An Incidental Adrenal Nodule in a Frail 86-Year-Old: Does the Workup Change Anything
A single patient whose incidental, imaging-benign adrenal nodule falls under a near-universal testing recommendation written for a population very different from her own.
Eleanor W., an 86-year-old retired librarian, has advanced COPD requiring home oxygen and a recent heart failure hospitalization that her cardiologist has been candid about — her own estimated life expectancy, independent of anything found today, is measured in a small number of years, not decades. A CT scan obtained for a pulmonary workup found an incidental 1.8 cm right adrenal nodule, homogeneous with an attenuation of 6 Hounsfield units on the non-contrast images — imaging characteristics squarely inside what the 2023 European Society of Endocrinology guideline calls a definitively benign lipid-rich adenoma, needing no further imaging follow-up regardless of size. The guideline's separate recommendation, though, is that essentially every adrenal incidentaloma, image-benign or not, receive a 1 mg dexamethasone suppression test to screen for mild autonomous cortisol secretion — a recommendation written for a population that, unlike Eleanor, usually has decades of remaining life in which cortisol-driven hypertension, diabetes, or bone loss could meaningfully accumulate.
The actual question in front of the team isn't whether the guideline's testing threshold is correct in general — it plausibly is, for most patients an incidentaloma is found in — but whether applying it reflexively to Eleanor specifically serves her. A positive result would not change whether she is offered adrenalectomy, which nobody on the team believes she could safely undergo; at most it would prompt a conversation about optimizing blood pressure or glucose control she is already receiving on other grounds. The test itself requires a return visit, correctly timed dexamethasone administration the night before, and a fasting morning draw — real burden for a patient already managing multiple specialist visits and oxygen logistics.
Pulmonology follow-up, reviewing the incidental finding
The 2023 ESE guideline recommends the 1mg dexamethasone suppression test for essentially every incidentaloma, regardless of symptoms, precisely because relying on individual judgment about who "probably doesn't need it" has historically been an unreliable filter. I'd rather apply the standard as written than make an exception based on her age.
I'd push back specifically on what this test would change for her. She isn't a surgical candidate under any plausible reading of her comorbidities, so a positive result doesn't open a treatment path that isn't already available — her blood pressure and glucose are already being managed by her primary care physician regardless of the cause. Adding a fasting, correctly-timed test that requires another visit, for a result that changes nothing concrete, is exactly the kind of low-value testing geriatric care is supposed to catch.
Your point about unreliable filters is well taken, and it's why I'd never make this argument from age. Make it from the referral pathway instead: name the intervention a positive result would unlock for her. If neither of us can, the guideline's own logic hasn't been overridden here — it simply hasn't been engaged.
I don't think either of you is wrong in general — I think the actual answer is specific to her. Let me check: if this test came back positive, would I change anything about how I'm already managing her blood pressure or glucose? Honestly, probably not — I'm already treating both to target. If the answer is genuinely no, that's a real reason to skip it for her, not because of her age, but because the guideline's testing threshold assumes a management consequence that, in her specific case, doesn't exist.
Agreed: skip the dexamethasone suppression test for Eleanor specifically, having confirmed with her primary care physician that a positive result would not change her current management, and no further adrenal imaging is needed given the nodule's definitively benign appearance.
Not agreed: whether this should become a standing practice — skipping functional workup whenever a patient's overall prognosis or care plan makes the result unlikely to be actionable — or whether it should remain a case-by-case exception requiring the same explicit "would this change anything" conversation each time. The endocrinologist is wary of the former becoming an informal, unwritten age-based cutoff; the geriatrician sees no meaningful difference between the two in practice.