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Adrenal incidentaloma — Clinical Guidelines

Overview

Adrenal incidentalomas are adrenal masses discovered incidentally through imaging performed for unrelated reasons. Most are nonfunctioning adrenocortical adenomas, but they may also represent hormonally active adenomas, pheochromocytomas, adrenocortical carcinomas, or metastatic lesions 3 7.

Diagnosis

Initial Assessment: Includes history, physical examination, and biochemical testing to rule out hormonal hypersecretion 3 4.

Hormonal Testing: Evaluate for cortisol, aldosterone, metanephrines, and other relevant hormones based on clinical suspicion 3 4.

Imaging: CT or MRI for characterization of mass size, density, and potential functional activity 3 10.

Grading: Use imaging characteristics (size, density) to stratify risk for malignancy; consider referral for specialist evaluation if suspicious features are present 3 8.

Management

Nonfunctioning Adenomas: Regular monitoring with imaging and hormonal assessments; intervention considered for large masses (typically >4 cm) or those with suspicious features 3 7 8.

Functioning Tumors: Specific treatment based on hormone type:

- Cushing Syndrome: Surgical resection or medical management with ketoconazole or mifepristone 3. - Primary Aldosteronism: Spironolactone or other mineralocorticoid receptor antagonists, with surgery if resistant or contraindications exist 3. - Pheochromocytoma: Preoperative alpha-adrenergic blockade followed by surgical removal 3.

Suspected Malignancy: Referral to an endocrinologist and possibly surgical consultation for definitive management 3 7.

Special Populations

Elderly: Consider comorbidities and life expectancy when deciding on aggressive management; conservative monitoring may be appropriate 8.

Comorbidities: Increased risk of incident diabetes in nonfunctioning adrenal tumors; monitor glucose levels closely 8.

Key Recommendations

Initial Evaluation: Perform comprehensive hormonal testing and imaging to assess functionality and risk stratification of adrenal incidentalomas (Evidence: Strong 3 4).

Monitoring Strategy: Regular follow-up with imaging and hormonal assessments for nonfunctioning adenomas, with intervention criteria based on size and imaging characteristics (Evidence: Moderate 3 7 8).

Surgical Intervention: Consider surgical removal for large nonfunctioning adenomas, hormonally active tumors, or those with suspicious features indicative of malignancy (Evidence: Moderate 3 7).

Special Considerations: Tailor management in elderly patients and those with comorbidities, balancing risks and benefits (Evidence: Expert opinion 8).

References

1 Baş Aksu Ö, Aydın RF, Gökçay Canpolat A, Demir Ö, Şahin M, Emral R et al.. Artificial intelligence in endocrine practice: comparing ChatGPT, Gemini, and Claude for adrenal incidentaloma care. Journal of endocrinological investigation 2026. link 2 Janiak K, Józwik-Plebanek K, Kamiński G. Recent guidelines for diagnostic and therapeutic management of accidentally detected adrenal tumours (incidentaloma) in adults. Endokrynologia Polska 2024. link 3 Fassnacht M, Tsagarakis S, Terzolo M, Tabarin A, Sahdev A, Newell-Price J et al.. European Society of Endocrinology clinical practice guidelines on the management of adrenal incidentalomas, in collaboration with the European Network for the Study of Adrenal Tumors. European journal of endocrinology 2023. link 4 Rowe NE, Kumar R, Schieda N, Siddiqi F, McGregor T, McAlpine K et al.. Diagnosis, Management, and Follow-Up of the Incidentally Discovered Adrenal Mass: CUA Guideline Endorsed by the AUA. The Journal of urology 2023. link 5 Sconfienza E, Tetti M, Forestiero V, Veglio F, Mulatero P, Monticone S. Prevalence of Functioning Adrenal Incidentalomas: A Systematic Review and Meta-analysis. The Journal of clinical endocrinology and metabolism 2023. link 6 Maas M, Nassiri N, Bhanvadia S, Carmichael JD, Duddalwar V, Daneshmand S. Discrepancies in the Recommended Management of Adrenal Incidentalomas by Various Guidelines. The Journal of urology 2021. link 7 Cambos S, Tabarin A. Management of adrenal incidentalomas: Working through uncertainty. Best practice & research. Clinical endocrinology & metabolism 2020. link 8 Morelli V, Scillitani A, Arosio M, Chiodini I. Follow-up of patients with adrenal incidentaloma, in accordance with the European society of endocrinology guidelines: Could we be safe?. Journal of endocrinological investigation 2017. link 9 Bednarczuk T, Bolanowski M, Sworczak K, Górnicka B, Cieszanowski A, Otto M et al.. Adrenal incidentaloma in adults - management recommendations by the Polish Society of Endocrinology. Endokrynologia Polska 2016. link 10 Paterson F, Theodoraki A, Amajuoyi A, Bouloux PM, Maclachlan J, Khoo B. Radiology reporting of adrenal incidentalomas - who requires further testing?. Clinical medicine (London, England) 2014. link 11 Patel HR, Harris AM, Lennard TW. Adrenal masses: the investigation and management of adrenal incidentalomas. Annals of the Royal College of Surgeons of England 2001. link 12 Stumvoll M, Schmülling RM, Brambs HJ, Wehrmann M, Eggstein M. Rudimentary second stomach as adrenal incidentaloma. The British journal of clinical practice 1994. link 13 Paul JG, Brosman S, Rhodes D. Pseudotumor of adrenal gland. Urology 1976. link90579-3)

Adrenal incidentaloma