Incidentaloma diagnostic criteria

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammed Abdelwahed M.D[2]

Overview

There are no definitive diagnostic criteria for adrenal incidentaloma management but there are guidelines to diagnose and treat the mass according to Endocrine Society. Radiological evaluation including noncontrast CT attenuation value expressed in Hounsfield unit (HU) is the best tool to differentiate between benign and malignant adrenal masses. All patients should undergo hormonal evaluation for subclinical Cushing's syndrome and pheochromocytoma, and those with hypertension should also be evaluated for primary hyperaldosteronism.

Diagnostic Criteria

  • There are no definitive diagnostic criteria for adrenal incidentaloma management but there are guidelines to diagnose and treat the mass according to Endocrine Society.[1]
  • The guidelines recommend urgent assessment of adrenal mass in children, adolescents, pregnant females, and adults younger than 40 years of age because of a higher likelihood of malignancy.[2]
  • The diagnostic approach in patients with adrenal incidentalomas should focus on two main questions:
  • Radiological evaluation including noncontrast CT attenuation value expressed in Hounsfield unit (HU) is the best tool to differentiate between benign and malignant adrenal masses.
  • All adrenal tumors with suspicious radiological features, most functional tumors, and all tumors more than 4 cm in size with malignant radiological features should be removed.
  • All patients should undergo hormonal evaluation for subclinical Cushing's syndrome and pheochromocytoma, and those with hypertension should also be evaluated for primary hyperaldosteronism.
  • Annual biochemical follow-up of most patients with an adrenal incidentaloma (especially if the tumor is more than 3 cm in size) for up to 5 years is resonable.
  • Patients with adrenal masses less than 4 cm in size and a noncontrast attenuation value greater than 10 HU should have a repeat CT study in 3–6 months and then yearly for 2 years.
  • Adrenal tumors with indeterminate radiological features that grow at least 0.8 cm over 3–12 months should be considered for surgical resection once other imaging and clinical characteristics have been taken into consideration.
 
 
 
 
Adrenal mass
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CT attenuation value< 10HU*
 
 
 
 
 
 
 
CT attenuation value> 10HU
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Nonfunctional
 
Functional
 
 
 
 
< 4cm
 
 
> 4cm
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yearly hormonal evlauation for up to 5 years
 
Surgical removal
 
Functional
 
NonfunctionalSurgical removal
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
surgical removal
 
Calculate enhancement washout within 15 minutes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
<60%
 
>60%
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Surgical removal
 
No change in size in 12 months
 
> 0.8cm increase in size in 12 months
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Follow up CT image for two years
 

HU;Hounsfield unit.

References

  1. Fassnacht M, Arlt W, Bancos I, Dralle H, Newell-Price J, Sahdev A; et al. (2016). "Management of adrenal incidentalomas: European Society of Endocrinology Clinical Practice Guideline in collaboration with the European Network for the Study of Adrenal Tumors". Eur J Endocrinol. 175 (2): G1–G34. doi:10.1530/EJE-16-0467. PMID 27390021.
  2. Sahdev A (2017). "Recommendations for the management of adrenal incidentalomas: what is pertinent for radiologists?". Br J Radiol. 90 (1072): 20160627. doi:10.1259/bjr.20160627. PMID 28181818.

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