In an 81-year-old patient with a history of melanoma treatment who previously experienced right adrenal hemorrhage, what adrenal workup is indicated now?

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Adrenal Workup for 81-Year-Old with History of Right Adrenal Hemorrhage from Melanoma Treatment

This patient requires comprehensive biochemical screening for hormone excess (pheochromocytoma, primary aldosteronism, and autonomous cortisol secretion), assessment for adrenal insufficiency given the history of hemorrhage, and repeat imaging to evaluate for metastatic disease or residual mass characteristics.

Biochemical Evaluation

Mandatory Hormone Screening

Given the patient's melanoma history and adrenal lesion, you must screen for functional tumors even though metastasis is likely, because pheochromocytoma cannot be reliably differentiated from adrenal metastasis on imaging and can cause significant morbidity 1. The 2025 Endocrine Practice guidelines are explicit that patients with extra-adrenal malignancy and adrenal masses require pheochromocytoma screening regardless of suspected etiology 1.

Order the following tests:

  • Plasma or urine fractionated metanephrines - to exclude pheochromocytoma 1
  • Paired plasma aldosterone and renin activity levels - to screen for primary aldosteronism 1
  • 1 mg overnight dexamethasone suppression test or late-night salivary cortisol - to assess for autonomous cortisol secretion 1

Adrenal Insufficiency Assessment

Critical consideration: Bilateral adrenal hemorrhage can cause primary adrenal insufficiency 1. Even with unilateral hemorrhage, assess for:

  • Morning cortisol level (8 AM)
  • ACTH level
  • Consider ACTH stimulation test if basal cortisol is borderline or if patient has symptoms of adrenal insufficiency (fatigue, hypotension, hyponatremia)

The evidence shows that adrenal function can remain impaired for years after hemorrhage, with one case demonstrating incomplete recovery even 19 years post-hemorrhage 2. Additionally, melanoma immunotherapy (checkpoint inhibitors) can independently cause secondary adrenal insufficiency 3, 4, making this assessment doubly important in your patient.

Imaging Evaluation

Immediate Imaging Needs

Obtain non-contrast CT (NCCT) or MRI of the adrenals now to:

  1. Characterize the current lesion - Hemorrhage typically decreases in size over time 1. If the lesion has grown or changed character, this raises concern for metastatic disease or other pathology.

  2. Assess for malignancy risk - In patients with extra-adrenal malignancy, up to 70% of indeterminate adrenal lesions are malignant 1. However, less than 30% of all adrenal lesions in cancer patients are actually metastatic 1.

  3. Compare with prior imaging - Review any previous imaging to assess growth or stability 1. This is the most useful discriminator in cancer patients.

Imaging Interpretation

  • Benign features on NCCT: <10 Hounsfield units (HU) indicates lipid-rich adenoma - likely benign
  • Indeterminate features: 10-30 HU requires further characterization
  • Suspicious features: >30 HU, irregular borders, heterogeneous enhancement, or growth >5 mm with >20% size increase warrants surgical consideration 1

Follow-Up Strategy

If Lesion Appears Benign and Stable

  • Repeat imaging in 6-12 months 1, 5
  • Lesions that decrease in size often represent resolving hemorrhage or pseudocysts 1
  • No further imaging needed if stable for 12 months and hormone screening remains negative 1

If Lesion is Indeterminate or Growing

  • Growth ≥8 mm in 12 months or ≥5 mm with >20% diameter increase requires surgical consideration 1
  • Adrenal biopsy should only be considered if: (1) pheochromocytoma and adrenocortical carcinoma are excluded biochemically, AND (2) histologic diagnosis would change management 1
  • FDG-PET may help if mass remains indeterminate after NCCT and pheochromocytoma is excluded 1

Critical Pitfalls to Avoid

  1. Never biopsy before excluding pheochromocytoma - this can precipitate hypertensive crisis
  2. Don't assume hemorrhage is benign - adrenocortical carcinoma can present with spontaneous hemorrhage 6
  3. Don't overlook adrenal insufficiency - both hemorrhage and melanoma immunotherapy can cause this 2, 3, 4
  4. Don't skip hormone testing in cancer patients - functional tumors require different management than metastases 1

Multidisciplinary Discussion

Discuss this case with endocrinology, oncology, and radiology 1, particularly given:

  • Age 81 with melanoma history
  • Previous adrenal hemorrhage
  • Need to balance cancer surveillance with age-appropriate intervention

The patient's advanced age and melanoma history create competing priorities between aggressive cancer surveillance and quality of life considerations, making shared decision-making essential 5.

References

1
Guideline

imaging of adrenal masses.

Endocrine practice : official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologist, 2025

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.