What is the next step in managing a female patient with a large, possibly vascular adrenal tumor in the upper pole of the kidney?

Management of Large, Vascular Upper Pole Mass Suspicious for Adrenal Tumor

Your immediate next step is to perform comprehensive hormonal screening to exclude functional tumors (particularly pheochromocytoma), followed by dedicated adrenal protocol imaging (CT or MRI) to characterize the mass and determine surgical approach. 1

Critical First Step: Exclude Pheochromocytoma

Never proceed with any intervention—including biopsy or surgery—without first ruling out pheochromocytoma, as manipulation of an undiagnosed catecholamine-secreting tumor can trigger fatal hypertensive crisis. 1

• Obtain fractionated plasma-free metanephrines immediately 1
• If plasma metanephrines are elevated or the mass shows >10 HU on unenhanced CT, pheochromocytoma must be excluded before any surgical planning 2
• This is non-negotiable regardless of whether the patient has classic symptoms 2

Complete Hormonal Evaluation Required

All patients with suspected adrenal masses require comprehensive functional assessment: 1, 2

• Cushing syndrome screening: Serum ACTH, cortisol, and DHEA-S with either overnight 1 mg dexamethasone suppression test (cortisol >138 nmol/L indicates autonomous secretion) or 2-3 repeated midnight salivary cortisols 1, 2
• Hyperaldosteronism screening: Plasma aldosterone and renin activity with electrolytes (aldosterone-to-renin ratio >30 indicates hyperaldosteronism) 1, 2
• Pheochromocytoma screening: As noted above 1

Dedicated Imaging with Adrenal Protocol

Perform adrenal protocol CT or MRI to determine size, heterogeneity, lipid content, contrast washout characteristics, and margin features—this is essential for distinguishing benign from malignant lesions. 1

CT Protocol Interpretation:

• Unenhanced CT <10 HU: Likely benign lipid-rich adenoma 1
• Unenhanced CT >10 HU: Proceed with enhanced CT and 15-minute washout 1
  • >60% washout at 15 minutes: Likely benign 1
  • <60% washout: Possibly malignant 1

MRI Protocol:

• Chemical-shift MRI is highly sensitive and specific for differentiating benign from malignant tumors (benign tumors contain fat, malignant typically do not) 1
• MRI better documents local invasion and inferior vena cava involvement than CT 1

Features Suggesting Malignancy:

Strongly suspect adrenal carcinoma in tumors >4 cm with irregular margins, internal heterogeneity, or local invasion. 1

• Size >6 cm with aggressive features mandates evaluation for metastases with chest, abdomen, and pelvis imaging 1
• Irregular/inhomogeneous morphology, lipid-poor appearance, lack of contrast washout, or secretion of multiple hormones all suggest malignancy 1

Surgical Planning Based on Findings

If Malignancy Suspected (Large, Heterogeneous, Aggressive Features):

Open adrenalectomy is mandatory for tumors with high malignancy risk—laparoscopic approach increases local recurrence and peritoneal spread risk. 1

• Surgical resection with removal of adjacent lymph nodes is the only potentially curative treatment for localized adrenal carcinoma 1
• May require en bloc resection of adjacent structures (liver, kidney, pancreas, spleen, diaphragm) for complete R0 resection 1
• R0 (margin-free) resection is the only means to achieve long-term survival 1
• Surgery should be performed only in centers with >10 adrenalectomies for adrenal cancer per year 1

If Pheochromocytoma Confirmed:

Mandatory preoperative alpha-blockade for 10-14 days before surgery to prevent intraoperative hypertensive crisis and arrhythmias. 1

• Target blood pressure <130/80 mmHg supine, systolic >90 mmHg upright 1
• Phenoxybenzamine 10 mg twice daily with adjustments every 2-4 days, or doxazosin as alternative 1
• Add calcium channel blockers or metyrosine if target not reached 1

If Benign-Appearing but Large (4-6 cm):

• Intermediate-size tumors (4-6 cm) with benign CT/MRI criteria: Repeat imaging in 3-6 months 1
• If enlarging >1 cm in 1 year: Adrenalectomy for suspected carcinoma 1
• Laparoscopic approach acceptable for masses <8 cm without preoperative evidence of invasiveness 1

Critical Pitfalls to Avoid

• Never biopsy a potentially resectable primary adrenal tumor—biopsies are not informative and potentially harmful, with risk of tumor seeding and hypertensive crisis if unsuspected pheochromocytoma 1, 2
• Never proceed with elective surgery without excluding functional pathology—undiagnosed pheochromocytoma can cause cardiovascular collapse, and untreated Cushing syndrome increases surgical morbidity and mortality 2
• Adrenal biopsy only indicated if metastatic disease from extra-adrenal malignancy would change management, and only after excluding pheochromocytoma 1, 2

Distinguishing Adrenal from Renal Origin

Given the upper pole location, consider that this could be a renal cell carcinoma rather than adrenal tumor: 3

• Evaluate blood supply pattern on imaging—adrenal tumors typically supplied by adrenal arteries, renal tumors by renal vessels 3
• If bilateral adrenal glands visualize normally on functional imaging, tumor more likely renal in origin 3
• MRI superior to CT for determining tissue of origin and local invasion 1