Preoperative Hormonal Evaluation for Adrenal Tumors

Mandatory Blood Tests for All Patients

The American Urological Association recommends that all patients with adrenal tumors undergo comprehensive hormonal evaluation, including cortisol, aldosterone, and catecholamine testing, before surgical workup, regardless of tumor characteristics 1, 2
Cortisol secretion assessment should include a 1 mg overnight dexamethasone suppression test as the preferred screening test 1
Plasma ACTH levels should be measured as part of the cortisol secretion assessment 3
Aldosterone secretion assessment should be performed in patients with hypertension and/or hypokalemia, and should include aldosterone-to-renin ratio and serum potassium levels 1, 4, 5
Catecholamine excess screening should be performed using plasma metanephrines or 24-hour urinary metanephrines, and is required for all patients with adrenal masses >10 HU on non-contrast CT or with symptoms of catecholamine excess 1, 6, 7
Androgen excess testing should be performed in specific cases, including measurement of DHEA-S, 17-OH-progesterone, androstenedione, and 17-beta-estradiol 1, 3, 8

A basic metabolic panel should be performed to assess electrolyte abnormalities that may accompany hormone-secreting tumors 5
A complete blood count should be performed to assess for potential hematologic abnormalities that might affect surgical planning 3, 5

Hormone testing should be completed before any surgical intervention is planned, according to the American Urological Association 2, 3
A multidisciplinary approach should be taken when reviewing results, including endocrinologists, surgeons, and radiologists, when there is evidence of hormone hypersecretion or when adrenal surgery is being considered 2, 7
Confirmatory testing, such as saline suppression test or salt loading test, may be required based on initial results 5

Hormone testing should not be skipped, even in apparently non-functioning tumors, as subtle hormone production can impact surgical management and perioperative care 1
Radiological appearance cannot reliably predict hormone secretion status, and should not be relied upon solely 7
Adrenal biopsy should not be performed without excluding pheochromocytoma, as biopsy of an undiagnosed pheochromocytoma can trigger life-threatening hypertensive crisis 6