The Effect of Radiological Imaging Reports in Clinical Decision-Making in the Management of Adrenal Incidentaloma

Abstract

Objectives

To assess the necessity of additional imaging by comparing the characteristics of adrenal lesions incidentally detected on abdominal, stone protocol, and chest computed tomography (CT) with those obtained from a second imaging modality specifically targeting the adrenal glands.

Methods

A total of 162 adrenal lesions imaged in 112 patients with adrenal incidentalomas were retrospectively analyzed. Radiology reports were reviewed for adrenal lesion laterality, location, number of lesions, maximum diameter, the number of dimensions specified, lesion density on CT measured in Hounsfield Units (HU), lesion characterization, presence of heterogeneity, and functional status. Cohen’s Kappa test assessed the agreement between the first and second imaging evaluations. Additionally, sensitivity, specificity, positive predictive value, and negative predictive value of the first imaging were calculated using adrenal-specific second imaging as the reference standard.

Results

No concordance was found between the initial and follow-up imaging in terms of HU measurements (κ=0.079; p=0.123). However, concordance ranging from weak to excellent was observed regarding bilaterality, localization, lesion count, diameter, and heterogeneity. Based on the second imaging reports as reference, the sensitivity of the initial imaging for diagnosing adenoma and myelolipoma was determined to be 26.49% and 42.85%, respectively. The success rate of adenoma diagnosis was associated with the number of lesions in the adrenal gland (≥2 lesions>single lesion), lesion size (>2 cm>≤ 2 cm), and location (left>right). Nine lesions initially reported as<4 cm on the first imaging were found to be≥4 cm on the second imaging, and seven lesions initially reported as unilateral were noted to be bilateral on the second imaging. In eight patients, adrenal lesions were detected on the first imaging, but the second imaging was reported as normal.

Conclusion

A more detailed definition of adrenal incidentalomas, especially in terms of heterogeneity and HU values in the first images in radiology reports, and the use of a standard reporting system will guide clinical practice and provide a cost-effective approach while avoiding unnecessary imaging and radiation.

Keywords

Incidentaloma - adrenal - adenoma - tomography - magnetic resonance

Publikationsverlauf

Eingereicht: 18. Februar 2025

Angenommen nach Revision: 29. Juli 2025

Artikel online veröffentlicht:
01. Oktober 2025

• References

• 1 Fassnacht M, Tsagarakis S, Terzolo M. 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. Eur J Endocrinol 2023; 189: G1-G42
• 2 Watari J, Vekaria S, Lin Y. et al. Radiology report language positively influences adrenal incidentaloma guideline adherence. Am J Surg 2022; 223: 231-236 Epub 2021 Jun 29
• 3 Araujo-Castro M, García Sanz I, Mínguez Ojeda C. et al. An integrated CT and MRI imaging model to differentiate between adrenal adenomas and pheochromocytomas. Cancers 2023; 15: 3736 PMID: 37509397 PMID: PMC10378495
• 4 Johnson PT, Horton KM, Fishman EK. Adrenal imaging with multidetector CT: Evidence-based protocol optimization and interpretative practice. Radiographics 2009; 29: 1319-1331 Erratum in: Radiographics 2009; 29: 2198
• 5 Expert Panel on Urological Imaging. Mody RN, Remer EM, Nikolaidis P. et al. ACR Appropriateness Criteria^® Adrenal Mass Evaluation: 2021 update. J Am Coll Radiol 2021; 18: S251-S267
• 6 Barat M, Cottereau AS, Gaujoux S. et al. Adrenal mass characterization in the era of quantitative imaging: State of the art. Cancers 2022; 14: 569 PMID: 35158836 PMID: PMC8833697
• 7 Israel GM, Korobkin M, Wang C. et al. Comparison of unenhanced CT and chemical shift MRI in evaluating lipid-rich adrenal adenomas. AJR Am J Roentgenol 2004; 183: 215-219
• 8 Korean Endocrine Society, Committee for Clinical Practice Guidelines. Lee JM, Kim MK, Ko SH. et al. Clinical guidelines for the management of adrenal incidentaloma. Endocrinol Metab 2017; 32: 200-218
• 9 Rowe NE, Kumar R, Schieda N. et al. Diagnosis, management, and follow-up of the incidentally discovered adrenal mass: CUA guideline endorsed by the AUA. J Urol 2023; 210: 590-599
• 10 Maas M, Nassiri N, Bhanvadia S. et al. Discrepancies in the recommended management of adrenal incidentalomas by various guidelines. J Urol 2021; 205: 52-59 Erratum in: J Urol 2021; 205: 942. doi: 10.1097/JU.0000000000001652
• 11 Wang F, Liu J, Zhang R. et al. CT and MRI of adrenal gland pathologies. Quant Imaging Med Surg 2018; 8: 853-875
• 12 Fassnacht M, Arlt W, Bancos I. et al. Management of adrenal incidentalomas: European Society of Endocrinology Clinical Practice Guideline in collaboration with the European Network for the Study of Adrenal Tumors. Eur J Endocrinol 2016; 175: G1-G34
• 13 Funder JW, Carey RM, Mantero F. et al. The management of primary aldosteronism: Case detection, diagnosis, and treatment: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2016; 101: 1889-1916
• 14 Stowasser M, Ahmed AH, Cowley D. et al. Comparison of seated with recumbent saline suppression testing for the diagnosis of primary aldosteronism. J Clin Endocrinol Metab 2018; 103: 4113-4124
• 15 Rowe NE, Kumar RM, Schieda N. et al. Canadian Urological Association guideline: Diagnosis, management, and follow-up of the incidentally discovered adrenal mass. Can Urol Assoc J 2023; 17: 12-24
• 16 American Association of Clinical Endocrinologists; American Association of Endocrine Surgeons. Zeiger MA, Thompson GB, Duh QY. et al. The American Association of Clinical Endocrinologists and American Association of Endocrine Surgeons medical guidelines for the management of adrenal incidentalomas. Endocr Pract 2009; 15: 1-20
• 17 Maas M, Nassiri N, Bhanvadia S. et al. Discrepancies in the recommended management of adrenal incidentalomas by various guidelines. J Urol 2021; 205: 52-59 Erratum in: J Urol 2021; 205: 942. doi: 10.1097/JU.0000000000001652
• 18 Korean Endocrine Society, Committee for Clinical Practice Guidelines. Lee JM, Kim MK, Ko SH. et al. Clinical guidelines for the management of adrenal incidentaloma. Endocrinol Metab. 2017. 32. 200-218
• 19 He X, Peter PR, Auchus RJ. Approach to the patient with an incidental adrenal mass. Med Clin North Am 2021; 105: 1047-1063
• 20 Young WF. Clinical practice. The incidentally discovered adrenal mass. N Engl J Med 2007; 356: 601-610
• 21 Angeli A, Osella G, Alì A. et al. Adrenal incidentaloma: an overview of clinical and epidemiological data from the National Italian Study Group. Horm Res 1997; 47: 279-283
• 22 Hrabak-Paar M, Đido V, Štern-Padovan R. Should we use CT or MRI for the detection and characterization of benign adrenal lesions?. Ann Endocrinol 2015; 76: 272-280
• 23 Kim J, Bae KH, Choi YK. et al. Clinical characteristics for 348 patients with adrenal incidentaloma. Endocrinol Metab 2013; 28: 20-25
• 24 Watari J, Vekaria S, Lin Y. et al. Radiology report language positively influences adrenal incidentaloma guideline adherence. Am J Surg 2022; 223: 231-236
• 25 Wickramarachchi BN, Meyer-Rochow GY, McAnulty K. et al. Adherence to adrenal incidentaloma guidelines is influenced by radiology report recommendations. ANZ J Surg 2016; 86: 483-486
• 26 Feliciani G, Serra F, Menghi E. et al. Radiomics in the characterization of lipid-poor adrenal adenomas at unenhanced CT: Time to look beyond usual density metrics. Eur Radiol 2024; 34: 422-432
• 27 Mahmood E, Loughner CL, Anastasopoulou C. Adrenal adenoma. 2023 Aug 17. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024