Abstract
Adrenal lesions are common in the general population, with reported rates approaching 10% particularly with increasing age. With the expanding use of imaging, the number of detected adrenal lesions has also risen. Although most are benign and of limited clinical significance, accurate characterization of hormonally active lesions or those with malignant potential is critical. The majority of cases can be correctly characterized with computed tomography and/or magnetic resonance imaging, and clinical management is shaped accordingly. Because endocrine evaluation both aids in diagnosing hormonally active lesions and influences treatment decisions, a multidisciplinary approach to adrenal gland pathology provides the greatest benefit for patients.
Keywords: Adrenal gland, incidentaloma, computed tomography, magnetic resonance imaging
References
Yokoyama K, Matsuki M, Isozaki T, Ito K, Imokawa T, Ozawa A, et al. Advances in multimodal imaging for adrenal gland disorders: integrating CT, MRI, and nuclear medicine. Jpn J Radiol. 2025; 43: 903-26.
Rowe NE, Kumar RM, Schieda N, Siddiqi F, McGregor T, McAlpine K, et al. Canadian Urological Association guideline: diagnosis, management, and followup of the incidentally discovered adrenal mass. Can Urol Assoc J. 2023; 17: 12-24.
Expert Panel on Urological Imaging; Mody RN, Remer EM, Nikolaidis P, Khatri G, Dogra VS, et al. ACR appropriateness criteria® adrenal mass evaluation: 2021 update. J Am Coll Radiol. 2021; 18: S251-67.
Kahramangil B, Kose E, Remer EM, Reynolds JP, Stein R, Rini B, et al. A Modern Assessment of Cancer Risk in Adrenal Incidentalomas: analysis of 2219 Patients. Ann Surg. 2022; 275: e238-44.
Bracci B, De Santis D, Del Gaudio A, Faugno MC, Romano A, Tarallo M, et al. Adrenal lesions: a review of imaging. Diagnostics (Basel). 2022; 12: 2171.
Chung R, Garratt J, Remer EM, Navin P, Blake MA, Taffel MT, et al. Adrenal neoplasms: lessons from adrenal multidisciplinary tumor boards. Radiographics. 2023; 43: e220191.
Adam SZ, Nikolaidis P, Horowitz JM, Gabriel H, Hammond NA, Patel T, et al. Chemical shift MR imaging of the adrenal gland: principles, pitfalls, and applications. Radiographics. 2016; 36: 414-32.
Sherlock M, Scarsbrook A, Abbas A, Fraser S, Limumpornpetch P, Dineen R, et al. Adrenal Incidentaloma. Endocr Rev. 2020; 41: 775-820.
Lattin GE Jr, Sturgill ED, Tujo CA, Marko J, Sanchez-Maldonado KW, Craig WD, et al. From the radiologic pathology archives: adrenal tumors and tumor-like conditions in the adult: radiologic-pathologic correlation. Radiographics. 2014; 34: 805-29.
Mete O, Erickson LA, Juhlin CC, de Krijger RR, Sasano H, Volante M, et al. Overview of the 2022 WHO classification of adrenal cortical tumors. Endocr Pathol. 2022; 33: 155-96.
Johnson PT, Horton KM, Fishman EK. Adrenal imaging with multidetector CT: evidence-based protocol optimization and interpretative practice. Radiographics. 2009; 29: 1319-31.
Nandra G, Duxbury O, Patel P, Patel JH, Patel N, Vlahos I. Technical and interpretive pitfalls in adrenal imaging. Radiographics. 2020; 40: 1041-60.
Seo JM, Park BK, Park SY, Kim CK. Characterization of lipid-poor adrenal adenoma: chemical-shift MRI and washout CT. AJR Am J Roentgenol. 2014; 202: 1043-50. Erratum in: AJR Am J Roentgenol. 2019; 212: 232.
Sangwaiya MJ, Boland GW, Cronin CG, Blake MA, Halpern EF, Hahn PF. Incidental adrenal lesions: accuracy of characterization with contrast-enhanced washout multidetector CT--10-minute delayed imaging protocol revisited in a large patient cohort. Radiology. 2010; 256: 504-10.
Corwin MT, Badawy M, Caoili EM, Carney BW, Colak C, Elsayes KM, et al. Incidental adrenal nodules in patients without known malignancy: prevalence of malignancy and utility of washout CT for characterization-A multiinstitutional study. AJR Am J Roentgenol. 2022; 219: 804-12.
Guccione J, Soliman M, Zhang M, Habra MA, Collins K, Zhao J, et al. Imaging characteristics of pathologically proven adrenal adenomas with myelolipomatous degeneration: correlation with clinical and pathologic features. Br J Radiol. 2022; 95: 20210555.
Corwin MT, Navarro SM, Malik DG, Loehfelm TW, Fananapazir G, Wilson M, et al. Differences in growth rate on CT of adrenal adenomas and malignant adrenal nodules. AJR Am J Roentgenol. 2019; 213: 632-6.
Hamidi O, Raman R, Lazik N, Iniguez-Ariza N, McKenzie TJ, Lyden ML, et al. Clinical course of adrenal myelolipoma: a long-term longitudinal follow-up study. Clin Endocrinol (Oxf). 2020; 93:11-8.
Schieda N, Siegelman ES. Update on CT and MRI of adrenal nodules. AJR Am J Roentgenol. 2017; 208: 1206-17.
Ranathunga DS, Cherpak LA, Schieda N, Flood TA, McInnes MDF. Macroscopic fat in adrenocortical carcinoma: a systematic review. AJR Am J Roentgenol. 2020; 214: 390-4.
Decmann Á, Perge P, Tóth M, Igaz P. Adrenal myelolipoma: a comprehensive review. Endocrine. 2018; 59: 7-15.
Howard B, Elsayed A, Klimkowski S, Lee J, Elsayes K. Imaging of adrenocortical carcinoma: an update. Semin Roentgenol. 2025; 60: 78-87.
Lam AK. Adrenocortical carcinoma: updates of clinical and pathological features after renewed World Health Organisation classification and pathology staging. Biomedicines. 2021; 9: 175.
Mete O, Erickson LA, Juhlin CC, de Krijger RR, Sasano H, Volante M, et al. Overview of the 2022 WHO classification of adrenal cortical tumors. Endocr Pathol. 2022; 33: 155-96.
Fassnacht M, Puglisi S, Kimpel O, Terzolo M. Adrenocortical carcinoma: a practical guide for clinicians. Lancet Diabetes Endocrinol. 2025; 13: 438-52.
Bedrose S, Daher M, Altameemi L, Habra MA. Adjuvant therapy in adrenocortical carcinoma: reflections and future directions. Cancers (Basel). 2020; 12: 508.
Constantinescu G, Preda C, Constantinescu V, Siepmann T, Bornstein SR, Lenders JWM, et al. Silent pheochromocytoma and paraganglioma: Systematic review and proposed definitions for standardized terminology. Front Endocrinol (Lausanne). 2022; 13: 1021420.
Neumann HPH, Young WF Jr, Eng C. Pheochromocytoma and paraganglioma. N Engl J Med. 2019; 381: 552-65.
Buitenwerf E, Korteweg T, Visser A, Haag CMSC, Feelders RA, Timmers HJLM, et al. Unenhanced CT imaging is highly sensitive to exclude pheochromocytoma: a multicenter study. Eur J Endocrinol. 2018; 178: 431-7.
Araujo-Castro M, García Centeno R, Robles Lázaro C, Parra Ramírez P, Gracia Gimeno P, Rojas-Marcos PM, et al. Predictive model of pheochromocytoma based on the imaging features of the adrenal tumours. Sci Rep. 2022; 12: 2671.
Alshahrani MA, Bin Saeedan M, Alkhunaizan T, Aljohani IM, Azzumeea FM. Bilateral adrenal abnormalities: imaging review of different entities. Abdom Radiol (NY). 2019; 44: 154-79.
Wang Y, Ren Y, Ma L, Li J, Zhu Y, Zhao L, et al. Clinical features of 50 patients with primary adrenal lymphoma. Front Endocrinol (Lausanne). 2020; 11: 595.
Abreu-Gomez J, Murad V, Ezzat S, Navin PJ, Westphalen AC. Adrenal infections update: how radiologists can contribute to patient care. Br J Radiol. 2025; 98: 496-508.
Mayo-Smith WW, Song JH, Boland GL, Francis IR, Israel GM, Mazzaglia PJ, et al. Management of incidental adrenal masses: a white paper of the ACR incidental findings committee. J Am Coll Radiol. 2017; 14: 1038-44.
