A 58-year-old man is referred to your office after evaluation in the emergency room for abdominal pain. The patient was diagnosed with gastritis, but a CT scan with contrast performed during the work-up of his pain revealed a 2-cm adrenal mass. The patient has no history of malignancy and denies erectile dysfunction (ED). Physical examination reveals a BP of 122/78 with no gynecomastia or evidence of Cushing syndrome. His serum potassium is normal. What is the next step in determining whether this patient's adrenal mass should be resected?
This patient has what is commonly referred to as an adrenal incidentaloma. If the mass is greater than 1 cm, the first step is to determine whether it is a functioning or nonfunctioning tumor via measurement of serum metanephrines (pheochromocytoma) and dexamethasone-suppressed cortisol (Cushing syndrome) levels. As the patient has no history of malignancy, a CT-guided fine-needle aspiration is not required. The patient has normal BP and potassium; therefore, plasma aldosterone/plasma renin ratio to evaluate primary hyperaldosteronism is not required. There are no signs of feminization or erectile dysfunction, so sex-steroid measurement is not indicated. Contrast-enhanced CT after appropriate serum work-up determines true size and characteristics (Hounsfield units ). Malignant indicators include large-size (>4-6cm), irregular margins, soft tissue calcifications, tumor inhomogeneity, high CT attenuation (values greater than 10 HU), or delayed washout of contrast. CT scan should be repeated in 6 months and again in 1 year to ensure stability of the adrenal mass, but only after a functioning tumor has been excluded.
Plasma aldosterone/renin ratio
Estradiol level
Plasma metanephrines and dexamethasone-suppressed cortisol level
Testosterone level
Endocrinology