Adrenal incidentalomas

The diagnosis of adrenal masses during abdominal imaging performed for an alternative reason, not associated with clinical hyperfunction.

General examination

To diagnose adrenal incidentalomas a detailed and full general examination is mandatory in the initial assessment of all patients. Signs of malignancy should specifically be sought in patients with an adrenal mass.

Patients with Cushing’s tend to have central adipositiy with relative sparing of the limbs.

A marfanoid habitus may be seen in multiple endocrine neoplasia type 2b.

Blood pressure

Blood pressure will typically be elevated in the presence of any functioning adrenal tumour.

Skin and mucous membranes

Extensive bruising, for example from venepuncture, thinning and redness of the skin, acne, livid striae, and acanthosis nigricans, may all be seen with Cushing’s syndrome and adrenal cancers.

Hirsuitism should be staged using the Ferriman Gallwey score and indicates androgen excess.

New pigmentation is suggestive of high levels of ACTH, which may be seen after bilateral adrenal infarction.

Neurofibromata may be obvious but cafe au lait patches and axillary freckling need to be sought in neurofibromatosis.

Mucosal neuromas may be seen in MEN2b.

Adrenal carcinoma may also metastasise to the skin and subcutaneous tissues which may be palpable.

Lymph nodes

It is essential to seek nodes elsewhere when seeking evidence of metastatic disease.

Musculature

Proximal myopathy is a sensitive sign in Cushing’s syndrome, though it may also occur wtih severe hypokalaemia. Increase in muscle bulk may be seen with virilising tumours.

Virilisation

Examine the musculature for increased bulk in women. Examine for changes in secondary sexual characteristics, and hair distribution and for clitoromegaly.

Abdomen

Gentle examination of the abdomen should be performed for the adrenal and other possible masses, particularly looking for metastatic disease.

Deep palpation is inappropriate when phaeochromocytoma is a possibility, as this may trigger an attack.

Renal and epidydimal masses should also be sought in Von Hippel Lindau.

Urine microscopy

Urine should be analysed in all patients with adrenal masses seeking evidence of end organ damage due to hypertension and as a screen for haematuria and malignant cells.