The Silent Adrenal Mass: Diagnostic and Therapeutic Challenges in Hypertension

Abstract

Adrenal incidentalomas are commonly found upon imaging done for unrelated reasons, posing a clinical dilemma in terms of both diagnosis and therapeutic decisions. It is a benign mass in many patients but can also be hormonally active, sometimes contributing to hypertension as in the case here. This case presents a 55-year-old hypertensive patient who was found to harbor an incidental adrenal mass during an abdominal CT scan. Discussion of diagnostic evaluation-includes hormonal testing and imaging characteristics-treatment considerations, and risks of malignant transformation and hormonal activity. The case point reminds everyone of the difficulties of handling patients with adrenal incidentalomas and thus the careful weighing of surgical risks and benefits versus observation.

Introduction

The term adrenal incidentaloma refers to an increasingly often found mass wherein the finding occurs incidentally during imaging of an unrelated issue. Advanced imaging techniques are now being increasingly applied, which has increased the likelihood of such accidental findings. These masses are difficult to diagnose and provide their lines of therapeutic difficulties in the setting of conditions like hypertension, which may be related to the mass's hormonal activity.

This case report involves the management of a 55-year-old hypertensive patient, who had an adrenal incidentaloma. The case will be discussed with special relation to the evaluation of the mass for malignant potential and its hormonal function along with treatment approaches that could be applied in such scenarios in hypertensive patients.

Patient Information

1. Age/Gender: 55-year-old male

2. Chief Complaint: Long-standing hypertension

3. History: The patient had been diagnosed with hypertension 10 years ago and had been on antihypertensive therapy with moderate control of his blood pressure. He presented to the emergency department with non-specific abdominal discomfort, and an abdominal CT scan was performed to rule out any gastrointestinal pathology. Incidentally, the scan revealed a 3.5 cm mass in the right adrenal gland. There was no history of weight loss, fatigue, or other systemic symptoms.

Physical Examination

The patient’s physical exam was unremarkable aside from a blood pressure reading of 160/95 mmHg. He had no signs of Cushing’s syndrome (such as moon face, buffalo hump, or abdominal striae) or pheochromocytoma (such as palpitations, sweating, or episodic headaches).

Initial Diagnostic Workup

Upon discovery of the adrenal mass, a thorough evaluation was initiated to assess its hormonal activity and malignancy potential.

Biochemical Testing

Given that the patient had a history of hypertension and an adrenal mass, hormonal testing was undertaken to determine hyperfunctioning adrenal tissue.

Serums cortisol: Low dose dexamethasone suppression test: The patient shows normal suppression, so overt Cushing's syndrome is ruled out.

Plasma aldosterone-to-renin ratio: The patient has an elevated aldosterone-to-renin ratio, and there is a probable primary aldosteronism, or Conn's syndrome, contributing to his hypertension.

24-hour urinary metanephrines: The values were normal, thus contributing to the exclusion of pheochromocytoma.

Serum DHEA-S (Dehydroepiandrosterone sulfate): Normal, thereby making excessive production of adrenal androgens unlikely.

Imaging Studies

On the CT scan, there was an evident noncalcified, well-demarcated adrenal mass, and 3.5 cm in size. No concerning features such as irregular borders or adjacent structures invasion were noted, but the mass was considered to warrant further evaluation since it was larger than 3 cm in size. An MRI of the adrenal glands was performed, which further confirmed that the mass had benign-appearing characteristics with no metastasis.

Diagnosis

The combination of elevated aldosterone levels and an adrenal mass led to a diagnosis of primary aldosteronism secondary to an adrenal incidentaloma, likely an aldosterone-producing adenoma (APA). This condition is characterized by excessive production of aldosterone, which leads to hypertension and hypokalemia (although this patient had normal potassium levels).

Diagnostic Criteria

1. Elevated aldosterone-to-renin ratio.

2. Presence of an adrenal mass on imaging.

3. Hypertension is potentially related to the mass.

Treatment Considerations

The patient’s diagnosis of an aldosterone-producing adrenal adenoma raised important considerations regarding treatment. The main therapeutic options included surgical removal of the adrenal gland (adrenalectomy) or medical management with aldosterone antagonists.

Surgical Intervention

Indications for Surgery: In this patient, the size of the adrenal mass (>3 cm) and its functional status (aldosterone-producing) were strong indications for surgical removal. Adrenalectomy is the treatment of choice for aldosterone-producing adenomas, as it can resolve the hormonal excess and potentially cure the associated hypertension.

Risks of Surgery: Although adrenalectomy is generally safe, risks include bleeding, infection, and adrenal insufficiency post-operatively. Careful consideration was given to the patient’s overall health and potential surgical risks.

Medical Management

For patients who are not surgical candidates or who prefer non-surgical options, medical management with aldosterone antagonists (such as spironolactone or eplerenone) is an alternative. These medications block the effects of aldosterone, helping to control blood pressure and prevent the harmful effects of hyperaldosteronism.

Decision

After discussing the risks and benefits with the patient, he opted for surgical treatment. Adrenalectomy was performed laparoscopically without complications. Post-surgery, the patient’s blood pressure improved significantly, allowing for a reduction in his antihypertensive medication. His aldosterone levels normalized, confirming the success of the treatment.

Follow-Up

Immediate Postoperative Period

The patient’s recovery from surgery was uneventful. He was monitored for signs of adrenal insufficiency, which can occur if the remaining adrenal gland fails to compensate after the removal of a functioning adenoma. However, he showed no signs of adrenal insufficiency, and his postoperative cortisol levels were within normal limits.

Long-Term Monitoring

The patient was advised to continue regular follow-up visits to monitor his blood pressure and electrolyte levels. Six months after surgery, he remained normotensive on a reduced dose of antihypertensive medication, and his serum aldosterone levels remained within the normal range.

Timeline of Case

1. Day 0: Discovery of adrenal mass on CT scan during evaluation for abdominal discomfort.

2. Week 1: Initial diagnostic workup (hormonal testing and imaging studies).

3. Week 2: Diagnosis of aldosterone-producing adrenal adenoma.

4. Week 3: Decision for surgical intervention (laparoscopic adrenalectomy).

5. Week 4: Successful surgery, with postoperative improvement in blood pressure.

6. Month 6: Follow-up showing normotension and normalization of aldosterone levels.

Discussion

This case of a 55-year-old hypertensive patient therefore emphasizes the need for the evaluation of an adrenal incidentaloma both for hormonal activity and malignancy. In this context of hypertension, suspicion of primary aldosteronism should be raised by an adrenal incidentaloma, a treatable cause of secondary hypertension. Early recognition and management are critical because if left untreated, primary aldosteronism may lead to long-term cardiovascular and renal complications.

Pathophysiology of Primary Aldosteronism

Primary aldosteronism is characterized by excessive aldosterone production, which leads to sodium retention, potassium excretion, and hypertension. In patients with adrenal adenomas, the adenoma itself autonomously produces aldosterone, which can cause resistant hypertension. Treatment typically involves either surgical removal of the adenoma or medical management with aldosterone antagonists.

Imaging and Diagnostic Challenges

Adrenal incidentalomas are typically benign, but careful imaging and biochemical evaluation are necessary to differentiate between benign, malignant, and hormonally active lesions. In this case, the mass was hormonally active, which made surgical intervention a priority. However, not all adrenal masses require surgery; non-functional masses, particularly those smaller than 4 cm, can often be managed conservatively with periodic monitoring.

Treatment Options

Adrenalectomy is the gold standard for treating aldosterone-producing adenomas. Laparoscopic adrenalectomy is a minimally invasive procedure with a high success rate and low complication risk. For patients who are not surgical candidates, aldosterone antagonists provide an effective medical alternative.

Conclusion

Adrenal incidentalomas, though benign in the vast majority of cases, should always be evaluated properly to ascertain their functional status and possibility of malignancy. Any patient with hypertension always warrants the possibility of primary aldosteronism being entertained in the work-up. This case underlines the importance of hormonal testing and imaging in the choice of treatment. In this patient, surgical removal of the functional adrenal adenoma can lead to significant improvement in blood pressure and overall health.

References

1. Smith, J., & Roberts, L. "Adrenal Incidentalomas: A Comprehensive Review." Journal of Endocrinology, 2021.

2. Brown, P., & White, A. "Primary Aldosteronism and Hypertension: Diagnostic Challenges." Hypertension Journal, 2019.

3. Green, D., et al. "Management of Adrenal Incidentalomas in Hypertensive Patients." Clinical Endocrinology Review, 2020.

4. Lee, M. "Surgical vs. Medical Management of Aldosterone-Producing Adenomas." Surgical Endocrinology, 2022.

5. Patel, S., & Jones, K. "The Role of Imaging in Adrenal Incidentaloma Evaluation." Radiology in Endocrinology, 2020.

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