Imaging of adrenal masses: from incidental detection to clinical decision-making. A radiologist’s evidence-based vade mecum
Keywords:
adrenal incidentaloma, adrenal tumors , computed tomography, magnetic resonance imaging, ultrasonographyAbstract
Background and aim: The widespread use of cross-sectional imaging has led to an increasing detection of adrenal masses as incidental findings. While most lesions are benign and non-functioning, a clinically relevant proportion may be hormonally active or malignant. Accurate imaging characterization is essential to guide management. This review provides an imaging-focused, evidence-based overview of adrenal mass evaluation, emphasizing radiological decision-making.
Methods: A narrative review of contemporary literature was conducted, focusing on the role of ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) in adrenal lesion assessment. Validated imaging criteria, diagnostic accuracy, and modality-specific limitations were analyzed, integrating clinical and biochemical considerations.
Results: Characteristic imaging features of common adrenal lesions, including adenomas, myelolipomas, and pheochromocytomas, are described. Less frequent but clinically significant entities are discussed. Strengths and limitations of imaging techniques are outlined, and practical imaging-based diagnostic strategies are proposed.
Conclusions: A structured, multiparametric imaging approach allows confident characterization of most adrenal masses and supports appropriate multidisciplinary management. Awareness of imaging limitations is essential to avoid misclassification and unnecessary investigations.
References
1. Fassnacht M, Tsagarakis S, Terzolo M, et al. 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. Eur J Endocrinol. 2023 Jul 20;189(1):G1-G42. doi: 10.1093/ejendo/lvad066
2. Delaney FT, Chung R, Blake MA, Sweeney AT. Imaging of Adrenal Masses. Endocr Pract. 2025 Jul;31(7):965-74. doi: 10.1016/j.eprac.2025.05.743
3. Heinz-Peer G, Memarsadeghi M, Niederle B. Imaging of adrenal masses. Curr Opin Urol. 2007 Jan;17(1):32-8. doi: 10.1097/MOU.0b013e328011ea00
4. Willatt JM, Francis IR. Radiologic evaluation of incidentally discovered adrenal masses. Am Fam Physician. 2010 Jun 1;81(11):1361-6
5. Mayo-Smith WW, Song JH, Boland GL, et al. Management of Incidental Adrenal Masses: A White Paper of the ACR Incidental Findings Committee. J Am Coll Radiol. 2017 Aug;14(8):1038-44. doi: 10.1016/j.jacr.2017.05.001
6. Vassiliadi DA, Delivanis DA, Papalou O, Tsagarakis S. Approach to the Patient With Bilateral Adrenal Masses. J Clin Endocrinol Metab. 2024 Jul 12;109(8):2136-48. doi: 10.1210/clinem/dgae164
7. Dietrich CF, Ignee A, Barreiros AP, et al. Contrast-enhanced ultrasound for imaging of adrenal masses. Ultraschall Med. 2010 Apr;31(2):163-8. doi: 10.1055/s-0028-1109357
8. Aggarwal A, Das CJ. Contrast-enhanced ultrasound in evaluation of adrenal lesions with CT/MRI correlation. Br J Radiol. 2021 Apr 1;94(1120):20201170. doi: 10.1259/bjr.20201170
9. Elbanan MG, Javadi S, Ganeshan D, et al. Adrenal cortical adenoma: current update, imaging features, atypical findings, and mimics. Abdom Radiol (NY). 2020 Apr;45(4):905-16. doi: 10.1007/s00261-019-02215-9
10. Vassilatou E, Vryonidou A, Michalopoulou S, et al. Hormonal activity of adrenal incidentalomas: results from a long-term follow-up study. Clin Endocrinol (Oxf). 2009 May;70(5):674-9. doi: 10.1111/j.1365-2265.2008.03492.x
11. Maurea S, Imbriaco M, D'Angelillo M, Mollica C, Camera L, Salvatore M. Diagnostic accuracy of chemical-shift MR imaging to differentiate between adrenal adenomas and non adenoma adrenal lesions. Radiol Med. 2006 Aug;111(5):674-86. doi: 10.1007/s11547-006-0065-9
12. Sherlock M, Scarsbrook A, Abbas A, et al. Adrenal Incidentaloma. Endocr Rev. 2020 Dec 1;41(6):775-820. doi: 10.1210/endrev/bnaa008
13. Terzolo M, Bovio S, Pia A, Reimondo G, Angeli A. Management of adrenal incidentaloma. Best Pract Res Clin Endocrinol Metab. 2009 Apr;23(2):233-43. doi: 10.1016/j.beem.2009.04.001
14. Lumachi F, Borsato S, Tregnaghi A, et al. CT-scan, MRI and image-guided FNA cytology of incidental adrenal masses. Eur J Surg Oncol. 2003 Oct;29(8):689-92. doi: 10.1016/s0748-7983(03)00159-8
15. Purenne E, Cornu E, Mezzarobba V, et al. To biopsy or not to biopsy adrenal mass: is that the question? Acta Radiol Open. 2024 Aug 21;13(8):20584601241269581. doi: 10.1177/20584601241269581
16. Schieda N, Krishna S, McInnes MDF, et al. Utility of MRI to Differentiate Clear Cell Renal Cell Carcinoma Adrenal Metastases From Adrenal Adenomas. AJR Am J Roentgenol. 2017 Sep;209(3):W152-W159. doi: 10.2214/AJR.16.17649
17. Lumachi F, Borsato S, Tregnaghi A, et al. High risk of malignancy in patients with incidentally discovered adrenal masses: accuracy of adrenal imaging and image-guided fine-needle aspiration cytology. Tumori. 2007 May-Jun;93(3):269-74. doi: 10.1177/030089160709300307
18. Grazzini G, Pradella S, De Litteris F, et al. Adrenal Mass Evaluation: Suspicious Radiological Signs of Malignancy. Cancers (Basel). 2025 Feb 28;17(5):849. doi: 10.3390/cancers17050849
19. Udare A, Agarwal M, Siegelman E, Schieda N. CT and MR imaging of acute adrenal disorders. Abdom Radiol (NY). 2021 Jan;46(1):290-302. doi: 10.1007/s00261-020-02580-w
20. Akamatsu H, Koseki M, Nakaba H, et al. Giant adrenal myelolipoma: report of a case. Surg Today. 2004;34(3):283-5. doi: 10.1007/s00595-003-2682-4
21. Bancos I, Prete A. Approach to the Patient With Adrenal Incidentaloma. J Clin Endocrinol Metab. 2021 Oct 21;106(11):3331-53. doi: 10.1210/clinem/dgab512
22. Ichijo T, Ueshiba H, Nawata H, Yanase T. A nationwide survey of adrenal incidentalomas in Japan: the first report of clinical and epidemiological features. Endocr J. 2020 Feb 28;67(2):141-52. doi: 10.1507/endocrj.EJ18-0486
23. Tu W, Abreu-Gomez J, Udare A, Alrashed A, Schieda N. Utility of T2-weighted MRI to Differentiate Adrenal Metastases from Lipid-Poor Adrenal Adenomas. Radiol Imaging Cancer. 2020 Oct 30;2(6):e200011. doi: 10.1148/rycan.2020200011
24. Goncalvesová E, Hnilica P, Motovská Z, Goncalves F, Kovác A. Adrenal incidentalomas—analysis of 23 cases discovered by ultrasound. Neoplasma. 1997;44(2):137-41. PMID: 9201295
25. Salgado-Álvarez GA, Grube-Pagola P, Martínez-Mier G, et al. Mielolipoma Suprarrenal, revisión de literatura en México a propósito de dos casos [Adrenal myelolipoma, review of the literature in Mexico apropos of two cases]. Rev Med Inst Mex Seguro Soc. 2022 Mar 1;60(2):229-35. PMID: 35759694
26. Boland GW, Lee MJ. Magnetic resonance imaging of the adrenal gland. Crit Rev Diagn Imaging. 1995;36(2):115-74. PMID: 7612177
27. Mannelli M, Colagrande S, Valeri A, Parenti G. Incidental and metastatic adrenal masses. Semin Oncol. 2010 Dec;37(6):649-661. doi: 10.1053/j.seminoncol.2010.10.018
28. Alberti C. Incidentalomi surrenali: identificazione eziologica ed elementi di gestione terapeutica. Mini-rassegna [Adrenal incidentalomas: etiologic diagnostics and basic therapeutic management. A mini review]. G Chir. 2009 May;30(5):243-50
29. Favia G, Lumachi F, Basso S, D'Amico DF. Management of incidentally discovered adrenal masses and risk of malignancy. Surgery. 2000 Dec;128(6):918-24. doi: 10.1067/msy.2000.109965
30. Platzek I, Sieron D, Plodeck V, Borkowetz A, Laniado M, Hoffmann RT. Chemical shift imaging for evaluation of adrenal masses: a systematic review and meta-analysis. Eur Radiol. 2019 Feb;29(2):806-17. doi: 10.1007/s00330-018-5626-5
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