An 8 cm left adrenal mass with irregular borders and high attenuation suggesting a lipid-poor lesion: next step in management?

• A. Percutaneous biopsy
• B. Observation with interval imaging
• C. Open adrenalectomy
• D. Laparoscopic adrenalectomy

Answer: (C)

The key idea is that an adrenal mass that is large and has lipid-poor features on imaging carries a high risk of malignancy, so it should be removed with oncologic principles rather than watched or biopsied.

Lipid-poor adrenal lesions are more suspicious for adrenocortical carcinoma or metastatic disease than lipid-rich adenomas. At 8 cm, the mass size itself raises concern for malignancy, since larger adrenal tumors have a higher probability of cancer. Irregular borders add to the suspicion because they can reflect invasion or aggressive behavior.

Percutaneous biopsy is not the right next step here because it often cannot reliably distinguish benign from malignant adrenal tumors and can carry risks such as bleeding or even tumor seeding along the needle tract. In the setting of a suspected malignancy, the management is typically surgical resection, not diagnosis by biopsy.

Open adrenalectomy is favored in this scenario to achieve complete oncologic resection with intact margins and to allow thorough evaluation for invasion and regional lymphatics. While laparoscopic removal is appropriate for many benign lesions or smaller tumors without invasion, an 8 cm lesion with irregular borders and high attenuation strongly argues for an open approach to maximize oncologic control.