See Figure 8 for the proper medical approach. An ACTH test with 60-minute cortisol levels will rule out the diagnosis. If found, suspect granulomatous disease, hemorrhage, or lymphoma. If found, surgical removal is usually indicated Exceptions include bilateral adrenal diseases such as ACTH-dependent Cushing's disease or bilateral hyperaldosteronism. If no hormonal excess is found and the ACTH test was unremarkable, FNA will distinguish between adrenal and metastatic disease.
Metastatic disease is managed according to the type of primary cancer.
Adrenal disease should be removed if the diameter is greater than 6 cm. Otherwise, follow up with repeat CT scans at periodic intervals. Abdominal laparotomy is preferred for bilateral disease and pheochromocytoma. A transthoracic approach is faster than fiberoptic laparoscopy but has a longer postoperative recovery period. An endocrinologist should be consulted to review the results of endocrine testing.