What specialty do you refer a patient with adrenal nodules to?

Referral for Adrenal Nodules

Patients with adrenal nodules should be referred to an endocrinologist for comprehensive hormonal evaluation and management. 1, 2

Rationale for Endocrinology Referral

Adrenal nodules require specialized evaluation for two main concerns:

1. Risk of malignancy - Requires proper imaging interpretation and risk stratification
2. Hormonal functionality - Even seemingly "non-functioning" nodules may produce subtle hormone excess

Hormonal Evaluation Required

Endocrinologists are specifically trained to conduct and interpret the comprehensive hormonal workup needed for all adrenal nodules:

• Cortisol evaluation - 1-mg overnight dexamethasone suppression test (cutoff ≤50 nmol/L or ≤1.8 μg/dL) 1, 2
• Catecholamine screening - Plasma free metanephrines or 24-hour urinary fractionated metanephrines 1
• Aldosterone evaluation - Aldosterone-to-renin ratio (ARR) 1
• Androgen assessment - DHEAS and testosterone levels 1

Imaging Interpretation

Endocrinologists work with radiologists to properly interpret adrenal imaging:

• Homogeneous lesions with HU ≤10 on unenhanced CT are benign 2
• Lesions >4 cm that are inhomogeneous or have HU >20 have higher risk of malignancy 2
• Contrast washout patterns and MRI signal characteristics require specialized interpretation 1

When to Consider Additional Specialty Referrals

While endocrinology is the primary referral, certain scenarios may warrant additional specialty involvement:

Endocrine Surgery Referral

Consider referral to an endocrine surgeon when:

• Nodules >4 cm with inhomogeneous appearance or HU >20 1, 2
• Any nodule >6 cm regardless of appearance 1
• Biochemically confirmed hormone-producing tumors:
  • Pheochromocytomas
  • Aldosterone-secreting adenomas
  • Cortisol-secreting adenomas 1
• Mild autonomous cortisol secretion (MACS) with related comorbidities 2

Oncology Referral

Consider oncology referral when:

• Features highly suspicious for adrenocortical carcinoma
• Known extra-adrenal malignancy with suspected metastasis to adrenal gland

Common Pitfalls to Avoid

1. Inadequate hormonal evaluation - Only 48% of patients receive proper hormonal workup even when recommended in radiology reports 3
2. Failure to recognize MACS - Patients with mild autonomous cortisol secretion have increased morbidity and mortality risk 2
3. Inappropriate biopsy - Biopsies of suspected adrenocortical carcinoma should be avoided as they are potentially harmful 1
4. Lack of standardized follow-up - Non-operated patients require systematic follow-up based on imaging characteristics and hormonal status 2

Benefits of Endocrinology Referral

Studies show that patients seen by endocrinologists have 100% adherence to proper hormonal evaluation protocols, compared to only 16.1% for those not seen by endocrinology 3. This specialized care ensures appropriate management decisions regarding:

• Need for surgical intervention
• Medical therapy options
• Surveillance protocols
• Management of hormone-related comorbidities

In summary, endocrinology referral is essential for all patients with adrenal nodules to ensure proper evaluation, risk stratification, and management planning.