Recent Updates on the Management of Adrenal Incidentalomas

Abstract

Adrenal incidentalomas represent an increasingly common clinical conundrum with significant implications for patients. The revised 2023 European Society of Endocrinology (ESE) guideline incorporates cutting-edge evidence for managing adrenal incidentalomas. This paper provides a concise review of the updated contents of the revised guideline. In the 2023 guideline, in patients without signs and symptoms of overt Cushing's syndrome, a post-dexamethasone cortisol level above 50 nmol/L (>1.8 μg/dL) should be considered as mild autonomous cortisol secretion. Regarding the criteria of benign adrenal adenomas, a homogeneous adrenal mass with ≤10 Hounsfield units on non-contrast computed tomography requires no further follow-up, irrespective of its size. The updated guideline also discusses steroid metabolomics using tandem mass spectrometry to discriminate malignancy. It underscores the importance of high-volume surgeons performing adrenalectomy and emphasizes the pivotal role of a multidisciplinary team approach in deciding the treatment plan for indeterminate adrenal masses. The guideline advocates for more proactive surgical treatment for indeterminate adrenal masses in young patients (<40 years) and pregnant women. This review of the 2023 ESE guideline underscores the ongoing evolution of the adrenal incidentaloma management landscape, emphasizing the need for further research and adaptation of diagnostic and therapeutic strategies.

Keywords: Adrenal cortex function tests; Adrenal cortex neoplasms; Cortisol; Metabolomics; Steroids.

Fig. 1.

Flow diagram on the management of patients with adrenal incidentaloma. Modified from Fassnacht et al. [7]. MDT, multidisciplinary team; ACTH, adrenocorticotropic hormone. ^aOnly in adrenal tumors with >10 Hounsfield units (HU) on unenhanced computed tomography (CT); ^bOnly in patients with hypertension or hypokalemia; ^cOnly in patients with findings suggestive of adrenocortical carcinoma; ^dIndeterminate adrenal mass: homogeneous with 11 to 20 HU and tumor ≥4 cm, homogeneous with >20 HU and tumor <4 cm, and heterogeneous tumors <4 cm; ^eFluorodeoxyglucose positron emission tomography/CT, adrenal magnetic resonance imaging (MRI) with chemical shift, or washout CT.