A 60-year-old man presents to the clinic to discuss the results of an abdominal computed t… — USMLE Step 2 CK

A 60-year-old man presents to the clinic to discuss the results of an abdominal computed tomography (CT) scan performed for chronic, nonspecific flank pain. The scan incidentally reveals a $5.5\text{-cm}$ right adrenal mass with heterogeneous contrast enhancement, irregular borders, and an attenuation of $32\text{ Hounsfield units}$ . His blood pressure is $128/82\text{ mmHg}$ and his heart rate is $76\text{/min}$ . The physical examination is unremarkable, with no striae, bruising, or central obesity. A comprehensive metabolic panel is within normal limits. Endocrine evaluation demonstrates a normal 1-milligram overnight dexamethasone suppression test, normal fractionated urinary metanephrines, and a normal plasma aldosterone-to-renin ratio. Which of the following is the most appropriate next step in the management of this patient?

Surgical resection of the right adrenal glandAnswer
B
Image-guided core needle biopsy of the adrenal mass
C
Repeat abdominal imaging with CT scan in 6 to 12 months
D
Initiation of prophylactic glucocorticoid therapy
E
Empiric initiation of broad-spectrum antibiotic therapy

Answer

The most appropriate next step is surgical resection of the right adrenal gland due to the high-risk imaging features of the mass.

Surgical resection of the right adrenal gland is the correct management. The decision to operate on an adrenal incidentaloma depends on two main factors: hormonal activity and risk of malignancy. Even though this patient's comprehensive hormonal workup is completely normal (indicating a non-functioning tumor), the mass is highly suspicious for adrenocortical carcinoma based on imaging. Current surgical guidelines recommend resection for any adrenal mass larger than

4\text{ cm}

or any mass exhibiting suspicious features such as an attenuation greater than

10\text{ Hounsfield units}

, heterogeneity, or irregular margins. This patient's

5.5\text{-cm}

32\text{-HU}

mass meets both size and radiologic criteria for immediate surgical intervention.

Step-by-Step Solution

Analyze the size and imaging characteristics of the incidentaloma.

The mass is

5.5\text{ cm}

in size, has heterogeneous enhancement, irregular borders, and a high attenuation of

32\text{ Hounsfield units}

Size greater than

4\text{ cm}

and attenuation greater than

10\text{ Hounsfield units}

are strong independent predictors of adrenocortical carcinoma.

Evaluate the hormonal workup results.

Tests for hypercortisolism (dexamethasone suppression), pheochromocytoma (metanephrines), and hyperaldosteronism (aldosterone-to-renin ratio) are all normal.

All adrenal incidentalomas must be evaluated for functional (hormone-secreting) status to determine if preoperative medical blockade is required and to guide surgical indications.

Determine the indication for surgery based on the combined data.

Although the mass is non-functioning, its large size (

>4\text{ cm}

) and suspicious radiographic features dictate that it must be surgically removed.

Non-functioning tumors with a high suspicion of malignancy require prompt surgical excision to improve survival outcomes.

Key Concept

Adrenal incidentalomas require surgical resection if they are functional (hormone-secreting) OR if they possess high-risk features for malignancy, such as a size greater than

4\text{ cm}

, irregular borders, or an attenuation greater than

10\text{ Hounsfield units}

on unenhanced CT.

Estimated Time:1m 30s

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