What is the recommended management for an adult patient with a history of hypertension and bilateral benign adrenal adenomas, who has been found to have a new 1.2 cm weakly enhancing right renal cortical lesion suspected to be an indolent renal neoplasm on MRI?

Management of Incidental 1.2 cm Renal Cortical Lesion with Bilateral Benign Adrenal Adenomas

The bilateral benign adrenal adenomas require no further follow-up imaging or functional testing, while the 1.2 cm renal cortical lesion warrants active surveillance with repeat imaging in 6-12 months given its small size and indolent characteristics.

Adrenal Adenoma Management

No Further Surveillance Required

• Patients with benign non-functional adenomas <4 cm do not require further follow-up imaging or functional testing 1
• Since your bilateral adenomas are lipid-rich (radiologically benign) and similar in size to prior imaging, they meet criteria for discontinuing surveillance 1
• Each lesion in bilateral adrenal incidentalomas should be characterized separately using the same criteria as unilateral lesions 1

Additional Considerations for Bilateral Lesions

• Measure serum 17-hydroxyprogesterone to exclude congenital adrenal hyperplasia, particularly given the bilateral nature 1, 2
• Assess for adrenal insufficiency only if there are clinical concerns for bilateral infiltrative disease, metastases, or hemorrhage—which is not suggested by your stable, benign-appearing adenomas 1
• Given the patient's hypertension history, confirm that prior functional workup excluded primary aldosteronism (plasma aldosterone-to-renin ratio) and autonomous cortisol secretion (1 mg dexamethasone suppression test), as bilateral hyperplasia can occasionally develop autonomous function over time 2, 3, 4

Renal Cortical Lesion Management

Active Surveillance Approach

• For a 1.2 cm weakly enhancing renal cortical lesion suspected to be an indolent renal neoplasm, active surveillance with repeat imaging in 6-12 months is the appropriate initial management 1
• This follows the same conservative surveillance principles applied to small, radiologically benign-appearing lesions 1
• The weak enhancement pattern and small size (<1.5 cm) favor an indolent process with low malignant potential

Surveillance Protocol

• Repeat cross-sectional imaging (MRI or CT) at 6-12 months to assess for growth 1
• If growth is <3 mm/year, no further imaging follow-up is required 1
• If growth exceeds 5 mm/year, consider urologic referral for potential intervention after repeat assessment 1

Key Clinical Pitfalls to Avoid

Common Errors in Bilateral Adrenal Management

• Do not assume all bilateral adrenal masses require ongoing surveillance—benign adenomas <4 cm with characteristic imaging features are exempt from follow-up 1
• Do not overlook the possibility that bilateral hyperplasia can develop unilateral autonomous function requiring adrenal vein sampling if new hormonal symptoms emerge 2, 4
• Failure to check 17-hydroxyprogesterone in bilateral adrenal masses can miss congenital adrenal hyperplasia 1, 2

Renal Lesion Considerations

• Small renal masses with weak enhancement can represent benign entities (oncocytoma, papillary RCC) or indolent malignancies—growth kinetics on surveillance imaging will guide management 1
• Avoid premature intervention for lesions <1.5 cm unless there are concerning features (rapid growth, heterogeneity, invasion) 1

Practical Management Summary

Immediate Actions:

• Confirm prior functional workup of adrenal adenomas was completed (if not, order 1 mg dexamethasone suppression test, plasma aldosterone-to-renin ratio, and plasma/urine metanephrines) 5
• Order serum 17-hydroxyprogesterone to exclude congenital adrenal hyperplasia 1, 2

Follow-up Plan:

• No further adrenal imaging or functional testing required for the bilateral adenomas 1
• Repeat renal imaging (MRI or CT) in 6-12 months to assess the renal cortical lesion for growth 1
• Reassess blood pressure control given hypertension history and ensure it is not related to undiagnosed primary aldosteronism 3