What is the next step in management for a patient with a 1.9 cm left adrenal adenoma and a 5.2 cm left renal mass suspected to be renal cell carcinoma (RCC)?

Management of Concurrent Left Adrenal Adenoma and Suspected Renal Cell Carcinoma

Immediately refer this patient to urology for surgical planning, and urgently obtain fractionated plasma-free metanephrines to exclude pheochromocytoma before any surgical intervention. 1

Immediate Priority: Exclude Pheochromocytoma

• Obtain fractionated plasma-free metanephrines immediately before proceeding with any surgical planning or biopsy, as failure to exclude pheochromocytoma can result in fatal hypertensive crisis during surgery 1
• If the adrenal mass shows >10 HU on unenhanced CT (your 1.9 cm adenoma), pheochromocytoma screening is mandatory 2, 1
• Alpha-blockade for 10-14 days preoperatively is required if pheochromocytoma is confirmed, targeting blood pressure <130/80 mmHg supine 1

Complete Functional Adrenal Workup

While the adrenal mass appears benign by size, complete hormonal evaluation is essential before surgery:

• Screen for autonomous cortisol secretion with 1 mg dexamethasone suppression test 2
• Screen for primary aldosteronism if the patient has hypertension or hypokalemia using aldosterone-to-renin ratio 2
• Measure serum ACTH, cortisol, and DHEA-S to assess for Cushing syndrome 1

Surgical Planning for the Renal Mass

The 5.2 cm left renal mass requires surgical resection as the definitive treatment:

• Partial nephrectomy should be prioritized for this T1b tumor (>4 cm but ≤7 cm) to preserve renal function, as nephron-sparing approaches provide equivalent oncologic outcomes to radical nephrectomy for T1 tumors 2
• Minimally invasive (laparoscopic or robotic) partial nephrectomy is preferred when technically feasible without compromising oncologic outcomes 2
• If partial nephrectomy is not technically feasible due to tumor location or complexity, laparoscopic radical nephrectomy is the preferred alternative 2

Management of the Ipsilateral Adrenal Adenoma

The 1.9 cm left adrenal adenoma does NOT require routine resection during nephrectomy:

• Ipsilateral adrenalectomy is only indicated if imaging shows abnormal appearance of the adrenal gland or if there is direct tumor invasion 2
• Systematic adrenalectomy is not recommended when CT shows no evidence of adrenal invasion 2, 3
• In your case, the small size (1.9 cm) and adenoma characteristics suggest a benign, non-functional lesion that can be preserved 2
• However, if functional testing reveals autonomous hormone secretion, adrenalectomy should be performed concurrently with the renal surgery 2, 1

Critical Pitfall to Avoid

The most common and dangerous pitfall is proceeding to surgery without excluding pheochromocytoma. Even though the adrenal mass appears to be a benign adenoma, approximately 1.5-14% of adrenal incidentalomas are pheochromocytomas 2, and undiagnosed pheochromocytoma during surgery can cause life-threatening hypertensive crisis and arrhythmias 1. This screening must be completed before any surgical intervention.

Additional Surgical Considerations

• Lymph node dissection should be performed if there is clinically concerning regional lymphadenopathy on imaging or intraoperative findings 2
• Renal mass biopsy is NOT recommended preoperatively for this 5.2 cm mass with imaging characteristics consistent with RCC, as surgical resection is already indicated 2
• Negative surgical margins should be prioritized during partial nephrectomy 2, 3

Coordination of Care

Refer to urology immediately for surgical planning, as the 5.2 cm renal mass requires definitive treatment 2. The urologist can coordinate the functional adrenal workup and determine whether concurrent adrenalectomy is needed based on hormonal testing results and intraoperative findings 2, 1.