Synopsis
Characterise an unexpectedly discovered adrenal lesion for malignancy and hormone excess, avoid unsafe biopsy, and direct surveillance or surgery through an endocrine-radiology multidisciplinary pathway.
- An adrenal incidentaloma is discovered on imaging performed for an unrelated reason; lesions found during known cancer staging require a modified metastasis pathway rather than casual use of the label.
- Answer two questions promptly: does imaging suggest malignancy, and does the lesion produce cortisol, catecholamines, aldosterone or, less commonly, sex steroids.
- Retrieve the original images and report unenhanced attenuation, homogeneity, size, margins, calcification, necrosis and growth; a generic adrenal nodule description is not adequate characterisation.
- A homogeneous lipid-rich lesion with unenhanced CT attenuation at or below 10 Hounsfield units is strongly benign, but local follow-up policy and the full clinical context still govern disposition.
- Use an overnight 1 mg dexamethasone suppression test to evaluate autonomous cortisol secretion unless frailty or limited life expectancy makes testing disproportionate.
- Check plasma or urinary metanephrines whenever phaeochromocytoma has not been confidently excluded by the endorsed imaging-hormone pathway, and always before biopsy or adrenal intervention.
- Measure aldosterone and renin in hypertension or unexplained hypokalaemia, adjusting interfering medicines and interpretation with endocrine advice rather than relying on potassium alone.
- Biopsy rarely distinguishes benign adrenal cortex from adrenocortical carcinoma and can trigger a catecholamine crisis; consider it only for a non-adrenal malignancy when phaeochromocytoma is excluded and histology would change care.
Key red flags
A planned adrenal biopsy or operation without biochemical exclusion of phaeochromocytoma creates a preventable risk of hypertensive crisis, arrhythmia and death.
Rapid virilisation, severe new Cushing features, unexplained weight loss or invasive imaging characteristics requires urgent referral to a specialist adrenal cancer pathway.
Paroxysmal hypertension with chest pain, neurological deficit, pulmonary oedema or shock may represent catecholamine crisis and needs emergency endocrine and critical-care input.
Acute flank pain with hypotension, falling haemoglobin or bilateral adrenal enlargement raises haemorrhage and possible adrenal crisis; treat physiological instability immediately.
Large bilateral infiltrative lesions with hyponatraemia, hyperkalaemia, hypoglycaemia or shock require urgent cortisol assessment and empirical hydrocortisone when crisis is suspected.
Investigation priorities
Characterise lipid content, morphology and features that determine benignity or MDT review.
Management branches
An adrenal mass is reported on imaging obtained outside a known adrenal diagnostic pathway.
- Confirm why imaging was performed, whether extra-adrenal cancer is present and whether prior scans establish stability.
- Request dedicated radiological characterisation and take a focused history for cortisol, catecholamine, aldosterone and sex-steroid features.
- Arrange hormone testing proportional to phenotype and imaging, ensuring phaeochromocytoma is addressed before any invasive plan.
- Discuss indeterminate, functioning, bilateral, enlarging or suspicious lesions in an adrenal endocrine-radiology MDT with a documented follow-up owner.