Management of Incidental Adrenal Masses: American College of Radiology white paper

Changed by Craig Hacking, 21 Sep 2017
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As of 2017, the Adrenal subcommittee of the Journal of the American College of RadiologyRadiology published an algorithm for the management of incidental adrenal masses based on the following principles

in patients who are:
  • Adults / 18 or over
  • Asymptomatic for adrenal pathology
  • Referred for imaging for reasons unrelated to adrenal pathology

Summary

  1. Adrenal masses less than 1cm (short axis) do not require further investigation

  2. Incidental masses should be categorised according to diagnostic imaging features, mass size, growth (per prior imaging if available) and cancer history.

  3. Dedicated adrenal CT is preferred to determine if a mass between 1 and- 4cms, that iswith density greater than 10 HU, is a benign adenoma

  4. Wherever possible, the stability of a lesion should be assessed with any modality that has imaged the adrenals in the past (eg Chestchest CT, PET CT, Abdominalabdominal US, lumbar spine MR.)

  5. Consider patients’ comorbidities, life-expectancy and ability to receive treatment before recommending further investigation.

These principles and the ACR algorithm should only be applied to patients who are:

  • Adults / 18 or over

  • Asymptomatic for adrenal pathology

  • Referred for imaging for reasons unrelated to adrenal pathology

The algorithm

Incidental, asymptomatic adrenal mass > 1cm

Diagnostic benign imaging features (see below)

  • Nomyelolipoma or lipid-rich adenoma

    • macroscopic fat
    • density < 10 HUs on plain CT
    • signal loss comparable the spleen on in-phase and opposed-phase images of a chemical-shift MRI

  • cyst
  • benign calcified mass eg old haematoma or granulomatous infection
  • haemorrhage
  • normal or benign serum calcium
  • no follow-up required
Indeterminate imaging features
>Size 1cm, < - 4cm

  1. 1. Prior imaging

    • Stable ≥ 1 year and no biochemical features of functioning adenoma or pheochromocytoma

      • No Follow-up
    • New or enlarging
      • No Cancer History
        • Consider follow-up adrenal CT or resection
      • Cancer History
        • Consider biopsy or PET-CT

  2. 2. No prior imaging, no cancer Hxhostory

    • <2cm
      • probably benign, consider 12 month adrenal CT
    • 2 - 4cm
      • Adrenal CT

  3. 3. No prior imaging, +with cancer Hxhistory and isolated adrenal mass

    • Adrenal CT
Size > 4cm

  • andwith no cancer history

    • Consider resection

  • andwith cancer history
    • Consider Biopsy or PET-CT

Adrenal CT

  • Reduced dose non-contrast CT ≤10 HU and no biochemical features of functioning adenoma or pheochromocytoma
    • benign adenoma, no follow-up
  • NCCT > 10 HU
    • Adrenal CT washout
      1. No enhancement (<10HU) = cyst or haemorrhage
        • Benignbenign, no follow-up
      2. APW/RPW ≥ 60/40%
        • (and no biochemical features of hyperfunctioning adenoma or pheochromocytoma)
        • Benignbenign adenoma, no follow-up
      3. APW < 60/40%
        • Imagingimaging follow-up, Biopsy, PET-CT or resection depending on clinical scenario

Diagnostic Benign Imaging Features

  • Myelolipoma or lipid-rich adenoma

    • Macroscopic fat

    • Density < 10 HUs on plain CT

    • Signal loss comparable the spleen on in-phase and opposed-phase images of a chemical-shift MRI

  • cyst

  • Benign calcified mass eg old haematoma or granulomatous infection

  • Haemorrhage

  • Normal or benign serum calcium
  • -<p>As of 2017, the Adrenal subcommittee of the Journal of the American College of Radiology published an algorithm for the management of incidental adrenal masses based on the following principles</p><ol>
  • +<p>As of 2017, the <strong>Adrenal subcommittee of the Journal of the American College of Radiolog</strong>y published an algorithm for the management of <strong>incidental adrenal masses</strong> in patients who are:</p><ul>
  • +<li>Adults / 18 or over</li>
  • +<li>Asymptomatic for adrenal pathology</li>
  • +<li>Referred for imaging for reasons unrelated to adrenal pathology</li>
  • +</ul><h4>Summary</h4><ol>
  • -<li><p>Incidental masses should be categorised according to diagnostic imaging features, mass size, growth (per prior imaging if available) and cancer history.</p></li>
  • -<li><p>Dedicated adrenal CT is preferred to determine if a mass between 1 and 4cms, that is greater than 10 HU, is a benign adenoma</p></li>
  • -<li><p>Wherever possible, the stability of a lesion should be assessed with any modality that has imaged the adrenals in the past (eg Chest CT, PET CT, Abdominal US, lumbar spine MR.)</p></li>
  • -<li><p>Consider patients’ comorbidities, life-expectancy and ability to receive treatment before recommending further investigation.</p></li>
  • -</ol><p>These principles and the ACR algorithm should only be applied to patients who are:</p><ul>
  • -<li><p>Adults / 18 or over</p></li>
  • -<li><p>Asymptomatic for adrenal pathology</p></li>
  • -<li><p>Referred for imaging for reasons unrelated to adrenal pathology</p></li>
  • -</ul><h4>The algorithm</h4><p>Incidental, asymptomatic adrenal mass &gt; 1cm</p><h5>Diagnostic benign imaging features (see below)</h5><ul><li><p>No follow-up</p></li></ul><h5>Indeterminate imaging features</h5><h6>&gt; 1cm, &lt; 4cm</h6><ol>
  • -<li>
  • -<p>Prior imaging</p>
  • -<ul>
  • +<li>Incidental masses should be categorised according to diagnostic imaging features, mass size, growth (per prior imaging if available) and cancer history</li>
  • +<li>Dedicated adrenal CT is preferred to determine if a mass between 1 - 4cms, with density greater than 10 HU, is a benign <a href="/articles/adrenal-adenoma">adenoma</a>
  • +</li>
  • +<li>Wherever possible, the stability of a lesion should be assessed with any modality that has imaged the adrenals in the past (eg chest CT, PET CT, abdominal US, lumbar spine MR)</li>
  • +<li>Consider patients’ comorbidities, life-expectancy and ability to receive treatment before recommending further investigation</li>
  • +</ol><h4>The algorithm</h4><p>Incidental, asymptomatic adrenal mass &gt; 1cm</p><h5>Diagnostic benign imaging features</h5><ul>
  • -<p>Stable ≥ 1 year and no biochemical features of functioning adenoma or pheochromocytoma</p>
  • -<ul><li>No Follow-up</li></ul>
  • +<a href="/articles/adrenal-myelolipoma">myelolipoma</a> or lipid-rich adenoma<ul>
  • +<li>macroscopic fat</li>
  • +<li>density &lt; 10 HUs on plain CT</li>
  • +<li>signal loss comparable the spleen on in-phase and opposed-phase images of a chemical-shift MRI</li>
  • +</ul>
  • +</li>
  • +<li><a href="/articles/adrenal-cyst">cyst</a></li>
  • +<li>benign calcified mass eg old <a href="/articles/adrenal-haemorrhage">haematoma </a>or granulomatous infection</li>
  • +<li><a href="/articles/adrenal-haemorrhage">haemorrhage</a></li>
  • +<li>normal or benign serum calcium</li>
  • +<li>no follow-up required</li>
  • +</ul><h5>Indeterminate imaging features</h5><h6>Size 1cm - 4cm</h6><p>1. Prior imaging</p><ul>
  • +<li>Stable ≥ 1 year and no biochemical features of functioning adenoma or <a href="/articles/pheochromocytoma-2">pheochromocytoma</a><ul><li>No Follow-up</li></ul>
  • -</ul>
  • -</li>
  • -<li>No prior imaging, no cancer Hx<ul>
  • +</ul><p>2. No prior imaging, no cancer hostory</p><ul>
  • -</ul>
  • +</ul><p>3. No prior imaging, with cancer history and isolated adrenal mass</p><ul><li>Adrenal CT</li></ul><h6>Size &gt; 4cm</h6><ul>
  • +<li>with no cancer history<ul><li>Consider resection</li></ul>
  • -<li>No prior imaging, + cancer Hx and isolated adrenal mass<ul><li>Adrenal CT</li></ul>
  • +<li>with cancer history<ul><li>Consider Biopsy or PET-CT</li></ul>
  • -</ol><h6>&gt; 4cm</h6><ul>
  • -<li>
  • -<p>and no cancer history</p>
  • -<ul><li><p>Consider resection</p></li></ul>
  • -</li>
  • -<li>and cancer history<ul><li>Consider Biopsy or PET-CT</li></ul>
  • -</li>
  • -</ul><h5>Adrenal CT</h5><ul>
  • +</ul><h4>Adrenal CT</h4><ul>
  • -<li>No enhancement (&lt;10HU) = cyst or haemorrhage<ul><li>Benign, no follow-up</li></ul>
  • +<li>No enhancement (&lt;10HU) = cyst or haemorrhage<ul><li>benign, no follow-up</li></ul>
  • -<li>Benign adenoma, no follow-up</li>
  • +<li>benign adenoma, no follow-up</li>
  • -<li>APW &lt; 60/40%<ul><li>Imaging follow-up, Biopsy, PET-CT or resection depending on clinical scenario    </li></ul>
  • +<li>APW &lt; 60/40%<ul><li>imaging follow-up, Biopsy, PET-CT or resection depending on clinical scenario</li></ul>
  • -</ul><h4>Diagnostic Benign Imaging Features</h4><ul>
  • -<li>
  • -<p>Myelolipoma or lipid-rich adenoma</p>
  • -<ul>
  • -<li><p>Macroscopic fat</p></li>
  • -<li><p>Density &lt; 10 HUs on plain CT</p></li>
  • -<li><p>Signal loss comparable the spleen on in-phase and opposed-phase images of a chemical-shift MRI</p></li>
  • -</ul>
  • -</li>
  • -<li><p>cyst</p></li>
  • -<li><p>Benign calcified mass eg old haematoma or granulomatous infection</p></li>
  • -<li><p>Haemorrhage</p></li>
  • -<li><p>Normal or benign serum calcium</p></li>

Sections changed:

  • Approach

Systems changed:

  • Urogenital

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