Management of Left Adrenal Mass

Initial Diagnostic Workup

The American Urological Association recommends that all patients with a left adrenal mass require both hormonal evaluation to exclude functional tumors and imaging characterization to assess malignancy risk, with management decisions based on size, imaging characteristics, and functional status 1, 2
Approximately 5% of radiologically benign incidentalomas have subclinical hormone production requiring treatment, highlighting the importance of comprehensive hormonal evaluation regardless of how benign the mass appears on imaging 3
The Endocrine Society suggests performing a 1 mg overnight dexamethasone suppression test to screen for autonomous cortisol secretion in all patients 2, 4
Measuring plasma free metanephrines or 24-hour urinary metanephrines/normetanephrines is recommended to exclude pheochromocytoma before any intervention 2, 3, 4

Adrenalectomy is indicated for pheochromocytomas, aldosterone-secreting adenomas causing primary aldosteronism, and cortisol-secreting masses with clinically apparent Cushing's syndrome, according to the American College of Surgeons 2, 4
Minimally invasive surgery should be used when feasible for these procedures, as recommended by the Society of Surgical Oncology 2
For mild autonomous cortisol secretion, adrenalectomy should be considered only in younger patients with progressive metabolic comorbidities attributable to cortisol excess after shared decision-making, as suggested by the Endocrine Society 3

Young adults, children, and pregnant patients require expedited evaluation, as adrenal lesions are more likely to be malignant in these populations, according to the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists 1, 5
Patients with a history of extra-adrenal malignancy require closer evaluation, even for smaller lesions, as metastatic disease to the adrenal gland occurs in 25-72% depending on primary tumor type, as reported by the National Comprehensive Cancer Network 3, 6

Adrenal biopsy should not be performed routinely, as it is rarely indicated for adrenal incidentalomas and carries a risk of tumor seeding in suspected adrenocortical carcinoma, according to the American Urological Association 2, 3, 6
Initial hormonal evaluation should not be skipped, as even radiologically benign-appearing lesions require hormonal screening, and approximately 5% harbor subclinical hormone production requiring treatment, as recommended by the Endocrine Society 3
Unnecessary repeated imaging should be avoided, as it leads to increased radiation exposure, patient anxiety, and healthcare costs, according to the American College of Radiology 3

Minimally invasive adrenalectomy can be offered for suspected adrenocortical carcinomas that can be safely resected without rupturing the tumor capsule, as suggested by the Society of Surgical Oncology 2
Open adrenalectomy should be considered for larger adrenocortical carcinomas or those with locally advanced tumors, lymph node metastases, or tumor thrombus in the renal vein/inferior vena cava, according to the American College of Surgeons 2

The American Urological Association recommends that any mass growing >5 mm/year after repeating functional work-up should be considered for adrenalectomy 7
For masses ≥4 cm with ≤10 HU, repeat imaging in 6-12 months is recommended 7
For indeterminate masses on imaging, repeat imaging in 3-6 months versus surgical resection should be considered based on shared decision-making, considering patient age, comorbidities, and anxiety level 7

For masses ≥4 cm that are radiologically benign, repeat unenhanced CT at 6-12 months is recommended 7
If growth >5 mm/year, repeat functional work-up and consider adrenalectomy 7

Young adults (<40 years), children, and pregnant patients require expedited evaluation because adrenal lesions are more likely malignant in these populations, and low-dose CT or chemical shift MRI should be used to minimize radiation exposure 7

Each lesion should be characterized separately using the same algorithm as for unilateral masses 7
Serum 17-hydroxyprogesterone should be measured to exclude congenital adrenal hyperplasia 7
Assess for adrenal insufficiency if bilateral infiltrative disease, metastases, or hemorrhage is suspected 7