Which specialist should I see for a left adrenal gland lesion?

Which Specialist Should Evaluate a Left Adrenal Gland Lesion

For an incidentally discovered left adrenal lesion, you should initially consult an endocrinologist, who will coordinate the comprehensive hormonal and radiological evaluation required for all adrenal masses. 1, 2, 3

Primary Specialist: Endocrinologist

• Endocrinologists are the primary specialists for adrenal incidentaloma evaluation because every patient requires mandatory complete hormonal screening regardless of symptoms or imaging appearance. 1, 2, 3

• The endocrinologist will coordinate the essential hormonal workup including:

  • 1 mg overnight dexamethasone suppression test to exclude autonomous cortisol secretion 2, 3
  • Plasma free metanephrines or 24-hour urinary fractionated metanephrines to exclude pheochromocytoma 2, 3
  • Aldosterone-to-renin ratio if hypertension or hypokalemia is present 3

When to Involve Additional Specialists

Urologist or Endocrine Surgeon

• Surgical consultation is indicated for any hormonally active tumor, masses >4 cm with suspicious imaging features, or any mass growing >5 mm/year on surveillance. 1, 2, 3

• Urologists specifically manage adrenal incidentalomas requiring surgical intervention, as outlined in the Canadian Urological Association guidelines endorsed by the American Urological Association. 1

Gastroenterologist (Interventional Endoscopist)

• For patients with known or suspected lung cancer requiring tissue diagnosis of a left adrenal lesion, a gastroenterologist trained in endoscopic ultrasound (EUS) can perform transgastric EUS-guided fine needle aspiration (FNA). 1

• EUS-FNA of the left adrenal gland has a diagnostic yield of 95% for detecting metastases and can be performed during the same session as mediastinal staging. 1

• The left adrenal gland is visualized in 97-100% of patients via transgastric approach, with sensitivity of at least 86% and fewer complications than percutaneous biopsy. 1

Radiologist

• Radiologists are essential for proper imaging characterization using unenhanced CT as the mandatory first-line modality. 2, 3

• Homogeneous lesions ≤10 Hounsfield Units on non-contrast CT are definitively benign regardless of size and require no further workup. 2, 3

Critical Multidisciplinary Coordination

Multidisciplinary discussion is mandatory when imaging is indeterminate, hormone hypersecretion is present, significant growth occurs, or surgery is considered. 1, 2, 3 This typically involves endocrinology, urology/surgery, and radiology working together.

Important Caveat

Never proceed with adrenal biopsy or surgery without first definitively excluding pheochromocytoma through biochemical testing, as failure to do so can be fatal. 2, 3 This underscores why endocrinology should be the initial consultation—hormonal evaluation must precede any invasive procedures.