Management of adrenal incidentalomas: who, why and how?

Purpose of review: To summarize the epidemiology and clinical implications of adrenal incidentalomas, as well as the recommended hormonal and radiological evaluation, treatment and follow-up that should be carried out in patients with adrenal incidentalomas.

Recent findings: The prevalence of adrenal incidentalomas has increased in the last decades due to advanced and more sensitive imaging modalities, their increased utilization, and the aging population. The evaluation of patients with adrenal incidentalomas should be focused on addressing two questions: Is the tumor functional, and is the tumor malignant? In relation to functionality, although most adrenal incidentalomas are clinically nonfunctioning, a significant proportion of patients have mild autonomous cortisol secretion and a lower proportion over functional adrenal syndromes. The differentiation between malignant and benign lesions is usually based on the radiological appearance of the lesion in CT and/or MRI. Adrenalectomy is considered the first-line treatment for malignant and functioning tumors. Radiological follow-up is not necessary for lesions classified as benign, but for indeterminate lesions, CT/MRI should be repeated in 6-12 months.

Summary: Adrenal incidentalomas are a common clinical problem, and their assessment should be focused on ruling out hormonal hypersecretion and malignancy. In general, adrenalectomy is considered the treatment of choice for malignant and functioning adrenal tumors.