1. The document discusses incidentalomas, which are adrenal masses discovered incidentally on imaging done for unrelated conditions. It provides recommendations on assessing and managing incidentalomas. 2. Assessment involves evaluating radiological features for malignancy risk, assessing for hormonal excess, and screening for associated conditions. Management depends on size, radiological characteristics, hormonal activity, and malignant risk. Masses with hormonal excess or malignancy are surgically removed. 3. Follow up involves repeat imaging and hormonal testing for indeterminate masses, and clinical monitoring for masses with possible autonomous cortisol secretion or related conditions. Treatment is individualized based on various clinical factors.

1. Incidentaloma
Dr. Khaled Alsharafy
3rd year surgical resident doctor
Supervised by
- Ass.Prof Waleed Ghialan
- Assist.Prof Loai Alqobati

2. In this lecture
•Normal anatomy and physiology
•Definition of incidentaloma
•Etiology of incidentaloma
•Assessment of patient with incidentaloma
•Management protocol for incidentaloma

3. Exercise
1
50 year old
patient with HTN
underwent
abdominal CT-
scan for Renal
stone
discovered 3 cm
adrenal mass
2
40 year old
unknown cases
of any medical
disease
underwent L.S CT
scan discovered
2cm adrenal
mass
3
50 year old
diabetic patient
underwent
abdominal CT
scan for chronic
abdominal pain
discovered 3cm
adrenal mass

4. Anatomy and physiology

5. Embryology

6. Anatomy
Sabiston textbook of surgery 21st edition

7. Anatomy
Sabiston textbook of surgery 21st edition

8. Anatomy
Sabiston textbook of surgery 21st edition

9. Anatomy
Sabiston textbook of
surgery 21st edition
In up to 20% of
individuals

10. Extra-adrenal cortical and medullary tissue

11. Histology
Zona
glomerulosa
Zona
fasciculata
Zona
reticularis
Mineralocorticoid
glucocorticoid
Androgen
Adrenal
medulla
Catecholamines

12. Incidentaloma

13. Incidentaloma
• Adrenal mass that discovered
through imaging performed for
unrelated nonadrenal disease
• Adrenal mass discovered during
metastatic work-up of extra-adrenal
cancer does not considered as
incidentaloma

14. Incidentaloma( epidemiology )
• In autopsy -------------------------8%
• In abdominal CT -----------------3-10%
• in patient age > 60years --------10%
• In patient with extra-adrenal cancer with unilateral adrenal mass
metastasis is ranged 32%-73%

15. Incidentaloma ( etiology )
Benign non-functioning
etiology about 80%

16. • R 1.1. We recommend that patients with adrenal incidentaloma
be discussed in a multidisciplinary expert team meeting, if at
least one of the following criteria is met:
– Imaging is not consistent with a benign lesion.
– There is evidence of hormone excess (including ‘autonomous
cortisol secretion’).
– Evidence of significant tumor growth during follow-up imaging.
– Adrenal surgery is considered.
Recommendations ( ESE / ENSAT)

17. Incidentaloma (assessment )
Assessment of risk of malignancies
Assessment of hormonal activities
Associated comorbidities ( in cortisol
secreting mass )

18. •R 2.1. We recommend aiming to establish if an
adrenal mass is benign or malignant at the time of
initial detection.
Recommendations ( ESE / ENSAT)

19. • R 2.2. We recommend that all adrenal incidentalomas undergo an
imaging procedure to determine if the mass is homogeneous and
lipid-rich and therefore benign. For this purpose, we primarily
recommend the use of non-contrast CT .
Recommendations ( ESE / ENSAT)

20. Incidentaloma (assessment )
Suspicious features
• High vascularity
• Lymphadenopathy
• Invasion to surrounding tissue
• metastases.
• Rapidity of contrast washout on IV
contrast < 50% at 10-15 min
• MRI T2 hyperintense relative to liver
• HU > 10-20
• Size > 4-6cm
• Heterogeneity
• Ill-defined and irregular margins
• presence of hemorrhage
• Necrosis
• Internal calcification

21. Incidentaloma (assessment )
Suspicious features • HU > 10-20

22. Incidentaloma (assessment )
Suspicious features
• Size > 4-6cm
• Heterogeneity
• Ill-defined and irregular margins
• Necrosis

23. Incidentaloma (assessment )
Suspicious features
• presence of hemorrhage
• Necrosis
• Internal calcification

24. Incidentaloma (assessment )
Suspicious features
• Invasion to
surrounding tissue

25. Incidentaloma (assessment )
Suspicious features
• Lymphadenopath
y

26. Incidentaloma (assessment )
Suspicious features
• MRI T2 hyperintense relative to liver

27. Incidentaloma (assessment )
Suspicious features
• metastases.

28. Incidentaloma (assessment )
Indication of FNAB in adrenal gland mass?

29. • R 2.5. We recommend against the use of an adrenal biopsy in the
diagnostic work-up of patients with adrenal masses unless there is a
history of extra-adrenal malignancy and additional criteria are
fulfilled :
(i) the lesion is hormonally inactive (in particular, a pheochromocytoma
has been excluded)
(ii) the lesion has not been conclusively characterized as benign by
imaging and
(iii) management would be altered by knowledge of the histology.
Recommendations ( ESE / ENSAT)

30. Exercise
1
50 year old
patient with HTN
underwent
abdominal CT-
scan for Renal
stone
discovered 3 cm
adrenal mass
homogeneous and lipid-rich well defined
mass with HU 5 and wash out of 70% of
contrast in 10min no signs of invasion of
surrounding tissue or lymphadenopathy
Benign radiologically

31. Exercise
2
40 year old
unknown cases
of any medical
disease
underwent L.S CT
scan discovered
2cm adrenal
mass
Ill-defined heterogenous mass with areas
of necrosis with HU 50 and wash out of
30% of contrast in 10min and
hyperintense signal on T2 MRI relative to
liver no sign of invasion surrounding
tissue or lymphadenopathy
highly Suspicious
radiologically

32. Exercise
3
50 year old
diabetic patient
underwent
abdominal CT
scan for chronic
abdominal pain
discovered 3cm
adrenal mass
well defined heterogenous mass with
areas of hemorrhage and calcifications
and necrosis HU 18 and wash out of 60%
of contrast in 10min no sign of invasion
surrounding tissue or lymphadenopathy
indeterminate
radiologically

33. •R 3.1. We recommend that every patient with an
adrenal incidentaloma should undergo careful
assessment including clinical examination for
symptoms and signs of adrenal hormone excess.
Recommendations ( ESE / ENSAT)

34. Incidentaloma (assessment )
Is it functioning
Clinical assessment
Biochemical assessment

35. Incidentaloma (assessment )
Clinical assessment
Resistant hypertension with hypokalemia
Cushing`s syndrome
Pheochromocytoma syndrome
Feminizing or Virilizing symptoms

36. Incidentaloma (assessment )
Biochemical assessment
PAC/PRA > 20
Low-dose (1 mg) dexamethasone suppression test
24hr urinary or free plasma level catecholamines
Urinary Testosterone and DHEA

37. • R 3.9. We recommend excluding pheochromocytoma by
measurement of plasma-free metanephrines or urinary fractionated
metanephrines.
• R 3.10. In patients with concomitant hypertension or unexplained
hypokalemia, we recommend the use of the aldosterone/renin ratio
to exclude primary aldosteronism.
• R 3.11. We suggest measurement of sex hormones and steroid
precursors in patients with clinical or imaging features suggestive
of adrenocortical carcinoma.
Recommendations ( ESE / ENSAT)

38. • R 3.2. We recommend that all patients with adrenal incidentalomas
undergo a 1mg overnight dexamethasone suppression test to
exclude cortisol excess .
• R 3.3. we recommend using serum cortisol levels post
dexamethasone ≤50nmol/L (≤1.8µg/dL) as a diagnostic criterion for
the exclusion of autonomous cortisol secretion .
• R 3.4. We suggest that post-dexamethasone serum cortisol levels
* between 51 and 138nmol/L (1.9–5.0µg/dL) should be considered
as evidence of ‘possible autonomous cortisol secretion’
* >138nmol/L (>5.0µg/dL) should be taken as evidence of
‘autonomous cortisol secretion’
Recommendations ( ESE / ENSAT)

39. • R 3.5. We recommend against considering ‘autonomous cortisol
secretion’ as a condition with a high risk for the development of overt
Cushing’s syndrome .
• R 3.6. We recommend screening patients with ‘possible
autonomous cortisol secretion’ or ‘autonomous cortisol secretion’ for
hypertension and type 2 diabetes mellitus and suggest offering
appropriate treatment of these conditions
• R 3.7. We suggest screening patients with ‘autonomous cortisol
secretion’ for asymptomatic vertebral fractures and to consider
appropriate treatment of these conditions.
Recommendations ( ESE / ENSAT)

40. Incidentaloma (assessment )
Associated
comorbidities

41. Exercise
1
50 year old
patient with HTN
underwent
abdominal CT-
scan for Renal
stone
discovered 3 cm
adrenal mass
homogeneous and lipid-rich well defined
mass with HU 5 and wash out of 70% of
contrast in 10min no signs of invasion of
surrounding tissue or lymphadenopathy
aldosterone/renin ratio 10
Normal plasma free catecholamine
serum cortisol levels 112nmol/L post 1mg dexamethasone
suppression test
Dyslipidemia and osteoporosis
Benign radiologically and
possible autonomous
cortisol secretion adrenal
mass with comorbidity

42. Exercise
2
40 year old
unknown cases
of any medical
disease
underwent L.S CT
scan discovered
2cm adrenal
mass
Ill-defined heterogenous mass with areas
of necrosis with HU 50 and wash out of
30% of contrast in 10min and
hyperintense signal on T2 MRI relative to
liver no sign of invasion surrounding
tissue or lymphadenopathy
Normal PAC/PRA
Normal plasma free catecholamines
Normal serum cortisol level post low dose dexamethasone
suppression test
Normal Urinary Testosterone and DHEA
highly Suspicious
radiologically with normal
hormonal activity

43. Exercise
3
50 year old
diabetic patient
underwent
abdominal CT
scan for chronic
abdominal pain
discovered 3cm
adrenal mass
well defined heterogenous mass with
areas of hemorrhage and calcifications
and necrosis HU 18 and wash out of 60%
of contrast in 10min no sign of invasion
surrounding tissue or lymphadenopathy
Patient is hypertensive
Normal PAC/PRA
Elevated plasma catecholamine
Normal serum cortisol level post low dose dexamethasone
suppression test
Normal Urinary Testosterone and DHEA
indeterminate
radiologically with
pheochromocytoma

44. Incidentaloma (approach )

45. •R 2.3. We suggest that if the noncontrast CT is consistent with
a benign adrenal mass (Hounsfield units ≤10) that is
homogeneous and smaller than 4cm, no further imaging is
required.
•R 5.1. We suggest against further imaging for follow-up in
patients with an adrenal mass <4cm with clear benign
features on imaging studies .
Recommendations ( ESE / ENSAT)

46. • in patients presenting without known extra-adrenal malignancy, a
noncontrast CT with HU of ≤10 was only found in those with benign disease,
• whereas in patients with extra-adrenal malignancy, 7% of cases with
noncontrast HU ≤10 turned out to be malignant.
Recommendations ( ESE / ENSAT)

47. • R 5.3. We suggest against repeated hormonal work-up in
patients with a normal hormonal work-up at initial evaluation
unless new clinical signs of endocrine activity appear or
there is worsening of comorbidities (e.g. hypertension and
type 2 diabetes).
Recommendations ( ESE / ENSAT)

48. Incidentaloma (approach )

49. • R 3.8. We suggest an individualized approach to consider
patients with ‘autonomous cortisol secretion’ due to a
benign adrenal adenoma and comorbidities potentially
related to cortisol excess for adrenal surgery.
Age, degree of cortisol excess, general health, comorbidities
and patient’s preference should be taken into account.
In all patients considered for surgery, ACTH-independency
of cortisol excess should be confirmed.
Recommendations ( ESE / ENSAT)

50. Incidentaloma (approach )
Adrenal adenoma with autonomous cortisol secretion

51. Incidentaloma (approach )

52. Incidentaloma (approach )
Clinically relevant hormonal
excess or malignant tumor

53. • R 4.1. We recommend adrenalectomy as the standard of care for unilateral
adrenal tumors with clinically significant hormone excess.
• R 4.3. We suggest performing laparoscopic adrenalectomy in patients with
unilateral adrenal masses with radiological findings suspicious of malignancy
and a diameter ≤6cm, but without evidence of local invasion
• R 4.4. We recommend performing open adrenalectomy for unilateral
adrenal masses with radiological findings suspicious of malignancy and signs
of local invasion.
Recommendations ( ESE / ENSAT)

54. • R 4.5. We suggest an individualized approach in patients that do not fall in
one of the above-mentioned categories
Recommendations ( ESE / ENSAT)

55. ‫الورشة‬ ‫محاور‬
5Ps
Recommendations ( AACE/AAES )
• R18. Any adrenal mass with concerning radiographic
characteristics and most lesions ≥4 cm should be resected because
of increased risk of adrenal cancer
• R21. Open adrenalectomy should be performed if ACC is
suspected

56. Incidentaloma (approach )

57. • R 2.4. If the adrenal mass is indeterminate on noncontrast CT and
the results of the hormonal work-up do not indicate significant
hormone excess, three options should be considered by a
multidisciplinary team :
* immediate additional imaging with another modality
* interval imaging in 6–12months (non-contrast CT or MRI)
* surgery without further delay.
Recommendations ( ESE / ENSAT)

58. • R 5.2. In patients with an indeterminate adrenal mass (by imaging) opting
not to undergo adrenalectomy following initial assessment, we suggest
a repeat non-contrast CT or MRI after 6–12months to exclude significant
growth.
We suggest surgical resection if the lesion enlarges by more than 20%
(in addition to at least a 5mm increase in maximum diameter) during this
period.
If there is growth of the lesion below this threshold, additional imaging
after 6–12months should be performed
Recommendations ( ESE / ENSAT)

59. Recommendations ( ESE / ENSAT)
• annual clinical follow-up in patients with ‘autonomous cortisol
secretion’ and in patients with both ‘possible autonomous cortisol
secretion’ and potentially associated comorbidities
• For development of overt Cushing syndrome or worsening
comorbidities .
• we suggest that follow-up by an endocrinologist for 2–4 years .

60. ‫الورشة‬ ‫محاور‬
5Ps
Recommendations ( AACE/AAES )
• R2. Patients with adrenal incidentalomas who do not fulfill
the criteria for surgical resection need to have
radiographic reevaluation at 3 to 6 months and then
annually for 1 to 2 years.
For all adrenal tumors, hormonal evaluation should be
performed at the time of diagnosis and then annually for 5
years

61. Exercise
homogeneous and lipid-rich well defined
mass with HU 5 and wash out of 70% of
contrast in 10min no signs of invasion of
surrounding tissue or lymphadenopathy
aldosterone/renin ratio 10
Normal plasma free catecholamine
serum cortisol levels 112nmol/L post 1mg dexamethasone
suppression test
Dyslipidemia and osteoporosis
Benign radiologically with
possible autonomous cortisol
secretion adrenal mass with
comorbidity
1
50 year old
patient with HTN
underwent
abdominal CT-
scan for Renal
stone
discovered 3 cm
adrenal mass
Either surgical or follow-up depend on :
Age, degree of cortisol excess, general health, comorbidities
and patient’s preference should be taken into account.

62. Exercise
well defined Heterogenous mass with
areas of necrosis with HU 50 and wash
out of 30% of contrast in 10min
Normal PAC/PRA
Normal plasma free catecholamines
Normal serum cortisol level post low dose dexamethasone
suppression test
Normal Urinary Testosterone and DHEA
Highly suspicious
radiologically with normal
hormonal activity
2
40 year old
unknown cases
of any medical
disease
underwent L.S CT
scan discovered
2cm adrenal
mass
Laparoscopic adrenalectomy

63. Exercise
well defined homogenous mass with
areas of hemorrhage and HU 15 and
wash out of 60% of contrast in 10min
Patient is hypertensive
Normal PAC/PRA
Elevated plasma catecholamine
Normal serum cortisol level post low dose dexamethasone
suppression test
Normal Urinary Testosterone and DHEA
indeterminate
radiologically with
pheochromocytoma
3
50 year old
diabetic patient
underwent
abdominal CT
scan for chronic
abdominal pain
discovered 3cm
adrenal mass
Laparoscopic adrenalectomy

64. Peri-operative care
For adrenal insufficiency and adrenal crisis
For Cushing`s syndrome
pheochromocytoma

65. Recommendations ( ESE / ENSAT)
• R 4.6. We recommend perioperative glucocorticoid treatment at major
surgical stress doses, as recommended by guidelines, in all patients
undergoing surgery for an adrenal tumor, where there is evidence of
‘possible autonomous cortisol secretion’ or ‘autonomous cortisol secretion’.

66. ‫الورشة‬ ‫محاور‬
5Ps
Recommendations ( AACE/AAES )
• R4. After adrenalectomy for a cortisol-producing
adenoma, patients should be treated with exogenous
glucocorticoids until the hypothalamic-pituitary-adrenal
(HPA) axis has recovered. This process may take 6 to 18
months after unilateral adrenalectomy

67. ‫الورشة‬ ‫محاور‬
5Ps
Recommendations ( AACE/AAES )
• R11. In all patients with a pheochromocytoma, an α
adrenergic blocking agent should be administered
preoperatively, in an effort to prevent intraoperative
hemodynamic instability

69. Reference
• Sabiston Textbook of Surgery 21st ed
• Schwartz’s Principles of Surgery 10th ed
• Baily and love short practice of surgery 28th ed
• ESE and ENSAT guideline on adrenal incidentaloma 2016
• AACE/AAES Adrenal Incidentaloma guidelines, Endocrine
Practice 2009;15(Suppl 1)