Clinical Guideline

SUSPECTED ADRENAL INCIDENTALOMA

SETTING Trust-wide

FOR STAFF Part 1 - Medical staff, including radiologists, who identify a possible case

Part 2 Specialist medical staff within Endocrine Team

PATIENTS Patients with an unexpected adrenal lesion following diagnostic imaging

_____________________________________________________________________________

BACKGROUND

Incidentaloma is an internationally accepted term for a lesion incidentally discovered through

diagnostic imaging, without prior clinical suspicion of tumour / disease.

Published evidence (1,2) suggest the following pathology for adrenal incidentalomas;

Endocrine inactive adenoma 41 - 85% of cases

Metastases 15 - 19%

%
Cortisol secreting adenoma 5 - 10

Adrenocortical carcinoma 2 - 10%

Phaeochromocytoma 3 - 8%

%
Conns 2- 5

Other causes 2 - 9%

Part 1
REFERRAL TO ENDOCRINE TEAM

Medical staff that identify a possible adrenal incidentaloma should refer the patient to
the Endocrine Team for further investigation.

Referral details should include

Hospital Registration Number

Surname
Forname
Date of Birth
Date of diagnostic imaging
Imaging report number

Part 2
ENDOCRINE TEAM ONLY (overleaf)

Version 1 Sept 2011 - Review Sept 2014 Author Dr Karin Bradley, Endocrinology Consultant Page 1 of 3
 Part 2
ENDOCRINE TEAM ONLY
The algorithm below describes the diagnostic pathway
There are no long term data to be confident of the appropriate duration of imaging or hormonal surveillance but
abnormal secretion has been detected during prolonged follow-up 3,4,5. The risk of endocrine abnormalities was
higher in patients with a baseline lesion 3cm. This guideline is consistent with recent clinical practice
guidelines1,6,7,8.

ASSESSMENT OF ENDOCRINE STATUS

Careful personal and family history and full examination
Proceed as appropriate if underlying endocrinopathy suspected

RECOMMENDED OUT-PATIENT TESTS IF NO ENDOCRINE PHENOTYPE SUSPECTED

1. Two 24 hour urine collection samples for catecholamines (N.B. regional laboratories may use alternative baseline screening
tests) to help exclude phaeochromocytoma#. Ideally avoid interfering medication including paracetamol, many
antihypertensives, catecholamine containing drugs & some antidepressants). Plasma metanephrines may be indicated,
especially in the context of a genetic phaeo/paraganglioma syndrome.
2. 1mg overnight dexamethasone suppression test to exclude subclinical Cushing's (*see below). (1mg dexamethasone at
11PM followed by serum cortisol at 9 am next morning. The morning cortisol should ideally be <50nmol/l. Values 50nmol/l-
138nmol/l fall into an area of clinical uncertainty and surgery may be discussed as an option especially in the presence of
diabetes or hypertension. In the absence of any classic phenotype further Cushings investigations probably only helpful if
overnight result >138nmol/l or clinical progression9. However, UFC (urinary free cortisol), low dose dexamethasone
suppression test, morning ACTH or midnight salivary cortisol may be considered.
3. Aldosterone/Renin ratio (ARR) only in hypertensive patients to exclude Conn's syndrome. Aldosterone and renin levels are
affected by many anti-hypertensive agents. Ideally use doxasozin alone for 4-6 weeks pre-testing. Correct potassium to
normal pre test. If ARR sufficiently elevated (refer to local laboratory range) then proceed to a confirmatory test e.g. saline
infusion or fludrocortisone suppression and adrenal CT. Adrenal vein sampling should be considered unless patient <40years
with clear unilateral >1cm adenoma10.
BIOCHEMICALLY FUNCTIONING
(Include subclinical Cushings in this
category but remember that surgery for
BIOCHEMICALLY NON-FUNCTIONING this indication remains controversial.
Consider presence of diabetes,
hypertension or other CV risk and patient
choice when counselling)

Less than 4cm in size

4cm or greater in size
Baseline malignancy risk ~ 2%
Baseline malignancy risk
Size 4-6cm ~ 6% risk6, Size >6cm ~ 25% risk6
Consider surgery. Refer to
neuroendocrine tumour (NET)
MDT. Remember the need for
peri- and post-operative steroids if
Hounsfield Hounsfield units more evidence of endogenous
units less than 10 (? fat poor hypercortisolaemia. Post-
than 10, benign adenoma in 25 operatively ensure resolution of
benign % cases) or history of any abnormal biochemistry.
appearance malignancy11,12 If adrenal carcinoma suspected
Repeat CT scan 6 months after measure testosterone, DHEA,
on CT & no
baseline scan and calculate 17OHP & androstenedione and CT
personal
contrast washout at 10 minutes. chest. FDG-PET can be a useful
history of
malignancy tool for identifying adrenal
Consider MRI in women of malignancy.
reproductive age or where there is
impaired renal function or known
contrast sensitivity

1. No repeat imaging required2.

2. Hormonal surveillance at baseline and at 2 years.
Hormonal surveillance at 4 years if baseline size
3 cm3. Up to 20% will become hormonally active2.
3. Consider surgery if mass becomes hormonally
Contrast washout Contrast washout less than 60% at 10
active. minutes3 or an increase in size >1cm.
greater than 60%
4. When discharging to GP care recommend referral
in 10 minutes 3
for re-evaluation if symptoms dictate as rarely likely fat poor
functional activity has been described after benign adenoma
prolonged follow-up.
Version 1 Sept 2011 - Review Sept 2014 Author Dr Karin Bradley, Endocrinology Consultant Page 2 of 3
#
It is worth noting that a phaeochromocytoma is extremely unlikely if Hounsfield units are less than 10. A phaeochromocytoma
diagnosis becomes more likely if the Hounsfield units are more than 10 and the lesion is more than 3cm in size.

*Various medications may interfere with dexamethasone metabolism and this should be taken into account when interpreting the
overnight dexamethasone suppression test. These include sertraline, fluoxetine, paroxetine, trazodone, citalopram, bupropion,
venlafaxine, atorvastatin, simvastatin, verapamil, diltiazem, amlodipine, nifedipine, felodipine, irbesartan, losartan, olanzapine,
quetiapine, proton pump inhibitors, propranolol, pioglitazone, clonazepam and topiramate13.

_________________________________________________________________________
1. National Institute of Health consensus statement. Management of the Clinically
REFERENCES Inapparent Adrenal Mass 2002. Volume 19 (2)
2. Mansmann G, Lau J, Balk E, Rothberg M, Miyachi Y & Bornstein SR. The Clinically
Inapparent Adrenal Mass: Update in Diagnosis and Management. Endocrine Reviews
25(2):309340.
3. Barzon L et al. Development of overt Cushings syndrome in patients with adrenal
incidentaloma. European Journal of Endocrinology (2002) 146 6166
4. Funder JW, Carey RM, Fardella C, Gomez-Sanchez CE, Mantero F, Stowasser M, Young
WF, Jr, Montori VM, Endocrine Society 2008 Case detection, diagnosis, and treatment of
patients with primary aldosteronism: An endocrine society clinical practice guideline. J
Clin Endocrinol Metab 93(9):3266-3281.
5. AACE/AAES Medical Guidelines for the Management of Adrenal Incidentalomas .
Endocrine practice 2009; 15 (Suppl 1)
6. Hamrahian H et al. Clinical utility of non contrast computed tomography attenuation value
(hounsfield units) to differentiate adrenal adenomas/hyperplasias from nonadenomas:
Cleveland Clinic experience. J Clin Endocrinol Metab 2005; 90(2):871-7.
7. Szolar D et al. Adrenocortical Carcinomas and Adrenal Pheochromocytomas: Mass and
Enhancement Loss Evaluation at Delayed Contrast-enhanced CT. Radiology 2005: 234
(2). 479-485
8. Barzon et al. Risk factors and long-term follow-up of adrenal incidentalomas. J. Clin.
Endocrinol. Metab. 1999 84: 520-526
9. Libe et al. Long-term follow-up study of patients with adrenal incidentalomas. European
Journal of Endocrinology (2002) 147 489494
10. Bulow B et al. Adrenal incidentaloma follow-up results from a Swedish prospective
study. European Journal of Endocrinology (2006) 154 419423
11. Gopan T et al. Evaluating and managing adrenal incidentalomas. Cleve Clin J Med. 2006
Jun;73(6):561-8
12. Young W. The Incidentally Discovered Adrenal Mass. N Engl J Med 2007;356:601-10
13. Valassi E et al. Concomitant medication use can confound interpretation of the combined
dexamethasone-corticotropin releasing hormone test in Cushings syndrome. JCEM
2009; 94: 4851-9.

Endocrine Specialist Registrar (referrals) bleep 6216

QUERIES
Endocrine Consultants via switchboard
Dr K Bradley,
Dr B Ahmad
Dr N Thorogood
Prof S Lightman
Prof A Levy
Prof D Wynick

Version 1 Sept 2011 - Review Sept 2014 Author Dr Karin Bradley, Endocrinology Consultant Page 3 of 3