Recommendations for the management of adrenal incidentalomas: what is pertinent for radiologists?

Abstract

Adrenal incidentalomas are unsuspected, asymptomatic adrenal masses detected on imaging. Most are non-functioning benign adrenocortical adenomas but can represent other benign lesions or lesions requiring therapeutic intervention including adrenocortical carcinoma, pheochromocytoma, hormone-producing adenoma or metastasis. This review summarizes and highlights radiological recommendations within the recently issued guidelines for the management of adrenal incidentalomas from the European Society of Endocrinology Clinical Practice in collaboration with the European Network for Study of Adrenal Tumours. Four pre-defined clinical questions were addressed in the guidelines and two have specific relevance and implications for radiologists: (1) how to assess risk of malignancy on imaging and (2) what follow-up is indicated if an adrenal incidentaloma is not surgically removed? The guidelines also include recommendations for frequently encountered special circumstances, including bilateral incidentalomas, incidentalomas in patients with extra-adrenal malignancy and in the young and elderly patients. This review highlights radiological recommendations within the guidelines and evidence used for formulating the guidelines.

Figure 1.

Management of patients with adrenal incidentalomas. Based on the European Society of Endocrinology and the European Network for the Study of Adrenal Tumours adrenal incidentaloma guideline. CSI, chemical shift imaging; MDT, multidisciplinary expert team.

Figure 2.

Evaluation of adrenal mass in patients with known extra-adrenal malignancy. Based on the European Society of Endocrinology and the European Network for the Study of Adrenal Tumours adrenal incidentaloma guideline. (1) Always take life expectancy into consideration. (2) If there is hormone excess, treatment individualized. (3) Fluorine-18 fludeoxyglucose (¹⁸F-FDG) positron emission tomography (PET)/CT to exclude other metastatic deposits in patients with no other obvious metastatic lesions and for whom surgical removal of the lesion is an option.