The importance of gas chromatography-mass spectrometry steroid profiling in selecting surgical strategy for large adrenal tumors

BACKGROUND: The selection of surgical strategies for large adrenal tumors remains clinically critical. For determining eligibility for endoscopic video-assisted surgery, the absence of malignancy features is essential. Steroid metabolome analysis by gas chromatography-mass spectrometry (GC-MS) provides the highest diagnostic yield for detecting early signs of malignancy during preoperative evaluation and, according to multiple studies, exceeds the accuracy of radiologic imaging techniques. AIM: To evaluate the clinical utility of urine steroid profiling by GC-MS for preoperative diagnosis and surgical decision-making in large malignant adrenocortical neoplasms. METHODS: Patients with adrenal tumors larger than 50 mm and without clinical or laboratory signs of hypercortisolism were examined. Based on histological analysis, the following diagnoses were established: adrenocortical carcinoma, adrenocortical adenoma (with malignancy grade assessed using the Weiss scoring system), and rare adrenal diseases (schwannoma, ganglioneuroma, myelolipoma, etc.). Patients with adrenocortical adenomas smaller than 50 mm served as the control group. Urinary steroid profiles were analyzed by gas chromatography-mass spectrometry in all patients before surgical treatment. The Mann-Whitney U test was used for comparison of urinary steroid excretion. RESULTS: According to gas chromatography-mass spectrometry (GC-MS), 23 patients (33.8%) with adrenal tumors 50 mm exhibited biochemical features of adrenocortical carcinoma (ACC) prior to surgery, which was later confirmed histologically. In patients with adrenocortical adenoma and a malignancy score of 2 on the Weiss scale (n = 16, 23.5%), urinary excretion of tetrahydro-11-deoxycortisol, androgens, progestogens, and mineralocorticoids was significantly higher than in patients with adrenocortical adenoma lacking malignant features (n = 14) and the control group (n = 30). No statistically significant differences were observed in the urinary excretion of 9 ACC biomarkers compared to patients with confirmed ACC. Open adrenalectomy was recommended for patients with large adrenal tumors and GC-MS evidence of malignancy. CONCLUSION: Preoperative GC-MS detection of early malignant features in large adrenal tumors is critical for determining the optimal surgical approach. Minimally invasive adrenalectomy is not recommended for large adrenal lesions with GC-MS signs of malignancy.