A 52-year-old woman is found to have an incidental 2.2 cm adrenal lesion on CT (non-contrast HU = 14). Urinary catecholamines are normal, aldosterone and renin are normal, but a low-dose dexamethasone suppression test shows cortisol of 3.8 mcg/dL (non-suppressed >1.8 mcg/dL). She has hypertension and osteopenia. What is the most appropriate next management?

• A Repeat CT adrenal in 12 months
• B Start ketoconazole therapy
• C Perform high-dose dexamethasone suppression test
• D Refer for laparoscopic adrenalectomy ✓

Explanation

This patient has autonomous cortisol secretion (mild hypercortisolism/subclinical Cushing's) from an adrenal incidentaloma, evidenced by cortisol >1.8 mcg/dL after 1 mg DST. Given the presence of related comorbidities (hypertension, osteopenia) and a unilateral adenoma, laparoscopic adrenalectomy is recommended per Endocrine Society guidelines. Surveillance CT is appropriate for non-secreting lesions. Ketoconazole is reserved for severe or inoperable cases. High-dose DST is used to distinguish pituitary from ectopic ACTH-dependent Cushing's, not adrenal disease.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.