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Adrenal Incidentalomas - Causes, Diagnosis, and Treatment

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The increased use of abdominal imaging techniques has led to identifying unusual adrenal masses. Read the article to know the causes and management.

Written by

Dr. Gayathri P

Medically reviewed by

Dr. Shaikh Sadaf

Published At August 11, 2022
Reviewed AtJanuary 30, 2023


Adrenal glands are a pair of endocrine glands present on the top of both kidneys. It produces hormones that maintain blood pressure, metabolism, immune system, and stress response. The various imaging techniques available in diagnosing diseases other than adrenal-related have increased the chances of identifying adrenal mass. Rarely the adrenal mass appears on both adrenal glands.

What Are Adrenal Incidentalomas?

The incidental findings of adrenal mass of size 1 cm or more during the diagnostic evaluation of diseases other than adrenal disorders are called adrenal incidentalomas. The detection of adrenal incidentalomas is shallow in children. However, older individuals of age more than 70 years have shown 10 % detection rates of adrenal incidentalomas. Mainly, imaging techniques with high resolution have increased the chances of detecting adrenal mass.

What Causes Adrenal Incidentalomas?

The exact cause of adrenal incidentalomas remains unknown.

However, the following factors increase the incidence of an adrenal mass.

  • Localized overgrowth of the adrenal gland occurs in older individuals due to any injury.

  • The adrenal incidentalomas also occur in individuals with hyperinsulinemia (increased insulin levels in the blood).

  • The prolonged stimulation of the adrenal gland by the adrenocorticotropic hormone (ACTH) produced by the pituitary gland in response to stress can lead to enlargement of the adrenal gland.

How Are Adrenal Incidentalomas Diagnosed?

The complications associated with adrenal incidentalomas are minor. But, the prompt diagnosis of adrenal mass to evaluate any malignant changes is essential in deciding the treatment plan. The various diagnostic methods of adrenal incidentalomas are as follows:

  • Physical Examination of patients regarding the signs that occur due to excess adrenal hormones and detailed medical and family history is essential.

  • Imaging Techniques differentiate the adrenal mass from other benign and malignant tumors. It detects the size, shape, and borders of the lesion. The malignant tumors are larger mostly (4 to 6 cm or greater than 6 cm), with irregular edges, and invade the surrounding tissues. Benign tumors of the adrenal gland grow slowly with sizes less than 4 cm and regular margins. The widely used imaging techniques include

  1. Computed tomography (CT) scan measures attenuation. It is the X-ray absorption as it passes the body tissue and is expressed in the Hounsfield unit (HU). In benign lesions rich in fat (lipid), the HU value is less, and in malignant tissue with poor fat, the HU value increases. But about 30 % to 40 % of benign tumors have poor lipid content; in such cases, CT scans with contrast material administration are helpful in diagnosis. The benign tumors quickly take up the intravenously administered contrast material, and it clears off in less time. Whereas the malignant tumor takes up the material soon, it washes out very slowly.
  2. Magnetic resonance imaging (MRI) differentiates benign and malignant lesions. Even though CT scans are cost-effective and readily available, an MRI is preferred in children and pregnant women to differentiate adrenal incidentaloma from pheochromocytoma (adrenal gland tumor).
  3. Positron emission tomography (PET) is a productive technique for evaluating malignant lesions. The principle of the method depends on the property of malignant cells to uptake glucose. PET scans use Fluorodeoxyglucose to decide the surgical removal depending on the uptake of glucose by the cancer cells.
  • Hormonal Examination to check the levels of hormones produced by the adrenal gland. It includes:
  1. Cortisol Level: When an adrenal mass is found on imaging techniques, the cortisol levels are checked to identify the presence of Cushing’s syndrome. Overproduction of cortisol with minor clinical symptoms are the characteristics of adrenal incidentalomas.
  2. Dexamethasone suppression test is done to evaluate the cortisol level changes in response to Dexamethasone as it helps diagnose adrenal incidentalomas.
  3. Liquid chromatography-mass spectrometry measures the catecholamine (metanephrine) levels in plasma and urine. The catecholamines are hormones produced by the adrenal gland to manage stress. The increased levels of metanephrine in plasma and urine suggest pheochromocytoma (a rare adrenal gland tumor).
  • Fine Needle Aspiration Biopsy (FNAB) is not a preferred method as it has more complications. However, it helps diagnose the spread of tumors from the surrounding tissue of adrenal glands. Therefore, adrenal masses that are not appropriately detected with imaging techniques can be tested with biopsy to confirm other rare adrenal gland tumors.

What Is the Differential Diagnosis of Adrenal Incidentalomas?

Adrenal incidentalomas are primarily benign (non-cancerous), but it provides an excellent challenge for the physician in diagnosing such a mass.

The conditions that possess similar features of adrenal incidentalomas are as follows:

  • Pheochromocytomas are rare non-cancerous tumors of the adrenal gland. The classical signs are headache, irregular heartbeat, and sweating. Sometimes, the individuals with pheochromocytoma do not possess or have mild symptoms, presenting as an adrenal incidentaloma.

  • Primary Aldosteronism is characterized by excess production of aldosterone hormone. The clinical features are high blood pressure and low potassium levels (hypokalemia). Individuals with adrenal mass, altered blood pressure, and potassium levels should be screened for aldosteronism.

How Are Adrenal Incidentalomas Treated?

The two options considered in the management of adrenal incidentalomas are listed down:

  • Non-surgical management is preferred in patients with adrenal mass that is non-cancerous and with minimal clinical symptoms. With imaging tests, the individuals with adrenal incidentaloma are reviewed after three to six months.

  • Surgical management is suggested if the adrenal mass is more prominent in size, is suspected of malignancy, and shows hormonal overactivity. The factors like age, co-existing systemic illness, and response to medical treatment are considered before planning surgery. The complications after adrenalectomy (surgical removal of adrenal glands) are high due to the lack of production of cortisol hormone.


The widespread use of imaging techniques has helped diagnose various lesions that do not show any clinical symptoms. Therefore, it provides an excellent challenge for the physician in the appropriate diagnosis and decision of surgical treatment of adrenal incidentaloma that possesses malignant characteristics.

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Dr. Shaikh Sadaf
Dr. Shaikh Sadaf



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