test for identifying autonomous cortisol secretion when clinically appropriate 1. If the nodule grows significantly (more than 1 cm) during follow-up or reaches a size greater than 4 cm, referral to an endocrinologist or endocrine surgeon would be appropriate, as the risk of malignancy increases with larger tumor size, as suggested by the guidelines 1. This conservative approach is based on the very low risk of malignancy in small adrenal nodules with benign imaging characteristics, balanced against the unnecessary risks of invasive procedures for what are most commonly benign, non-functional adenomas.

From the Research

Incidental Adrenal Nodule Findings

• The detection of adrenal nodules has increased due to the frequent use of cross-sectional imaging of the abdomen 2.
• The majority of these nodules are found to be benign adrenal adenomas after biochemical and radiological evaluation 2.
• A small minority of cases may be diagnosed with a functional or malignant lesion, which can result in significant morbidity and mortality, requiring specialist management 2.

Further Workup and Referral

• There is no direct evidence in the provided studies to suggest a specific course of action for a 1.12 cm likely benign adrenal adenoma.
• However, the study on adrenal nodules for the non-specialist suggests that appropriate biochemical and radiological evaluation is necessary to determine the nature of the nodule 2.
• The study on incidental findings in brain imaging research emphasizes the importance of anticipating and articulating plans for handling incidental findings, prioritizing subject welfare and privacy, as well as scientific integrity 3.
• The other studies provided do not directly address the issue of adrenal nodules, but rather focus on incidental findings in genetic testing and imaging research 4, 5, 6.