Endocrine Abstracts

New adrenal lesions discovered during cross-sectional abdominal imaging pose an increasingly common diagnostic challenge; their initial management should focus on the exclusion of malignancy and autonomous hormone excess. The role of adrenal biopsies in this context is limited and pathologists often struggle to differentiate benign from malignant adrenal tissue even when analysing the entire tumour specimen. Guidelines recommend that adrenal biopsy should only be considered if two criteria are met: firstly, history of extra-adrenal malignancy and an isolated new adrenal lesion with suspicious imaging criteria; secondly, biochemical exclusion of phaeochromocytoma. We reviewed all cases of adrenal biopsies performed at University Hospital Birmingham (UHB) in the time period from January 2004 to October 2013, with a view to assessing compliance with standards of best practice, reviewing histopathology and clinical medical records. We identified 18 UHB patients with adrenal biopsies in the defined 10-year period. The decision for adrenal biopsy was taken in accordance with guideline recommendations in only three patients; an additional 12 fulfilled the clinical criterion only and in the remaining three none of the required criteria was fulfilled. MDT review prompted biopsy in seven of 18 but only three patients underwent endocrine review. In ten of the 14 patients with underlying history of malignancy the histopathology result was informative, prompting chemotherapy in six of them. All but two patients died within a year of biopsy (median 2 months, range 3 days–12 months). In one patient with a recent history of melanoma the biopsy indicated adrenocortical adenoma; the adrenal mass was removed surgically 3 years later due to significant growth and histopathology revealed a melanoma metastasis embedded in a large phaeochromocytoma. In conclusion, patients undergoing adrenal biopsies are frequently managed hazardously, with only the minority receiving MDT and endocrine review. Histopathology is regularly non-informative and can be misleading.