Management of Adrenal Incidentalomas
General remarks
R.1.1
- Imaging is not consistent with a benign lesion.
- There is evidence of hormone excess (including mild autonomous cortisol secretion [MACS] in patients with clinically relevant comorbidities potentially attributable to cortisol).
- Adrenal surgery is considered.
- Evidence of significant tumor growth during follow-up imaging.
Figure 4
![](https://54d4f314-8f94-415c-acb7-fd0a6332f070.s3.amazonaws.com/3097101/3097101__Fig%204__209567851.jpeg?X-Amz-Content-Sha256=UNSIGNED-PAYLOAD&X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Credential=AKIAU2BE4PNFKE2WZV7V%2F20240907%2Fus-east-1%2Fs3%2Faws4_request&X-Amz-Date=20240907T202546Z&X-Amz-SignedHeaders=host&X-Amz-Expires=86400&X-Amz-Signature=6022659db7c5c4854c71236ab27303f772077450270d4d71730047859275c77c)
Figure 5
![](https://54d4f314-8f94-415c-acb7-fd0a6332f070.s3.amazonaws.com/3097102/3097102__Fig%205__731537857.jpeg?X-Amz-Content-Sha256=UNSIGNED-PAYLOAD&X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Credential=AKIAU2BE4PNFKE2WZV7V%2F20240907%2Fus-east-1%2Fs3%2Faws4_request&X-Amz-Date=20240907T202546Z&X-Amz-SignedHeaders=host&X-Amz-Expires=86400&X-Amz-Signature=b4106df3d4bc568b5c1ecc1a3d2adef5b83d310f2d017c12f85c5c0b806591cb)
Figure 6
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Figure 7
![](https://54d4f314-8f94-415c-acb7-fd0a6332f070.s3.amazonaws.com/3097104/3097104__Fig%207__-428232503.jpeg?X-Amz-Content-Sha256=UNSIGNED-PAYLOAD&X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Credential=AKIAU2BE4PNFKE2WZV7V%2F20240907%2Fus-east-1%2Fs3%2Faws4_request&X-Amz-Date=20240907T202546Z&X-Amz-SignedHeaders=host&X-Amz-Expires=86400&X-Amz-Signature=80a3b1fa6cc15fc96541b563a9cf0fbf8cda79fe1f01ac4068cbcadcc9deef1c)
Figure 9
![](https://54d4f314-8f94-415c-acb7-fd0a6332f070.s3.amazonaws.com/3097105/3097105__Fig%209__246161786.jpeg?X-Amz-Content-Sha256=UNSIGNED-PAYLOAD&X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Credential=AKIAU2BE4PNFKE2WZV7V%2F20240907%2Fus-east-1%2Fs3%2Faws4_request&X-Amz-Date=20240907T202546Z&X-Amz-SignedHeaders=host&X-Amz-Expires=86400&X-Amz-Signature=35e2f29e4d5399fbc54b8158fe2745e450964bfc600034bb9a69359b06bda4fd)
Assessment of the risk of malignancy
R.2.1
R.2.2
R.2.3
R.2.4
R.2.5
R.2.6
R.2.7
R.2.8
Figure 1. Diagnostic performance of unenhanced CT in adrenal incidentaloma
![](https://54d4f314-8f94-415c-acb7-fd0a6332f070.s3.amazonaws.com/3097098/3097098__fig%201__1204725276.jpeg?X-Amz-Content-Sha256=UNSIGNED-PAYLOAD&X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Credential=AKIAU2BE4PNFKE2WZV7V%2F20240907%2Fus-east-1%2Fs3%2Faws4_request&X-Amz-Date=20240907T202546Z&X-Amz-SignedHeaders=host&X-Amz-Expires=86400&X-Amz-Signature=817102a68fb83317a82a767a3ace6f93959788a7d6a5ee01178d5c4bac503c0c)
Figure 2. Diagnostic performance of FDG-PET/CT in adrenal incidentaloma
![](https://54d4f314-8f94-415c-acb7-fd0a6332f070.s3.amazonaws.com/3097099/3097099__Fig%202__589502705.jpeg?X-Amz-Content-Sha256=UNSIGNED-PAYLOAD&X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Credential=AKIAU2BE4PNFKE2WZV7V%2F20240907%2Fus-east-1%2Fs3%2Faws4_request&X-Amz-Date=20240907T202546Z&X-Amz-SignedHeaders=host&X-Amz-Expires=86400&X-Amz-Signature=12c38eabf79b7c6d10f9700925d02b072118e54fbc2ebcca295f79dd5c6ae31d)
Figure 3. Morbidity in patients with mild autonomous cortisol secretion (MACS)
![](https://54d4f314-8f94-415c-acb7-fd0a6332f070.s3.amazonaws.com/3097100/3097100__Fig%203__1647098262.jpeg?X-Amz-Content-Sha256=UNSIGNED-PAYLOAD&X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Credential=AKIAU2BE4PNFKE2WZV7V%2F20240907%2Fus-east-1%2Fs3%2Faws4_request&X-Amz-Date=20240907T202546Z&X-Amz-SignedHeaders=host&X-Amz-Expires=86400&X-Amz-Signature=0f87a71d222f77f7eb73efb465ab50ff4a11076a1884fd9add0ed5b1819cac5c)
Assessment for hormone excess
R.3.1
R.3.2
R.3.3
R.3.4
R.3.5
R.3.6
R.3.7
R.3.8
R.3.9
R.3.10
Surgical treatment
R.4.1
R.4.2
R.4.3
R.4.4
R.4.5
R.4.6
R.4.7
R.4.8
Follow-up of patients not undergoing adrenal surgery after initial assessment
R.5.1
R.5.2
R.5.3
R.5.4
Special circumstances
Patients with bilateral adrenal incidentalomas
R.6.1.1
R.6.1.2
R.6.1.3
R.6.1.4
R.6.1.5
R.6.1.6
R.6.1.7
R.6.1.8
Adrenal incidentalomas in young or elderly patients
R.6.2.1
R.6.2.2
R.6.2.3
R.6.2.4
Patients with newly diagnosed adrenal mass and a history of extra-adrenal malignancy
R.6.3.1
R.6.3.2
R.6.3.3
R.6.3.4
R.6.3.5
R.6.3.6
Recommendation Grading
Disclaimer
Overview
Title
Management of Adrenal Incidentalomas
Authoring Organization
European Society of Endocrinology
Publication Month/Year
June 15, 2023
Last Updated Month/Year
April 1, 2024
Supplemental Implementation Tools
Document Type
Guideline
Country of Publication
European
Document Objectives
Adrenal incidentalomas are adrenal masses detected on imaging performed for reasons other than suspected adrenal disease. In most cases, adrenal incidentalomas are nonfunctioning adrenocortical adenomas but may also require therapeutic intervention including that for adrenocortical carcinoma, pheochromocytoma, hormone-producing adenoma, or metastases. Here, we provide a revision of the first international, interdisciplinary guidelines on incidentalomas. We followed the Grading of Recommendations Assessment, Development and Evaluation system and updated systematic reviews on 4 predefined clinical questions crucial for the management of incidentalomas: (1) How to assess risk of malignancy?; (2) How to define and manage mild autonomous cortisol secretion?; (3) Who should have surgical treatment and how should it be performed?; and (4) What follow-up is indicated if the adrenal incidentaloma is not surgically removed?
Inclusion Criteria
Male, Female, Adolescent, Adult, Child, Older adult
Health Care Settings
Ambulatory, Outpatient, Operating and recovery room
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Diagnosis, Assessment and screening, Treatment, Management
Keywords
Adrenal Incidentalomas
Source Citation
Martin Fassnacht and others, 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, Volume 189, Issue 1, July 2023, Pages G1–G42, https://doi.org/10.1093/ejendo/lvad066