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Guideline: Adrenal incidentaloma

essary adrenalectomy, some patients’ care is delayed, 5. Fassnacht M, Arlt W, Bancos I, et al. Management of adrenal incidentalomas: European
Society of Endocrinology clinical practice guideline in collaboration with the European
and some are subjected to unnecessary followup Network for the Study of Adrenal Tumors. Eur J Endocrin 2016175:G1-34. https://doi.
investigations with associated ionizing radiation. To org/10.1530/EJE-16-0467
address this, recent research efforts have focused on 6. Zeiger MA, Thompson GB, Duh QY, et al. American Association of Clinical Endocrinologists
and American Association of Endocrine Surgeons medical guidelines for the management
the development of urine steroid metabolomics to of adrenal incidentalomas. Endocrine Pract 2009;15:1-20. https://doi.org/10.4158/
better risk-stratify patients. Studies have shown that EP.15.S1.1
ACC have a distinct pattern of urinary corticoste- 7. Lee JM, Kim MK, Ko SH, et al. Clinical guidelines for the management of adrenal
incidentaloma. Endocrin Metab 2017;32:200-18. https://doi.org/10.3803/
roid excretion, characterized by an excess of precur- EnM.2017.32.2.200
sor steroid metabolites. Using a combination of mass 8. Mayo-Smith WW, Song JH, Boland GL, et al. Management of incidental adrenal masses:
spectrometry-based urinary steroid metabolite profiling A white paper of the ACR Incidental Findings Committee. J Am Coll Radiol 2017;14:1038-
44. https://doi.org/10.1016/j.jacr.2017.05.001
and machine learning-based data analysis, urine steroid 9. Maas M, Nassiri N, Bhanvadia S, et al. Discrepancies in the recommended management
metabolomic testing can quantify this. of adrenal incidentalomas by various guidelines. J Urol 2021;205:52-9. https://doi.
In a 2020, prospective, multicenter study (EURINE- 10. org/10.1097/JU.0000000000001342
McInnes M, Schieda N. Revising adrenal incidentalomas followup recommendations in CUA
ACT), urine steroid metabolomics were used in con- guideline. Can Urol Assoc J 2021;15:E232. https://doi.org/10.5489/cuaj.7267
junction with tumor diameter and imaging character- 11. Azoury SC, Nagarajan N, Young A, et al. Computed tomography in the management
istics to characterize adrenal incidentalomas, and this of adrenal tumors. J Computer Assist Tomograph 2017;41:628-32. https://doi.
org/10.1097/RCT.0000000000000578
“triple test” strategy had a sensitivity of 82.7% and spec- 12. Kahramangil B, Kose E, Remer EM, et al. A modern assessment of cancer risk in
ificity of 95.7%. Interestingly, in this study, the authors adrenal incidentalomas. Ann Surg 2020;275:e238-44. https://doi.org/10.1097/
77
also showed that using a cutoff of 20 HU instead of 10 13. SLA.0000000000004048
Young WF Jr. The incidentally discovered adrenal mass. N Engl J Med 2007;356:601-10.
HU increased the specificity of unenhanced CT scans https://doi.org/10.1056/NEJMcp065470
in detecting malignant lesion to 80% from 64%, while 14. Dinnes J, Bancos I, Ferrante di Ruffano L, et al. Imaging for the diagnosis of malignancy
sensitivity remained similar. These results are certainly in incidentally discovered adrenal masses — a systematic review and meta-analysis. Eur J
Endocrinol 2016;175:R51-64. https://doi.org/10.1530/EJE-16-0461
promising and require further validation. Hopefully, 15. Ranathunga DS, Cherpak LA, Schieda N, et al. Macroscopic fat in adrenocortical
these non-invasive tests are able to help further risk- carcinoma: A systematic review. Am J Roentgenol 2020;214:390-4. https://doi.
stratify patients in the future, allowing for prompt man- 16. org/10.2214/AJR.19.21851
Guccione J, Soliman M, Zhang M, et al. Imaging characteristics of pathologically proven
agement of patients with ACC, and avoiding the need adrenal adenomas with myelolipomatous degeneration: Correlation with clinical and
for unnecessary followup testing and associated harms pathologic features. Br J Radiol 2022;95:20210555. https://doi.org/10.1259/
in those with benign lesions. 17. bjr.20210555
Boland GW, Lee MJ, Gazelle GS, et al. Characterization of adrenal masses using
unenhanced CT: An analysis of the CT literature. Am J Roentgenol 1998;171:201-4.
CONCLUSIONS https://doi.org/10.2214/ajr.171.1.9648789
Incidental adrenal masses are common, and most of 18. Caoili EM, Korobkin M, Francis IR, et al. Delayed enhanced CT of lipid-poor adrenal
adenomas. Am J Roentgenol 2000;175:1411-5. https://doi.org/10.2214/
these lesions are benign. Nonetheless, identification ajr.175.5.1751411
and timely management of functional and malignant 19. Pena CS, Boland GW, Hahn PF, et al. Characterization of indeterminate (lipid-poor)
lesions is crucial. This guideline provides a contempo- adrenal masses: Use of washout characteristics at contrast-enhanced CT. Radiology
2000;217:798-802. https://doi.org/10.1148/radiology.217.3.r00dc29798
rary approach to the appropriate clinical, radiographical, 20. Zhang HM, Perrier ND, Grubbs EG, et al. CT features and quantification of the
and endocrine assessments required for the evalua- characteristics of adrenocortical carcinomas on unenhanced and contrast-enhanced studies.
tion, management, and followup of patients with such 21. Clin Radiol 2012;67:38-46. https://doi.org/10.1016/j.crad.2011.03.023
Corwin MT, Remer EM. Adrenal washout CT: Point-not useful for characterizing
lesions. incidentally discovered adrenal nodules. Am J Roentgenol 2021;216:1166-7. https://doi.
org/10.2214/AJR.20.24417
COMPETING INTERESTS: The authors and reviewers do not report any 22. Corwin MT, Badawy M, Caoili EM, et al. Incidental adrenal nodules in patients
competing personal or financial interests related to this work. without known malignancy: Prevalence of malignancy and utility of washout CT for
characterization — a multi-institutional study. Am J Roentgenol 2022;219:804-12.
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