Do all patients really need hormonal screening before an adrenal biopsy?

e23070 Background: Timely tissue diagnosis is critical in patients with suspected advanced cancer, particularly as many deteriorate rapidly and may not reach treatment. Current guidelines, including NCCN, mandate exclusion of pheochromocytoma/paraganglioma (PH/PG) through hormonal screening prior to adrenal biopsy, due to concern for catecholamine-related complications. In patients with a low pretest probability of PH/PG, this requirement may introduce clinically meaningful delays that conflict with the urgency of oncologic care. We evaluated the safety of adrenal biopsy without prior hormonal screening and its impact on time to biopsy within a rapid cancer diagnostic pathway. Methods: Using the Sheba Medical Center Institutional Data Lab, OncoMind RWD, we identified patients seen at the Rapid Cancer Diagnostic Unit (2018–2025) with suspected advanced cancer and an adrenal mass considered a metastatic lesion who underwent CT-guided adrenal biopsy. Time from diagnostic intake to biopsy, diagnostic yield, and complications were recorded. To contextualize the risk of inadvertent PH/PG biopsy, we identified patients diagnosed with PH/PG at our institution outside the rapid diagnostic pathway who underwent CT-guided biopsy without documented hormonal screening. Results: Forty patients underwent adrenal biopsy within the Rapid Cancer Diagnostic Unit; 33 did not undergo hormonal screening and seven underwent screening prior to biopsy. Median age was 69 years, and 75% were male. Adrenal biopsy yielded the definitive diagnosis in 94%. Among the 33 cases without hormonal screening, 20 cases (63%) were deemed urgent due to severe symptoms, most commonly symptomatic brain metastases (n=9), severe respiratory symptoms (n=4), superior vena cava syndrome (n=3) and impending spinal cord compression (n=2). The most frequent diagnoses were non–small cell lung cancer (73%), small cell lung cancer (9%), and lymphoma (6%). No patient in either group was diagnosed with PH/PG, and no biopsy-related complications occurred. Time to biopsy was significantly longer in patients who underwent hormonal screening compared with those who did not (median 13 vs 3 days; p=0.001). Outside the rapid diagnostic unit, five patients with PH/PG underwent CT-guided biopsy (1 lung, 1 adrenal and 3 retroperitoneal) without documented hormonal screening; one experienced a hormonal-related complication. Conclusions: In patients with suspected advanced cancer and a low pretest probability of pheochromocytoma, adrenal biopsy without prior hormonal screening appears safe and substantially shortens time to diagnosis. Current guideline requirements may not fully reflect real-world oncologic urgency. In carefully selected patients managed in experienced centers, guidelines dictating for hormonal exclusion of pheochromocytoma may be over-cautious and warrant reconsideration.