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?
Plasma aldosterone/renin ratio
Estradiol level
Plasma metanephrines and dexamethasone-suppressed cortisol level
Testosterone level
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.
Endocrinology