Management of Newly Diagnosed Adrenal Adenoma
All patients with newly diagnosed adrenal adenoma require comprehensive hormonal evaluation and risk stratification based on imaging characteristics and size, with management determined by functional status, size, and imaging features. 1
Initial Hormonal Evaluation (Mandatory for All Patients)
Every patient requires screening for hormone hypersecretion, regardless of how benign the lesion appears radiologically, as approximately 5% of radiologically benign lesions harbor subclinical hormone production requiring treatment 1, 2:
Cortisol assessment: Perform 1 mg overnight dexamethasone suppression test with plasma ACTH levels. Serum cortisol ≤50 nmol/L excludes autonomous secretion, 51-138 nmol/L indicates possible secretion, and >138 nmol/L confirms autonomous cortisol secretion 1
Pheochromocytoma screening: Measure plasma metanephrines or 24-hour urinary metanephrines for all patients—this is mandatory before any surgical consideration to prevent life-threatening intraoperative hypertensive crisis 1, 3
Aldosterone assessment: Check aldosterone-to-renin ratio and serum potassium if the patient is hypertensive or hypokalemic 1
Androgen testing: Measure DHEA-S, 17-OH-progesterone, androstenedione, and 17-beta-estradiol only if clinically indicated 1
Imaging Characterization
Non-contrast CT is the gold standard initial test 1:
- <10 Hounsfield Units (HU): Confidently benign 1
- 10-20 HU: Low malignancy risk 1
- >20 HU: 6.3% malignancy risk 1
Management Algorithm Based on Size and Function
Benign Non-Functional Adenomas <4 cm
No further imaging or hormonal testing is required if the lesion is homogeneous, <10 HU, and hormonally inactive 1, 2. This represents the majority of adrenal adenomas and requires only initial characterization.
Lesions ≥4 cm
Repeat imaging at 6-12 months is required, even if the lesion appears benign on initial CT, due to higher malignancy risk 1, 2, 3. Most surgically resected pheochromocytomas and adrenocortical carcinomas were >4 cm at diagnosis 2.
Functional Adenomas
Cortisol-secreting adenomas: Screen for associated comorbidities (glucose intolerance, weight gain, osteopenia) and consider adrenalectomy based on symptoms and overall health status 1
Aldosterone-secreting adenomas: Perform confirmatory testing with saline suppression test and bilateral adrenal vein sampling to lateralize production. Laparoscopic adrenalectomy is the treatment of choice 1
Pheochromocytoma: Mandatory surgical resection is required. Preoperatively, initiate alpha blocker therapy for 1-3 weeks, followed by beta blocker for reflex tachycardia control 1
Growth-Based Intervention Thresholds
If follow-up imaging is performed 1, 2, 3:
- <3 mm/year growth: No further imaging or testing required
- >5 mm/year growth: Consider adrenalectomy after repeating functional workup
Special Population Considerations
Patients with history of extra-adrenal malignancy: These patients have a metastatic risk ranging 25-72% depending on primary tumor. However, standard hormonal evaluation is still required regardless of cancer history, as up to 50% of adrenal masses in cancer patients represent independent adrenal pathology rather than metastases 1, 2, 4
Young adults, children, and pregnant patients: Expedited evaluation is required, as adrenal lesions are more likely malignant in these populations. MRI is preferred over CT when possible 1, 2
Hormonal Follow-Up Controversy
There is divergence in guideline recommendations regarding repeat hormonal testing 2:
- The American Urological Association (2023) does not recommend repeat hormonal testing if initial workup was normal
- The American Association of Clinical Endocrinologists and American Association of Endocrine Surgeons recommend annual hormonal panel for 5 years
Given the low but real risk of developing hormone hypersecretion over time, annual hormonal screening for 5 years is the more cautious approach for lesions requiring imaging surveillance.
Critical Pitfalls to Avoid
Never perform adrenal biopsy as part of initial workup due to limited clinical value and risks including tumor seeding 1, 2, 3
Never skip pheochromocytoma screening before surgery—undiagnosed pheochromocytoma can cause life-threatening intraoperative hypertensive crisis 1, 3
Avoid laparoscopic approach for suspected adrenocortical carcinoma—open surgery is required for large, invasive tumors to prevent carcinomatosis 1
Do not assume imaging characteristics alone determine functional status—rare cases show discordance between non-contrast CT diagnosis and hormonal activity 5