Cook recommended a workup for a patient with a mass found incidentally in the adrenal gland. The author is from Oregon Health Sciences University in Portland.
Parameters:
(1) cortrosyn (cosyntropin, ACTH IV) stimulation test
(2) screening tests for hormone excess
(3) size of the lesion
(4) FNA (fine needle aspiration)
The cortrosyn test is performed to identify adrenal insufficiency or evidence of congenital adrenal hyperplasia.
If the cortrosyn test is normal, then the patient is screened for:
(1) urine free cortisol
(2) plasma catecholamines and urinary metanephrines (to exclude pheochromocytoma)
(3) aldosterone
(4) renin
If excess hormone production can be demonstrated, then the mass is surgically resected.
NOTE: Pheochromocytoma must be excluded or identified before attempting to resect an adrenal mass since this will affect surgical management.
If hormone tests are normal, then consider FNA, especially if suspect a metastatic carcinoma. If the FNA demonstrates metastatic carcinoma, then management depends on the primary tumor.
If the FNA is negative for tumor or is not performed, then management depends on the size and rate of change in size over time as seen on imaging studies.
(1) If the size is >= 6 cm, then surgical resection is recommended.
(2) If the size is < 6 cm, then the patient can be followed using CT scan.
(a) If the lesion remains stable then continued monitoring is performed.
(b) If the lesion increases in size then surgical resection is recommended.
where:
• The size range of 4-6 cm is a borderline size range. Tumors < 4 cm are unlikely to be primary adrenal malignant tumors, but 5-25% are metastatic carcinomas.
