COMMUNICATION STATION

Approach to Incidental Adrenal Mass

Adrenal Incidentaloma • MRCP (UK) PACES

A structured PACES approach to counselling a patient after the incidental discovery of an adrenal mass. Learn how to explain the finding, screen for functioning adrenal tumours, address concerns about cancer and discuss the next steps in investigation and follow-up.

8 min read Communication High Yield

At a Glance

Presentation Incidental adrenal mass on imaging
Likely Diagnosis Adrenal Incidentaloma
Must Not Miss Functioning adrenal tumour or adrenal carcinoma
Key Investigation Hormonal assessment + Adrenal CT protocol
Treatment Observation or adrenalectomy depending on findings
PACES Tip Reassure first, investigate systematically

Red Flags

Rapid weight loss Symptoms of hormone excess Previous malignancy Mass ≥4 cm Suspicious CT features Urgent endocrine referral

PACES Approach

① Explain the incidental finding ② Screen for hormone excess ③ Exclude malignancy ④ Arrange endocrine investigations ⑤ Reassure and discuss follow-up

Overview

An adrenal incidentaloma is an adrenal mass discovered unexpectedly during imaging performed for another reason. Most lesions are benign and non-functioning, but every patient should be assessed for hormonal excess and features suggestive of malignancy. In PACES, candidates should explain the finding clearly, address concerns about cancer, arrange appropriate endocrine and radiological investigations, and discuss follow-up or referral where indicated. :contentReference[oaicite:1]{index=1}

Structured History

  • Reason the CT or MRI scan was performed
  • Previous history of any malignancy
  • Recent unexplained weight loss or fever
  • Symptoms of Cushing's syndrome (weight gain, bruising, proximal weakness)
  • Symptoms of Phaeochromocytoma (headache, palpitations, sweating)
  • Symptoms of Primary Hyperaldosteronism (hypertension, muscle weakness)
  • Symptoms suggesting adrenal carcinoma (virilisation or feminisation)
  • History of tuberculosis or chronic infection
  • Current medications including corticosteroids
  • Smoking, alcohol and relevant family history

Examination

  • Blood pressure and pulse
  • General appearance and body habitus
  • Features of Cushing's syndrome
  • Skin pigmentation, bruising or striae
  • Evidence of hirsutism or virilisation
  • Hand sweating or tremor
  • Assess for proximal myopathy
  • Abdominal examination for masses
  • Examine for lymphadenopathy
  • Complete cardiovascular examination

Differential Diagnosis

Non-functioning adrenal adenoma Phaeochromocytoma Cortisol-secreting adenoma Primary Hyperaldosteronism Adrenocortical carcinoma Adrenal metastasis Adrenal cyst Adrenal tuberculosis

Investigations

  • 1 mg overnight dexamethasone suppression test
  • Plasma free or urinary fractionated metanephrines
  • Aldosterone : Renin Ratio (if hypertensive or hypokalaemic)
  • DHEAS, testosterone or oestradiol when carcinoma suspected
  • Non-contrast adrenal CT (Hounsfield Units)
  • MRI adrenal if CT findings are indeterminate
  • Routine blood tests including U&E and glucose
  • Adrenal biopsy only in selected patients after excluding phaeochromocytoma

Diagnosis

Adrenal Incidentaloma

An adrenal incidentaloma is an adrenal lesion discovered incidentally during imaging performed for another indication. The key objectives are to determine whether the lesion is functioning and whether there are radiological features suggesting malignancy.

Management

Small Benign Lesions Observation with endocrine and radiological follow-up
Surgical Referral Functioning tumours, suspicious imaging or lesions ≥4 cm
Follow-up Repeat hormonal assessment and interval imaging where indicated

Explaining to the Patient

"The scan has shown a small growth on one of your adrenal glands. Most of these are harmless and are found by chance. Our priority is to determine whether it is producing excess hormones or has features suggesting cancer. This requires some blood tests, urine tests and specialised imaging. Only a minority of patients require surgery, and many can be safely monitored with regular follow-up."

Examiner's Corner

What is an adrenal incidentaloma?

An adrenal incidentaloma is an adrenal mass discovered unexpectedly during imaging performed for an unrelated reason. Although most are benign and non-functioning, every patient should be assessed for hormone excess and features suggesting malignancy.

Which hormones should be assessed?
Cortisol Catecholamines Aldosterone Renin DHEAS Sex Hormones (when indicated)
When should surgery be considered?
  • Functioning adrenal tumour
  • Radiological suspicion of malignancy
  • Lesion ≥4 cm (depending on imaging characteristics and MDT discussion)
  • Progressive increase in lesion size during follow-up
Common Viva Questions
  • What is an adrenal incidentaloma?
  • Which adrenal hormones should be screened?
  • Which CT features suggest malignancy?
  • When should adrenal biopsy be performed?
  • Why must phaeochromocytoma be excluded before biopsy?
  • When is adrenalectomy indicated?

Pathfinder Pearls

Most incidentalomas are benign Always exclude hormone excess Screen for phaeochromocytoma first Review CT size and Hounsfield Units Ask about previous malignancy Biopsy is rarely required Reassure while explaining uncertainty Refer to the Endocrine MDT when appropriate

Common Pitfalls

  • Assuming every adrenal mass is malignant.
  • Failing to screen for hormone secretion.
  • Overlooking subtle features of Cushing's syndrome.
  • Performing adrenal biopsy before excluding phaeochromocytoma.
  • Ignoring previous history of malignancy.
  • Providing false reassurance before investigations are complete.
  • Not discussing follow-up imaging and endocrine review.

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