For GPs

When to refer

• Any hormone-active adrenal mass: confirmed or strongly suspected phaeochromocytoma, Conn's syndrome, Cushing's syndrome, or virilising tumour.
• Adrenal mass larger than 4 cm or with indeterminate/concerning imaging features.³
• Adrenal mass that grows on serial imaging.
• Adrenal lesion in the context of a known primary cancer where metastatic involvement is a realistic possibility.
• Complex incidentalomas where the workup is unclear.

Biochemical screen for any adrenal mass

The minimum workup, guided by the ESE clinical practice guideline and the Endocrine Society phaeochromocytoma guideline:^3,6

• Plasma free metanephrines or 24-hour urinary fractionated metanephrines - to exclude phaeochromocytoma (must be done before any biopsy or surgery).
• Overnight 1 mg dexamethasone suppression test - to screen for autonomous cortisol secretion. Urinary free cortisol and ACTH as follow-up if abnormal.
• Aldosterone-to-renin ratio - especially if hypertensive or hypokalaemic; attention to washout of interfering antihypertensives where clinically safe.
• Consider serum DHEAS, androstenedione and testosterone in women with features of androgen excess, or oestradiol in men with feminising features (uncommon).

Imaging

• Dedicated adrenal CT is the preferred first-line study: non-contrast phase (Hounsfield unit density), portal-venous and delayed phases for washout characteristics.
• MRI with chemical shift imaging is an alternative, particularly in younger patients or when radiation exposure is a concern.
• Functional imaging (MIBG, Ga-DOTATATE PET, FDG-PET) is reserved for selected cases and is usually arranged by the specialist team.

How to refer

Patient information leaflets