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Adrenal incidentaloma

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Updated 2023 ESE/ENSAT guidelines for the evaluation and management of adrenal incidentaloma.



AI refers to an adrenal mass unexpectedly detected through an imaging procedure performed for reasons unrelated to adrenal pathology.
AIs are caused due to hormone excess (adenoma, carcinoma, pheochromocytoma, congenital adrenal hyperplasia, massive macronodular adrenal disease, nodular variant of Cushing's disease), no hormone excess (adenoma, myelolipoma, neuroblastoma, ganglioneuroma, hemangioma, carcinoma, metastasis, cyst, hemorrhage, granuloma, amyloidosis, and infiltrative disease.
Disease course
A cluster of different pathologies in the adrenal gland due to physiological process of aging detected incidentally during an imaging procedure is known as AI. The majority of tumors are non-functioning, but incidentaloma with hormonal and malignancy evolution may cause life-threatening complications.
Prognosis and risk of recurrence
AIs are not associated with an increase in mortality, except for adrenal metastasis.


Key sources

The following summarized guidelines for the evaluation and management of adrenal incidentaloma are prepared by our editorial team based on guidelines from the Canadian Urological Association (CUA 2023), the European Society of Endocrinology (ESE/ENSAT 2023), the American Association of Endocrine Surgeons (AAES 2022), the American College of Radiology (ACR 2021), and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES ...
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Classification and risk stratification

Risk stratification: as per AAES 2022 guidelines, consider using washout characteristics on an adrenal protocol CT to stratify the risk of malignancy for adrenal nodules when the non-contrast HU is > 10 and other clinical risk factors for malignancy are not present. Recognize that adrenal protocol CT does not improve diagnostic accuracy for nodules with non-contrast HU < 10 nor does it improve evaluation for pheochromocytoma.
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Diagnostic investigations

History and physical examination
As per CUA 2023 guidelines:
Elicit a focused history and perform a physical examination to identify signs/symptoms of adrenal hormone excess, adrenal malignancy, and/or extra-adrenal malignancy in patients with an AI.
Set a low threshold for a multidisciplinary review by endocrinologists, surgeons, and radiologists when the imaging is not consistent with a benign lesion, there is evidence of hormone hypersecretion, the tumor has grown significantly during follow-up imaging, or adrenal surgery is being considered.

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  • Diagnostic imaging

  • Dexamethasone suppression test

  • Metanephrine assays

  • Aldosterone-to-renin ratio

  • Hormonal evaluation

  • Multidisciplinary assessment

Diagnostic procedures

Adrenal mass biopsy: as per CUA 2023 guidelines, do not perform adrenal mass biopsy routinely for the evaluation of an AI.

Therapeutic procedures

Ablation and stereotactic radiation: as per AAES 2022 guidelines, avoid performing ablation or stereotactic radiation as an alternative to adrenalectomy in patients with adrenal lesions because of inadequate data supporting these modalities. Include surgeons in the decision-making early in the treatment algorithm.

Perioperative care

Perioperative corticosteroids: as per ENSAT/ESE 2023 guidelines, administer perioperative corticosteroids at surgical stress doses in all patients undergoing surgery with a preoperative morning serum cortisol > 50 nmol/L (1.8 µg/dL) after a 1 mg overnight dexamethasone test.

Surgical interventions

Indications for adrenalectomy, nonfunctioning tumors
As per CUA 2023 guidelines:
Consider performing adrenalectomy in patients with AIs growing > 5 mm/year after repeating a functional workup.
Ensure shared decision-making for the management (repeat imaging in 3-6 months versus surgical resection) of patients with indeterminate nonfunctioning adrenal lesions.

More topics in this section

  • Indications for adrenalectomy (hormone-secreting tumors)

  • Indications for adrenalectomy (malignant tumors)

  • Technical considerations for adrenalectomy

Specific circumstances

Pediatric and young patients: as per ENSAT/ESE 2023 guidelines, consider obtaining MRI over CT in pediatric and adolescent patients requiring dedicated adrenal imaging.
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  • Pregnant patients

  • Elderly patients

  • Patients with autonomous cortisol secretion (evaluation)

  • Patients with autonomous cortisol secretion (management)

  • Patients with bilateral AIs (evaluation)

  • Patients with bilateral AIs (management)

  • Patients with adrenal metastases

  • Patients with extra-adrenal malignancy

Follow-up and surveillance

Imaging follow-up: as per CUA 2023 guidelines, do not obtain further follow-up imaging in patients with benign nonfunctioning adenomas < 4 cm, myelolipomas, and other small masses containing macroscopic fat detected on the initial workup for an AI.
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  • Laboratory follow-up