Is adrenal insufficiency a complication of adrenal biopsy?

Adrenal Insufficiency as a Complication of Adrenal Biopsy

Yes, adrenal insufficiency can occur as a complication of adrenal biopsy, though it is relatively rare compared to other complications such as bleeding, pneumothorax, and infection.

Risk of Adrenal Insufficiency Following Adrenal Biopsy

Adrenal biopsy is a procedure that carries several potential complications, with adrenal insufficiency being one of the possible adverse outcomes. While the literature does not extensively document this specific complication, case reports and clinical guidelines acknowledge its possibility, particularly in certain scenarios:

Complication Profile of Adrenal Biopsy

• The overall complication rate for adrenal biopsy ranges from 2.5% to 12% 1, 2
• Most common complications include:
  • Bleeding (most frequent)
  • Pneumothorax
  • Infection
  • Tumor seeding along needle tract
  • Adrenal insufficiency (less common)

Mechanisms of Adrenal Insufficiency After Biopsy

Adrenal insufficiency following biopsy may occur through several mechanisms:

1. Bilateral adrenal involvement: When both adrenal glands are biopsied or when biopsy is performed on a single functioning adrenal gland (with the contralateral gland already compromised)

2. Hemorrhage: Significant bleeding into the adrenal gland can cause tissue destruction and impair function

3. Rapid tumor growth: In cases of adrenal lymphoma or other aggressive malignancies, the biopsy procedure may coincide with rapid destruction of functional adrenal tissue 3, 4

Risk Factors for Post-Biopsy Adrenal Insufficiency

Certain clinical scenarios increase the risk of developing adrenal insufficiency following adrenal biopsy:

• Bilateral adrenal masses requiring biopsy 3, 4
• Pre-existing subclinical adrenal insufficiency
• Large adrenal masses that have replaced significant portions of normal adrenal tissue
• Aggressive malignancies such as primary adrenal lymphoma that can rapidly destroy adrenal tissue 3, 4
• Hemorrhagic complications during or after the procedure

Clinical Considerations Before Adrenal Biopsy

Before proceeding with adrenal biopsy, several important considerations should be addressed:

Indications for Adrenal Biopsy

Adrenal biopsy is generally indicated in limited circumstances:

• Suspected metastatic disease to the adrenal gland in patients with known extra-adrenal malignancy 1, 2
• Indeterminate adrenal masses when diagnosis would alter management 1
• Suspected infection (e.g., tuberculosis, fungal infection)

Important Precautions

• Rule out pheochromocytoma: Biochemical exclusion of catecholamine-producing tumors is mandatory before biopsy to prevent potentially life-threatening complications 1, 2
• Avoid biopsy of suspected adrenocortical carcinoma: Due to risk of tumor seeding along the needle tract 1
• Baseline adrenal function assessment: Consider evaluating cortisol levels before biopsy, especially with bilateral adrenal masses 5

Management of Adrenal Insufficiency After Biopsy

If adrenal insufficiency develops following adrenal biopsy, prompt management is essential:

• Acute management: Hydrocortisone 100 mg IV immediately followed by 100-300 mg/day as continuous infusion or divided doses every 6 hours 5

• Long-term management:

  • Glucocorticoid replacement: Hydrocortisone 15-25 mg daily in divided doses
  • Mineralocorticoid replacement: Fludrocortisone 0.05-0.2 mg daily
  • Patient education on stress dosing and adrenal crisis prevention 5

Alternative Diagnostic Approaches

Given the potential complications of adrenal biopsy, alternative diagnostic approaches should be considered first:

• Non-contrast CT (with HU measurements)
• Contrast-enhanced washout CT
• Chemical shift MRI
• FDG-PET/CT (especially for suspected metastases) 1

Conclusion

While adrenal insufficiency is not among the most common complications of adrenal biopsy, it represents a serious potential outcome that clinicians should be aware of, particularly when performing biopsies on bilateral adrenal masses or in patients with limited adrenal reserve. The risk-benefit ratio should be carefully evaluated, with consideration of alternative diagnostic approaches when possible.