Adrenal adenoma vs Adrenal hyperplasia
How to tell Adrenal adenoma and Adrenal hyperplasia apart when a board question makes them look alike.
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Adrenal venous sampling lateralization is the decisive discriminator between unilateral adenoma and bilateral hyperplasia.
Side by side
In primary aldosteronism, unilateral aldosterone excess on adrenal venous sampling indicates aldosterone-producing adenoma and supports surgery.
Bilateral aldosterone secretion indicates bilateral adrenal hyperplasia and is treated medically.
A unilateral adrenal cortical adenoma autonomously secretes aldosterone.
Bilateral zona glomerulosa hyperplasia drives diffuse aldosterone overproduction.
Primary aldosteronism screening shows elevated aldosterone renin ratio with suppressed renin; adrenal venous sampling lateralization index above about 4 after cosyntropin supports unilateral adenoma.
Bilateral hyperplasia shows no significant lateralization on adrenal venous sampling, despite biochemical confirmation of primary aldosteronism.
The trap
A common error is relying on adrenal CT nodule appearance alone. The resolving clue is that nonfunctioning incidentalomas are common, so adrenal venous sampling is needed before irreversible surgery in most patients.
The repair move
Next best step: after biochemical confirmation of primary aldosteronism, perform adrenal venous sampling to establish unilateral versus bilateral secretion. If unilateral, offer laparoscopic adrenalectomy; if bilateral, start mineralocorticoid receptor blockade such as spironolactone 25 to 50 mg daily and titrate to blood pressure and potassium goals.
Try a free question
CoreA patient with confirmed primary aldosteronism has unilateral secretion on adrenal venous sampling. What is the next best step in management?
Show answer and explanation
Answer: A. Refer for laparoscopic adrenalectomy. Unilateral aldosterone-producing adenoma is treated definitively with adrenalectomy when feasible.
Why the other choices are tempting
- B. Observation leaves persistent cardiovascular and renal risk.
- C. Stopping antihypertensives is unsafe and does not treat endocrine cause.
- D. Thyroid suppression is unrelated.
- E. Glucocorticoids are not primary therapy for aldosterone excess.
Flashcards
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What test definitively separates unilateral adenoma from bilateral hyperplasia in primary aldosteronism?
Adrenal venous sampling.
What AVS pattern supports bilateral adrenal hyperplasia?
Lack of significant lateralization despite confirmed aldosterone excess.
Quick answers
What is the fastest way to tell Adrenal adenoma from Adrenal hyperplasia?
Adrenal venous sampling lateralization is the decisive discriminator between unilateral adenoma and bilateral hyperplasia.
What is the key clue for Adrenal adenoma?
In primary aldosteronism, unilateral aldosterone excess on adrenal venous sampling indicates aldosterone-producing adenoma and supports surgery.
What is the key clue for Adrenal hyperplasia?
Bilateral aldosterone secretion indicates bilateral adrenal hyperplasia and is treated medically.
What is the common trap with Adrenal adenoma vs Adrenal hyperplasia?
A common error is relying on adrenal CT nodule appearance alone. The resolving clue is that nonfunctioning incidentalomas are common, so adrenal venous sampling is needed before irreversible surgery in most patients.