Imaging verdicts with washout traps, blockade arithmetic, and Conn cure counselling

(A) Judge the nodule by density first, washout second, hormones always: at 2.8 cm lipid-poor it needs dedicated adrenal imaging — HU 10 or less exempts everything, while only inhomogeneous lesions above 4 cm with HU above 20 default to surgery with the middle ground discussed multidisciplinarily.^[1] Washout rules benignity in at 100% predictive value with 30 mm/20 HU, 40 mm/15 HU, relative above 53% or absolute above 78% — classical 60/40 only with normal metanephrines.^[16] Never trust washout to exclude phaeochromocytoma: 60%-plus washout still hides 6.9% phaeochromocytomas, and 28.9% of phaeochromocytomas wash like adenomas — so HU 10 or less alone exempts metanephrine testing.^[17][18] Screen every mass with metanephrines plus 1-mg dexamethasone at 50 nmol/L (1.8 µg/dL); above-cutoff cortisol without Cushing features is MACS with morbidity-mortality risk, operated individualistically with comorbidities and weighed on malignancy, hormones, age, fitness and preference.^[1]

(B) Block two to three weeks to pressure targets and quote the split: PRESCRIPT ties out-of-target time at 11.1% phenoxybenzamine against 12.2% doxazosin but favours phenoxybenzamine on instability score 38.0 against 50.0 — stability without proven outcome gain, cardiovascular events tied.^[2] Selectivity costs support: sub-80 systolic in 67% against 35% with more postoperative pressor or ICU need.^[4] Size warns: each centimetre multiplies severe hypertensive episodes 1.40-fold and pressor odds 1.23-fold, with selective blockade multiplying over-200 episodes 20.9-fold.^[7]

(C) Promise chemistry, forecast pressure: PASO counts 37% complete and 47% partial clinical success against 94% biochemical cure across 705 adrenalectomies.^[12] Favour the young woman on few drugs: female 2.25-fold complete-success odds, 5% less per year of age, 20% less per extra drug unit — operate lateralised disease for near-certain biochemical cure with probable partial pressure gain.^[12]