Adrenal Tumor/Pheochromocytoma · Observe vs Resection

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Functional assessment + size/imaging
   Functioning? Size/imaging suspicious? (Functional screen: pheo (plasma/urine metanephrines), aldosteronoma (ARR), cortisol (1 mg dexamethasone suppression); imaging-suspicious: ≥4 cm, HU >10, irregular, growing.)
   • Functioning — pheochromocytoma (raised catecholamines) → Pheochromocytoma → resection (preoperative alpha-blockade)
   • Functioning — aldosteronoma/cortisol-secreting (Cushing) → Aldosteronoma/cortisol tumor → resection
   • Non-functioning, ≥4 cm or imaging-suspicious → ≥4 cm/suspicious → resection
   • Non-functioning, <4 cm, benign imaging → Non-functioning small → surveillance
2. [End] Pheochromocytoma → resection (preoperative alpha-blockade)
   Pheochromocytoma → adrenalectomy; preoperative alpha-blockade for 7–14 days (± volume expansion, then add a beta-blocker) to prevent intraoperative hypertensive crisis; laparoscopic preferred (open for large/suspected malignancy).
3. [End] Aldosteronoma/cortisol tumor → resection
   Aldosteronoma/cortisol-secreting adenoma → (unilateral) laparoscopic adrenalectomy; primary aldosteronism needs adrenal vein sampling (AVS) to lateralize; cortisol-secreting cases need perioperative glucocorticoid replacement to prevent crisis.
4. [End] ≥4 cm/suspicious → resection
   Non-functioning but ≥4 cm or imaging-suspicious → adrenalectomy (open for suspected adrenocortical carcinoma to avoid rupture).
5. [End] Non-functioning small → surveillance
   Non-functioning, <4 cm, benign imaging → surveillance (imaging + functional re-testing); stable lesions may stop surveillance after the prescribed period.

Source guidelines & references

• Adrenal incidentaloma and pheochromocytoma management (ESE/ENSAT; Endocrine Society)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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