Editing Diagnosis and Evaluation of Adrenal Mass (section)

== Management ==

* '''Options (2):'''
** '''Adrenalectomy'''
** '''Observation'''

=== Adrenalectomy ===

* '''<span style="color:#ff0000">Indications (11):</span>'''
*# '''<span style="color:#ff0000">Size ≥ 4 cm (with exception of myelolipoma)</span>'''
*#* '''Most adrenocortical carcinomas are >4cm in size'''
*#** '''Masses >6 cm should be considered malignant until proved otherwise.'''
*#** Although management of masses between 4-6 cm is controversial, in otherwise healthy individuals, masses >4 cm should be resected
*#*** Radiologically benign masses >4 cm may be followed in patients who are not prime candidates for surgery
*#* '''The incidence of benign adrenal adenomas increases with age'''
*#** '''Adrenal lesions in younger patients, even those < 4 cm, must be managed with greater caution than similar lesions in an older patient.'''
*#** Lesions >4 cm in older patients with significant comorbidities may be better served with observation than resection
*# '''<span style="color:#ff0000">Size increases > 1 cm on follow-up imaging</span>'''
*#* '''Current recommendation is to resect masses that grow >1 cm; however, incidence of malignancy among these patients is low'''
*# '''<span style="color:#ff0000">Adrenal hyperfunction</span>'''
*#* Some patients with primary aldosteronism may be managed medically, especially if they are poor surgical candidates
*#* '''Clinically silent adrenal hyperfunction is an area of debate.'''
*#** Due to the potentially life-threatening complications, it is accepted that '''any lesions exhibiting silent pheochromocytoma''', an adrenal incidentaloma with hormonal and radiologic signs of pheochromocytoma but without clinical symptoms, '''should be surgically removed after adequate adrenergic blockade'''
*#** '''Surgery may be elected for younger patients with subclinical Cushing syndrome''' or those with new onset, medically resistant or deteriorating disease attributable to cortisol excess'''.''' The remainder should be admitted to follow-up and recommended for surgery '''if''' they develop clinical signs of Cushing’s syndrome.
*# '''<span style="color:#ff0000">Mass with imaging findings that are suggestive of malignancy (e.g., lipid poor, heterogeneous, irregular borders, infiltrates surrounding structures), regardless of size</span>'''
*# '''<span style="color:#ff0000">Extremely large and/or symptomatic cyst or myelolipoma</span>'''
*# '''<span style="color:#ff0000">Isolated adrenal metastasis (multidisciplinary decision making required)</span>'''
*# '''<span style="color:#ff0000">During renal surgery for renal cell carcinoma if:</span>'''
*## '''<span style="color:#ff0000">Adrenal abnormal or not visualized because of large renal tumor size on imaging</span>'''
*## '''<span style="color:#ff0000">Vein thrombus to level of adrenal vein</span>'''
*# '''<span style="color:#ff0000">Failed neurosurgical treatment of Cushing disease, necessitating bilateral adrenalectomy</span>'''
*# '''<span style="color:#ff0000">Select patients with ectopic adrenocorticotropic hormone (ACTH) syndrome, requiring bilateral adrenalectomy</span>'''
*# '''<span style="color:#ff0000">ACTH-independent macronodular adrenal hyperplasia (AIMAH)</span>'''
*# '''<span style="color:#ff0000">Primary pigmented nodular adrenocortical disease (PPNAD)</span>'''
** '''*First 4 consistent with CUA Incidental Adrenal Mass Guidelines'''

=== Observation ===

* '''<span style="color:#ff0000">Follow-up protocol</span>'''
** '''<span style="color:#ff0000">Myelolipomas, hemorrhages, cysts do not necessarily require further evaluation</span>'''
** '''<span style="color:#ff0000">Non-functioning adenomas, typically < 4 cm, and masses not deemed resectable at initial diagnosis should undergo clinical, hormonal, and radiological surveillance.</span>'''
** No consensus on the proper methodology for follow-up. 
*** '''Surveillance proposed in 2011 CUA Guidelines''':
**** '''Annual clinical and hormonal testing for up to 4 years'''
***** There is no agreement on the best mechanism and frequency for hormonal follow-up. However, it should include the same screening tests used at primary evaluation
**** '''Radiographic assessments (depends on lesion characteristics +/- size)'''
***** Benign appearing masses
****** <1 cm, consider no further follow-up or enrolment in a clinical trial
****** 1-2cm, first follow-up scan at 12 months if clinical picture warrants
****** 2-4cm, first follow-up scan at 12 months
***** Radiologically suspicious lesions not initially removed
****** Any size, first follow-up scan should be at 3-6 months
***** Further imaging follow-up should be directed by clinical judgment. Consider 1-3 assessments with the first 2 years of diagnosis.
**** '''Tumours that remain stable on imaging and annual hormonal evaluation may be considered for discharge from follow-up after 4 years'''