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Question 9#

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 workup of his pain revealed a 2-cm adrenal mass. The patient has no history of malignancy and denies erectile dysfunction. 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?

A. Plasma aldosterone/renin ratio
B. Estradiol level
C. Plasma metanephrines and dexamethasone-suppressed cortisol level
D. Testosterone level
E. Repeat CT scan in 6 months

Correct Answer is C

Comment:

 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 sexsteroid measurement is not indicated. Unenhanced CT would be required after appropriate serum workup to determine true size and characteristics (Hounsfield units [HU]). Malignant indicators include large-size (> 4-6 cm), irregular margins, soft tissue calcifications, tumor inhomogeneity, or high unenhanced CT attenuation values greater than 10 HU. CT scans should be performed in 6 months and again in 1 year to ensure stability of the adrenal mass, but only after a functioning tumor has been excluded.