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.
Key red flags
A planned adrenal biopsy or operation without biochemical exclusion of phaeochromocytoma creates a preventable risk of hypertensive crisis, arrhythmia and death.
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.
Key medicines
Dexamethasone for overnight suppression testingGive 1 mg orally at the locally specified late-evening time and measure serum cortisol the following morning within the laboratory window.
Alpha-adrenoceptor blockadeInitiate and titrate phenoxybenzamine or a selective alpha blocker only through the specialist phaeochromocytoma preoperative protocol with fluid and salt planning.