Dr. med. Dirk Manski

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Diagnosis and Treatment of Adrenal Tumors (Incidentaloma)


An adrenal incidentaloma is an (incidentally discovered) tumor of the adrenal gland. The most common cause is an adenoma without hormone production and without clinical significance. In 20%, a need for therapy arises from either progressive growth or hormone production.

CT of the abdomen showing a right-sided (=>) incidentaloma (histology: adrenal adenoma). The horizontal plane is on the left, and the frontal reconstruction is on the right. With kind permission, Prof. Dr. K. Bohndorf (Augsburg).
figure CT of the abdomen showing an adrenal incidentaloma

Pathology of Adrenal Incidentaloma

Diagnosis of Adrenal Incidentaloma

A rational diagnostic workup of incidentaloma is shown in the flowchart below.

Algorithm for the diagnosis and treatment of adrenal incidentalomas, modified from (Langer et al., 2007).
figure Algorithm for the diagnosis and treatment of adrenal incidentalomas

Physical examination:

Hypertension? Tachycardia? Flushing symptoms? Hirsutism? Cushing disease? Virilization?


The diagnosis of an incidentaloma most commonly arises during imaging in case of complaints or during follow-up examinations of other diseases. CT characteristics of adrenal adenoma include evidence of fat in the tumor (native density of less than 10 HU); after contrast media, adenomas typically enhance. 15 min after contrast media, at least 60% of the enhancement should have disappeared. Contrast-enhancing lesions with native density values above 10 HU are suspicious for malignancy (Joudi et al., 2006). MRI is an alternative imaging technique and fat detection is possible with "chemical shift imaging"). For follow-up (size progression?), ultrasonography is also suitable.

Ultrasound imaging of the right retroperitoneum shows an 8 cm adrenal tumor. Histology: myelolipoma. The tumor's echogenicity indicates fat content. With kind permission, Dr. med. H. Kempter, Augsburg.
figure Ultrasound imaging of the right retroperitoneum showing an 8 cm adrenal tumor.

Hormone activity:

The hormone activity of adrenal tumor should be determined with blood tests and 24-hour urine collection:

Differential Diagnosis of Adrenal Tumors

Active Surveillance and Treatment of Adrenal Tumors

A rational treatment for incidentaloma is shown in the flowchart above.

Index: 1–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z


Barzon und Boscaro 2000 BARZON, L. ; BOSCARO, M.: Diagnosis and management of adrenal incidentalomas.
In: J Urol
163 (2000), Nr. 2, S. 398–407

M. Fassnacht 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.,” European journal of endocrinology, vol. 189, no. 1, pp. G1–G42, Jul. 2023, doi: 10.1093/ejendo/lvad066.

Joudi u.a. 2006 JOUDI, Fadi N. ; KUEHN, David M. ; WILLIAMS, Richard D.: Maximizing clinical information obtained by CT.
In: Urol Clin North Am
33 (2006), Aug, Nr. 3, S. 287–300

  Deutsche Version: Inzidentalom der Nebennieren