Adrenal incidentalomas

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

What was the indication of the scan initially? 

Incidentally noted adrenal lesions are most commonly benign, clinically non functioning adreno-cortical adenomas.

However, a patient with a known malignancy undergoing staging investigations has a different pre test probability for an adrenal metastasis, than one undergoing imaging for benign disease such as renal colic or diverticulosis.

Medical history, indication for the scan, imaging characteristics of the lesion and the results of functional investigations must all be considered by the multidisciplinary team.

What is the patient's medical history? 

Intermittent or severe hypertension may accompany any functioning adrenal tumour, though normotension does not exclude one.

The presence of diabetes, hypertension and osteoporosis make a diagnosis of Cushing’s more likely.

General health, fitness for an anaesthetic and the likelihood of malignancy also need to be assessed prior to determining future management.

Is there any other relevant family or personal history? 

Essential hypertension frequently runs in families.

A family history may however be highly suggestive of familial phaeochromocytoms, for example sudden or early unexpected deaths.

Any history of parathyroid problems, thyroid cancers, pituitary problems, renal cell carcinoma, renal or pancreatic cysts, skin or mucosal lesions, or neurological tumours also raises the possibility of a phaeochromocytoma arising within a familial syndrome: multiple endocrine neoplasia type 2, succinate dehydrogenase mutations, Von Hippel Lindau and neurofibromatosis.

Adreno-cortical adenomas and Cushing’s syndrome may also occur as part of multiple endocrine neoplasia type 1 and familial adenomatous polyposis syndrome.

In Carney complex, the adrenals are usually bilaterally hyperplastic with a pigmented micronodular appearance.

In McCune Albright, macronodular hyperplasia may occur, as may adenomas.

Are they taking any prescribed or non prescribed medications? 

Almost all antidepressants may lead to false positive urine metanephrine results.

Multiple medications interfere with the measurement of serum glucocorticoids including steroid containing creams, inhalers, joint injections and estrogen preparations.

Symptoms suggestive of malignancy

Is the patient being staged for a possible malignancy elsewhere? 

In a patient with a known malignancy, an adrenal mass noted on a staging CT scan may be a metastasis and require careful investigation.

This may well include biopsy if the adrenal lesion is the only possible metastatic disease identified.

Has there been any change in appetite or weight? 

Anorexia and weight loss are alarm symptoms for possible malignant disease.

Both may also occur with bilateral adrenal metastases causing glucocorticoid deficiency.

Has there been any change of bowel habit, new prostatic symptoms, new respiratory symptoms: persistent cough or haemoptysis, or new lymph nodes, or breast lumps? 

Many cancers including colon, prostate, lung and breast can metastasise to the adrenal gland.

Bilateral adrenal hyperplasia may also be found in multiple malignancies without obvious metastases.

Does the patient smoke? 

Smoking increases the risk of multiple cancers which might metastasise to the adrenal glands.

It is also important to address all modifiable cardiovascular risk factors in patients with newly diagnosed hypertension or a functioning adrenal mass.

Symptoms suggestive of phaeochromocytoma

Does the patient complain of generalised anxiety or fear? 

Although typically this occurs in acute attacks, some patients with phaeochromocytoma describe a more generalised increase in anxiety.

Do they complain of palpitations? 

Typical attacks include rapid regular palpitations.

Have they experienced severe abdominal pain? 

Although this may have many other causes, patients with phaeochromocytoma may present with an apparent 'acute abdomen'.

Adrenal haemorrhage or infarction may also present with severe pain and a heterogeneous adrenal mass on imaging.

Do they experience panic attacks or other 'funny turns'? 

Ask the patient to describe exactly what happens. Typically, people with a phaeochromocytoma will describe episodes of sudden intense fear, with palpitations, anxiety, looking pale and clammy and sometimes collapsing.

Attacks have no recognised triggers and tend to start and stop abruptly.

Symptoms suggestive of Cushing's syndrome or a virilising tumour

Has the patient developed new acne, increased redness of their face, or have they started to bruise more easily than previously? 

Plethora, acne, hirsuitism and easy bruising are all suggestive of a diagnosis of Cushing’s.

Has the patient noticed new onset hirsuitism, an increase in their muscle bulk or deepening of their voice? 

Overt virilisation is secondary to androgen excess. This may occur with adenomas of adrenal or ovary, but a short history is more suggestive of an adrenal carcinoma.

Has the patient noticed a change in their menstrual cycle if female, or a change in their libido, or in their sexual characteristics? 

Oligomenorrhoea or secondary amenorrhoea may be associated with adrenal androgen excess or Cushing’s syndrome.

Women with androgen secreting adrenal tumours may develop an increase in energy, well being and in libido, as well as objective virilisation with clitoromegaly.

Male patients may notice a loss of libido and erectile dysfunction with Cushing’s syndrome.

Has the patient developed hypertension or ankle swelling? 

High levels of glucocorticoids may access the mineralocorticoid receptor causing fluid retention and hypokalaemia.

Has the patient gained weight recently and, if so, what is the pattern of weight distribution? Do they have muscle weakness as well? 

New onset, central weight gain is typical of Cushing’s syndrome, with relative wasting of the limbs and proximal myopathy.

Does the patient have diabetes mellitus, osteoporosis or depression? 

All of these conditions are common and hypertension and glucose intolerance may form part of the metabolic syndrome in association with obesity.

However, in combination with an adrenal mass, these are suggestive of Cushing’s syndrome.

Symptoms suggestive of Conn's syndrome

Does the patient have hypertension? If so, how and when was it detected? Which medications have been used to date? 

Hypertension due to Conn’s Syndrome is typically difficult to control on standard medications, for example calcium channel blockers or diuretics alone, but responds well to aldosterone antagonists.

Hypokalaemia is also exacerbated by diuretics.

Has the patient been noted to have hypokalaemia? If so, what treatments were they on when this was documented? 

Severe hypokalaemia is rarely seen in the absence of underlying disease even with diuretic use.

Does the patient have symptoms of end organ damage or cardiovascular disease? 

End organ damage, for example retinopathy or vascular disease, tends to predict a poor surgical outcome for Conn’s syndrome.