Evaluation and Management of Adrenal Masses

First, Dr. Kutikov shares important general information about adrenal masses. He notes that oftentimes, referral patterns for adrenal cancers are diverse. Although multiple specialties can take care of these patients, he thinks that the retroperitoneal space is best known by urologists, who emphasize non-surgical intervention. Adrenal masses are most likely to be found incidentally on imaging on CAT scans for urolithiasis or staging for urologic cancers. Dr. Kutikov notes that adrenal masses are quite common in patients older than 70 years old as well.

Next, Dr. Kutikov summarizes his typical work up of adrenal masses. Because the majority of masses are benign and non-functional, it is important to distinguish these from malignant and functional masses. To assess if the mass is metabolically active (releasing hormones, catecholamines, and aldosterone), he looks for hypertension. Additionally, he observes the patient for the classic triad of a pheochromocytoma—sweating, headaches, and tachycardia. He also notes that extra-adrenal paragangliomas are much more likely to be malignant than pheochromocytomas, but the distinction between the two tumors has to be made clinically. As for the specific lab tests he orders, he checks aldosterone and renin levels, plasma metanephrines (a more specific surrogate for catecholamine levels), and performs a dexamethasone cortisol suppression test. If any of these tests are abnormal, he recommends that urologists partner with endocrinologists to interpret the results and manage the patient.

Next, the doctors discuss imaging for adrenal masses. A non-contrast CT is the standard imaging modality for adrenal masses, as it can show lipid-rich areas (less than 10 houndsfield units). If the lesion is lipid-rich, it is most likely an adenoma and not malignant. Lipid-poor lesions have a 30% chance of also being adenoma—in these cases, Dr. Kutikov recommends doing an adrenal washout study, which is simply a delayed CT urogram. If the patient washes out lots of contrast, it is indicative of lots of intracellular lipids. It is important to note that CT with contrast does not show lipid-rich areas, and MRI serves the same function as a non-contrast CT. Dr. Kutikov also adds the importance of size—tumors larger than 4.5 cm are large enough to consider resection with the appropriate clinical and laboratory data. Adrenocortical carcinomas (ACC) are malignant and should always be taken out if greater than 4.6 cm and in patients with no contraindications.

Next, Dr. Kutikov explains the role of adrenal biopsies in evaluating adrenal masses. He notes that biopsies are useful because they can differentiate between ACC and adenomas if imaging was not definitive, but require careful technique as ACC is known to seed the needle tract. Also, a needle biopsy should never be performed on a pheochromocytoma. His general rule is to only perform a biopsy if he suspects that metastatic disease confirmation will change cancer treatment. Then, Dr. Kutikov discusses management of myelolipomas, which are tumors made of bone marrow and fat. He usually laves these patients alone, but repeats imaging if he suspects an alternate diagnosis of malignant sarcoma or that the myeloliipoma is hiding another tumor within it.

Finally, Dr. Kutikov outlines his surgical management of adrenal masses. Dr. Bagrodia and Dr. Kutikov discuss the pros and cons of minimally invasive and open surgeries. Dr. Kutikov strongly recommends open surgery for ACC if the tumor is larger than 6 cm but acknowledges that small pheochromocytomas can be managed laparoscopically. As for follow-up for his non-surgical adrenal mass patients, he agrees with the 2016 European Association of Urology guidelines and does not repeat imaging or lab work up in patients with lipid rich masses smaller than 4 cm.