What blood tests are recommended for a patient with an adrenal tumor prior to surgical workup?

Blood Tests Required for Adrenal Tumor Workup Before Surgery

All patients with adrenal tumors should undergo comprehensive hormonal evaluation including cortisol, aldosterone, and catecholamine testing before surgical workup, regardless of tumor characteristics. 1

Mandatory Blood Tests for All Patients

• Cortisol secretion assessment 1

  • 1 mg overnight dexamethasone suppression test (preferred screening test)
  • Serum cortisol (morning baseline)
  • Plasma ACTH levels
  • Consider 24-hour urinary free cortisol in cases of elevated cortisol

• Aldosterone secretion assessment (for patients with hypertension and/or hypokalemia) 1

  • Aldosterone-to-renin ratio
  • Serum potassium levels
  • Note: Adrenal vein sampling is recommended prior to adrenalectomy if primary aldosteronism is confirmed

• Catecholamine excess screening 1

  • Plasma metanephrines (preferred) or 24-hour urinary metanephrines
  • Required for all patients with adrenal masses >10 HU on non-contrast CT or with symptoms of catecholamine excess
  • Can be omitted only in patients with unequivocal adrenocortical adenomas (<10 HU) without signs of adrenergic excess

• Androgen excess testing (in specific cases) 1

  • DHEA-S (serum)
  • 17-OH-progesterone (serum)
  • Androstenedione (serum)
  • Testosterone (serum)
  • 17-beta-estradiol (serum, only in men and postmenopausal women)
  • Required when adrenocortical carcinoma is suspected or clinical signs of virilization are present

Additional Tests to Consider

• Basic metabolic panel 1

  • Particularly important to assess electrolyte abnormalities that may accompany hormone-secreting tumors
  • Glucose levels (cortisol-secreting tumors can cause hyperglycemia)

• Complete blood count 1

  • To assess for potential hematologic abnormalities that might affect surgical planning

Important Considerations

• Timing of tests: Hormone testing should be completed before any surgical intervention is planned 1

• Medication interference: Stop medications that affect pituitary or adrenocortical function before hormone testing (consider at least 5 half-lives to avoid interference) 2

• Multidisciplinary approach: Results should be reviewed by a team including endocrinologists, surgeons, and radiologists when there is evidence of hormone hypersecretion or when adrenal surgery is being considered 1

• Confirmatory testing: Additional testing may be required based on initial results:

  • Saline suppression test or salt loading test for suspected hyperaldosteronism 1
  • Higher-dose dexamethasone suppression tests for abnormal cortisol results 3

Pitfalls to Avoid

• Don't skip hormone testing: Even apparently non-functioning tumors may have subtle hormone production that can impact surgical management and perioperative care 1, 4

• Don't rely solely on imaging: Radiological appearance cannot reliably predict hormone secretion status 1, 5

• Don't perform adrenal biopsy without excluding pheochromocytoma: Biopsy of an undiagnosed pheochromocytoma can trigger life-threatening hypertensive crisis 1

• Don't overlook genetic testing: Consider genetic testing in patients with pheochromocytoma as over 35% have germline mutations 5

• Don't forget to assess for comorbidities: Patients with mild autonomous cortisol secretion should be screened for potential cortisol-related comorbidities 4

Following this comprehensive hormonal evaluation will ensure proper preoperative planning, reduce perioperative complications, and guide appropriate surgical approach for patients with adrenal tumors.