What is the significance of a focal isodense lesion in the trunk of the left adrenal gland, and how should it be further evaluated in the absence of intravenous (IV) contrast?

Evaluation of Focal Isodense Adrenal Lesion Without IV Contrast

The focal isodense lesion in your left adrenal gland cannot be definitively characterized without IV contrast, and you must obtain either a non-contrast CT to measure Hounsfield Units (HU) or proceed directly to contrast-enhanced CT with washout protocol or chemical shift MRI for definitive characterization. 1, 2

Why This Lesion is Indeterminate

An isodense adrenal lesion on contrast-enhanced CT is inherently indeterminate because:

• Approximately one-third of adrenal adenomas are lipid-poor and cannot be characterized by contrast-enhanced CT alone, as they lack sufficient intracytoplasmic lipid content to lower their attenuation 3
• The presence of IV contrast obscures the ability to measure baseline attenuation (HU), which is the single most important initial discriminator between benign adenomas (<10 HU) and lesions requiring further evaluation (>10 HU) 1, 2
• Isodense lesions can represent benign adenomas, pheochromocytomas, metastases, or even adrenocortical carcinoma, making imaging characterization essential before any management decisions 3

Recommended Diagnostic Algorithm

Step 1: Obtain Non-Contrast CT (Preferred Initial Approach)

• Measure the lesion's attenuation in Hounsfield Units on non-contrast CT - this is the essential first step recommended by the American College of Radiology 1, 2
• If the lesion measures <10 HU and is homogeneous and well-circumscribed, it is definitively a benign lipid-rich adenoma requiring no further imaging workup 1, 2
• If the lesion measures >10 HU, proceed immediately to second-line imaging 1, 2

Step 2: Second-Line Imaging for Lesions >10 HU

Choose one of the following:

Option A: Contrast-Enhanced CT with Washout Protocol

• Adenomas typically demonstrate >60% absolute washout at 15 minutes post-contrast 3, 2
• Critical pitfall: Approximately 1/3 of pheochromocytomas may washout in the characteristic range of an adenoma, and 1/3 of adenomas do not washout in the adenoma range 3, 2
• Malignant masses including adrenocortical carcinoma and hypervascular metastases can also washout in the adenoma range 3

Option B: Chemical Shift MRI

• Homogeneous signal intensity drop on MRI is diagnostic of lipid-rich adenoma 3, 2
• Heterogeneous signal intensity drop is controversial as minute amounts of microscopic fat have been identified in pheochromocytomas, adrenocortical carcinoma, and some metastases 3

Step 3: Mandatory Hormonal Evaluation

All patients with adrenal incidentalomas require biochemical screening regardless of imaging characteristics:

• Screen for pheochromocytoma with plasma or 24-hour urinary metanephrines - this is mandatory before any surgical intervention or biopsy, as several deaths have been reported after biopsies of undiagnosed pheochromocytomas 3, 1, 4
• Check aldosterone-to-renin ratio only if hypertension and/or hypokalemia are present 1
• Screen for cortisol excess with 1-mg dexamethasone suppression test or late-night salivary cortisol, as autonomous cortisol secretion without overt Cushing's syndrome may benefit from surgical resection 3, 5

Size-Based Management Considerations

• Lesions <3 cm: Most are benign in patients without cancer history; extensive workup usually not justified after basic characterization 3, 1
• Lesions 3-5 cm: Consider follow-up CT at 6-12 months, additional imaging characterization, or surgical consultation depending on imaging characteristics 3, 1
• Lesions >5 cm: Should be removed due to higher risk of malignancy 3, 1

Correlation with Prior Studies

Review any prior imaging studies (with and without contrast) to assess:

• Stability over time - lesions growing <3 mm/year require no further follow-up, while growth >5 mm/year warrants surgical consideration after repeating functional workup 3, 1
• Baseline characteristics - if prior non-contrast imaging exists showing <10 HU, this may obviate need for repeat imaging 1

Critical Pitfalls to Avoid

• Never perform adrenal biopsy without first excluding pheochromocytoma biochemically - this carries risk of fatal hypertensive crisis 3, 4
• Do not rely on contrast-enhanced CT alone for characterization - it cannot distinguish lipid-poor adenomas from other lesions 3
• Avoid biopsy for suspected adrenocortical carcinoma - risk of tumor seeding along needle tract 3, 1
• Do not use FDG-PET as first-line imaging - reserve for cases where CT and MRI remain inconclusive, particularly in oncology patients 3