Home > Adults > Endocrinology >

Adrenal incidentaloma

Checked: 23-06-2021 by Vicky Ryan Next Review: 23-06-2022

Overview

These guidelines have been provided by the Endocrinology Team at NBT so pathways might be slightly different at UHBW

Definition

An asymptomatic adrenal mass detected on imaging, not performed for suspected adrenal disease

Important points

In most cases, adrenal incidentalomas are non-functioning adrenalcortical adenomas but may represent nodules which require further intervention e.g. adrenal cortical carcinoma, phaeochromocytoma, hormone producing adenomas or metastases

Take a thorough history and clinical examination of patients with an incidentally diagnosed adrenal incidentaloma:

Red flags for malignancy
Symptoms suggestive of a phaeochromocytoma – hypertension, palpitations, sweating, episodic headaches and chest pain
Signs and symptoms suggestive of Cushing’s syndrome - central adiposity, proximal myopathy, striae, easy bruising
Rapidly developing hirsutism, virilisation, or recent onset gynaecomastia – suggestive of an androgen or oestrogen producing tumour respectively

Who to refer

Routine referral to Endocrinology for all new adrenal incidentalomas.

Red Flags

Urgent eRS referral to Endocrinology if an adrenal incidentaloma is noted in an adolescent, pregnant women or adults <40years due to the high risk of malignancy

Urgent eRS referral if an adrenal lesion is highly likely malignant e.g. known cancer and an isolated adrenal metastasis, malignant appearances on CT

Urgent eRS referral if clinical or biochemical suggestion of a phaeochromoytoma or Cushing’s disease

Before referral

Please do the following checks below prior to referral:

Blood pressure
HbA1c to exclude diabetes
U&Es to assess for hypokalaemia

Please also consider the following tests which can be done in primary care:

Overnight dexamethasone suppression test (ODST) – screening test for Cushings syndrome. Prescribe 1mg dexamethasone which should be taken at 10pm the night before a blood test for 9am cortisol. Ensure you state it is an ODST in the free text box.
24 hour collection for urinary metanephrines - test for phaeochromocytoma. The appropriate urine collection container (HCl acid -red label) can be ordered from your local biochemistry lab. Once collected this can be sent with a request on ICE - use search button for metanephrines (UHB) or metadrenalines (NBT).
17 hydroxyprogesterone (17 0HP) - If bilateral adrenal lesions on imaging then consider this test for congenital adrenal hyperplasia (discuss with your local Clinical biochemistry department before collection) and also a 9am cortisol if not already done.

Services

Endocrinology NBT

Endocrinology UHBW

Resources

References

https://eje.bioscientifica.com/view/journals/eje/175/2/G1.xml

https://www.nbt.nhs.uk/sites/default/files/Suspected%20Adrenal%20Incidentaloma.pdf

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.