Management of Adrenal Incidentalomas According to the Latest 2023 Guidelines

Author: Zacharieva S.1,2,3,4

1 Department of Endocrinology, Medical University, Sofia,
2 Expert Center for Rare Endocrine Diseases, Sofia,
3 European Network on Rare Endocrine Conditions (ENDO-ERN),
4 USHATE “Acad. Ivan Penchev”.


Adrenal incidentalomas are tumors larger than 1 cm that are discovered by chance during imaging diagnostics performed for non-endocrine diseases. The incidence of adrenal incidentalomas has increased 10-fold over the past 2 decades, with the majority being diagnosed in older adults. With any newly discovered adrenal mass, 2 questions must be answered: whether it is malignant and whether it is hormonally active. The answer to both questions is equally important in determining treatment, as these tumors can lead to significant morbidity and even mortality if they are malignant or hormonally active. Malignant tumors are more often found in younger patients. Suspicious signs for adrenal carcinoma are bilateral adrenal tumors, history of other malignancy, tumor size greater than 4 cm on computer tomography (CT), indeterminate imaging features, radiologic density greater than 10 Hounsfield units (HE) on native CT and delayed contrast washout after contrast enhancement. Although marked hormonal hypersecretion is unusual in adrenal incidentalomas, mild autonomous cortisol secretion can be diagnosed in 30% to 50% of all patients. As this condition is associated with increased cardiovascular morbidity and metabolic disturbances, a dexamethasone suppression test is recommended in all patients with adrenal incidentalomas. In the latest 2023 recommendations for the management to adrenal incidentalomas, special attention is paid to cases with autonomous cortisol secretion and important additions were included. A new term “metabolic autonomous cortisol syndrome” is introduced for patients with autonomous cortisol secretion and metabolic disorders. Management of adrenal incidentalomas varies depending on etiology, comorbidities, and patient‘s preference. Adrenal tumors suspected of being malignant or proven hormonally active (Cushing syndrome, primary aldosteronism and pheochromocytoma) are treated surgically with adrenalectomy. Hormonally inactive and apparently benign adenomas on imaging should be followed-up by an endocrinologist.

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Journal of the Bulgarian Society of Endocrinology

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