What is the best course of action for an asymptomatic elderly female patient with a stable 3cm (centimeter) adrenal gland lesion, likely an adrenal adenoma, that has been present for several years?

Management of Stable 3cm Adrenal Lesion in Asymptomatic Elderly Female

For an asymptomatic elderly female with a stable 3cm adrenal lesion present for several years, no further imaging follow-up is required if the lesion demonstrates benign characteristics on CT (<10 HU, homogeneous) and hormonal screening is negative. 1

Initial Assessment Required

Imaging Characterization

• Obtain an adrenal protocol CT (if not already done) to assess density, homogeneity, lipid content, and margins 1
• Benign adenomas demonstrate: unenhanced density <10 Hounsfield Units (HU), homogeneous appearance, well-circumscribed margins, and size <4 cm 1
• If the lesion shows <10 HU on unenhanced CT, it is likely benign and requires minimal follow-up 1

Mandatory Hormonal Screening

Even in asymptomatic patients, all adrenal incidentalomas require functional evaluation to exclude subclinical hormone excess 1, 2:

• Pheochromocytoma screening: Fractionated plasma-free metanephrines 1
• Cushing syndrome screening: 1 mg overnight dexamethasone suppression test with 8 AM plasma cortisol, plus serum ACTH, cortisol, and DHEA-S 1, 2
  • Cortisol ≤50 nmol/L (1.8 μg/dL) excludes autonomous secretion 2
  • Cortisol >138 nmol/L (>5.0 μg/dL) indicates autonomous cortisol secretion 2
• Hyperaldosteronism screening: Plasma aldosterone and renin activity, plus electrolytes 1

Management Algorithm Based on Findings

If Benign-Appearing (<10 HU) and Non-Functioning

Since this lesion has been stable for several years and is 3cm (below the 4cm threshold), no further follow-up imaging or hormonal testing is needed 1. The NCCN guidelines specifically state that benign non-functional adenomas <4 cm with unchanged appearance do not require further follow-up 1.

If Indeterminate Imaging Features (>10 HU)

For lesions that don't meet benign criteria on unenhanced CT 1:

• Perform washout CT protocol: >60% washout at 15 minutes suggests benign lesion 1
• Alternative: Chemical shift MRI showing signal dropout indicates lipid-rich adenoma 1

If Hormonal Abnormalities Detected

Mild Autonomous Cortisol Secretion (MACS):

• In elderly patients, observation with annual clinical screening for metabolic comorbidities is appropriate 1, 2
• Adrenalectomy is reserved for younger patients with progressive metabolic complications 1, 2
• MACS rarely progresses to overt Cushing's syndrome 1

Overt Cushing's Syndrome:

• Unilateral adrenalectomy is indicated, preferably minimally invasive 1, 2

Pheochromocytoma or Aldosterone-Secreting Adenoma:

• Surgical resection is required 1

Critical Pitfalls to Avoid

• Never biopsy an adrenal mass without first excluding pheochromocytoma through plasma metanephrine testing, as this can trigger life-threatening hypertensive crisis 2, 3
• Do not skip hormonal screening even in asymptomatic patients, as subclinical hormone excess (particularly MACS) is common and associated with metabolic complications including diabetes, hypertension, cardiovascular events, and vertebral fractures 1, 2
• Avoid unnecessary repeated imaging for small benign-appearing masses that have been stable for years 1, 2

Special Considerations for Elderly Patients

In this elderly patient with a stable lesion over several years 1:

• The prolonged stability strongly favors benign disease
• Age and comorbidities should factor into any surgical decision-making
• Conservative management is appropriate for non-functioning lesions <4 cm 1
• Quality of life considerations take precedence over aggressive intervention in elderly patients with benign-appearing, stable lesions 1

The key distinguishing factor is whether this lesion demonstrates benign imaging characteristics (<10 HU) and negative hormonal screening—if both criteria are met, surveillance can be discontinued entirely 1.