Management of Suspected Adrenal Tumors

Initial Evaluation and Diagnosis

• The National Comprehensive Cancer Network recommends comprehensive hormonal screening to exclude functional tumors, particularly pheochromocytoma, followed by dedicated adrenal protocol imaging (CT or MRI) to characterize the mass and determine surgical approach 1
• The American College of Surgeons and other guideline societies emphasize the importance of excluding pheochromocytoma before any intervention, including biopsy or surgery, to prevent fatal hypertensive crisis 1, 2
• Obtain fractionated plasma-free metanephrines immediately to screen for pheochromocytoma 1
• If plasma metanephrines are elevated or the mass shows >10 HU on unenhanced CT, pheochromocytoma must be excluded before any surgical planning 3

Hormonal Evaluation

• The Endocrine Society recommends comprehensive functional assessment, including Cushing syndrome screening with serum ACTH, cortisol, and DHEA-S, and hyperaldosteronism screening with plasma aldosterone and renin activity 1, 3
• Pheochromocytoma screening should be performed as noted above 1

Imaging and Diagnosis

• The National Comprehensive Cancer Network recommends adrenal protocol CT or MRI to determine size, heterogeneity, lipid content, contrast washout characteristics, and margin features to distinguish benign from malignant lesions 1, 4, 5
• Unenhanced CT <10 HU is likely benign, while unenhanced CT >10 HU requires enhanced CT and 15-minute washout 5, 1
• Chemical-shift MRI is highly sensitive and specific for differentiating benign from malignant tumors 4, 5

Surgical Planning

• The American College of Surgeons recommends open adrenalectomy for tumors with high malignancy risk, as laparoscopic approach increases local recurrence and peritoneal spread risk 4, 5, 2
• Surgical resection with removal of adjacent lymph nodes is the only potentially curative treatment for localized adrenal carcinoma 4, 5
• R0 (margin-free) resection is the only means to achieve long-term survival 2

Pheochromocytoma Management

• The Endocrine Society recommends mandatory preoperative alpha-blockade for 10-14 days before surgery to prevent intraoperative hypertensive crisis and arrhythmias 2
• Target blood pressure <130/80 mmHg supine, systolic >90 mmHg upright, and use phenoxybenzamine or doxazosin as alpha-blockade 2

Follow-up and Surveillance

• Intermediate-size tumors (4-6 cm) with benign CT/MRI criteria should be repeated in 3-6 months, and if enlarging >1 cm in 1 year, adrenalectomy should be considered for suspected carcinoma 1
• Laparoscopic approach is acceptable for masses <8 cm without preoperative evidence of invasiveness 2