Understanding Adrenal Masses: Diagnosis and Management

Adrenal masses are often discovered incidentally during imaging studies, raising questions about their nature and potential impact on health. While some masses may arise from the adrenal glands themselves, distinguishing between benign and malignant lesions is crucial for effective management. In older patients with co-morbidities, the approach to treatment can vary, especially if blood pressure is already controlled through medications like mineralocorticoid receptor (MR) antagonists.

To assess adrenal masses accurately, adrenal venous sampling is a key diagnostic procedure performed by an interventional radiologist. This process involves measuring cortisol and aldosterone levels from both the adrenal veins and inferior vena cava. Elevated cortisol levels in adrenal veins compared to peripheral blood confirm proper catheter placement. Some medical centers offer rapid assays for immediate results, enhancing the efficiency of the diagnosis.

When examining an adrenal mass, the first consideration is whether the mass is primary or metastatic. A thorough patient history is essential; for instance, the absence of symptoms such as weight loss or changes in appetite may indicate a benign origin. If the mass is suspected to be from the adrenal gland, it could either be cortical or medullary in nature. Initial classifications may include the possibility of a non-functional 'incidentaloma' or hormonal secreting tumors such as phaeochromocytomas, which can lead to hypertension and diabetes.

Screening tests play a vital role in evaluating hormone secretion from the adrenal mass. For suspected phaeochromocytomas, a 24-hour urine collection for catecholamines is a prudent choice. If there is a high level of suspicion, measuring serum normetanephrine can exclude this type of tumor most effectively. Additionally, in cases of hypertension accompanied by hypokalaemia, measuring the aldosterone-to-renin ratio is essential to screen for primary hyperaldosteronism.

Cushing syndrome is another condition to consider, particularly if the patient exhibits symptoms of cortisol excess. Standard screening tests for this syndrome should be employed to rule it out. Furthermore, measuring sex steroid precursors such as androstenedione and DHEA can provide additional insights into the mass’s characteristics.

The management of incidental adrenal tumors typically depends on their size and hormonal activity. For masses smaller than 4 cm with no signs of malignancy, a conservative approach may be taken. Follow-up strategies often include repeat evaluations after six months; normal results can lead to annual monitoring. If two assessments show no hormone secretion, the likelihood of future secretion is markedly reduced, allowing for continued observation without immediate intervention.