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

Changed by Daniel J Bell, 21 Sep 2017
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Management of Incidental Adrenal Massesincidental adrenal masses: ACR White PaperAmerican College of Radiology white paper
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As ofIn 2017, the Adrenal subcommitteeSubcommittee of the Journal ofIncidental Findings Committee of the American College of RadiologRadiology y published ana revised algorithm for the management of incidental adrenal masses in patients who are:

  • Adults /adults (i.e. 18-year-old or over)
  • Asymptomaticasymptomatic for adrenal pathology
  • Referredreferred for imaging for reasons unrelated to adrenal pathology

Summary

  1. Adrenaladrenal masses less than 1cm (short axis)<1 cm do not require further investigation
  2. Incidentalincidental masses should be categorised according to diagnostic imaging features, mass size, growth (per(cf. prior imaging if available) and cancer history
  3. Dedicateddedicated adrenal CT is preferred to determine if a 1-4 cm mass between 1 - 4cms, with density greater than 10>10 HU, is a benign adenoma
  4. Whereverwherever possible, the stability of a lesion should be assessed with any modality that has imaged the adrenals in the past (eg(e.g. chest CT, PET CT-CT, abdominal US, lumbar spine MRMRI)
  5. Considerconsider patients’ comorbidities, life-expectancy expectancy and ability to receive treatment before recommending further investigation

The algorithm

Incidental, asymptomatic adrenal mass > 1cm≥1 cm

Diagnostic benign imaging features
  • myelolipoma or lipid-rich adenoma
    • macroscopic fat
    • density &lt; 10 HUs;10 HU on plainnon-contrast CT
    • signal loss comparablecompared to the spleen on in-phase and opposed-phase images of a chemical-shift MRI sequence
  • cyst
  • benign calcified mass ege.g. old haematomaor or granulomatous infection
  • haemorrhage
  • normal or benign serum calcium
  • no follow-up required
Indeterminate imaging features
Size 1cm1 cm - 4cm4 cm

1. Priorprior imaging

  • Stable ≥ 1stable ≥1 year and no biochemical features of functioning adenoma or pheochromocytomaphaeochromocytoma
    • No Followno follow-up
  • Newnew or enlarging
    • No Cancer Historyno cancer history
      • Considerconsider follow-up adrenal CT or resection
    • Cancer Historycancer history
      • Considerconsider biopsy or PET-CT

2. Nono prior imaging, no cancer hostoryhistory

  • &lt;2cm;2 cm
    • probably benign, consider 12 month adrenal CT
  • 2 - 4cm-4 cm
    • Adrenaladrenal CT

3. Nono prior imaging, with cancer history and isolated adrenal mass

  • Adrenaladrenal CT
Size &gt; 4cm;4 cm
  • with no cancer history
    • Considerconsider resection
  • with cancer history
    • Consider Biopsyconsider biopsy or PET-CT

Adrenal CT

  • Reducedreduced dose non-contrast CT ≤10 HU and no biochemical features of functioning adenoma or pheochromocytomaphaeochromocytoma
    • benign adenoma, no follow-up
  • NCCTnon-contrast CT &gt; 10;10 HU
    • Adrenaladrenal CT washout
      1. Nono enhancement (&lt;10HU;10 HU) = cyst or haemorrhage
        • benign, no follow-up
      2. APW/RPW ≥ 60absolute percentage washout (APW) / relative percentage washout (RPW) ≥60/40%
        • (andand no biochemical features of hyperfunctioning adenoma or pheochromocytoma)phaeochromocytoma
        • benign adenoma, no follow-up
      3. APW/RPW &lt; 60;60/40%
        • imaging follow-up, Biopsybiopsy, PET-CT or resection depending on clinical scenario
  • -<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>
  • +<p>In 2017, the <strong>Adrenal Subcommittee</strong> of the <strong>Incidental Findings Committee</strong> of the <strong>American College of Radiology </strong>published a revised algorithm for the <strong>management of incidental adrenal masses</strong> in patients who are:</p><ul>
  • +<li>adults (i.e. 18-year-old or over)</li>
  • +<li>asymptomatic for adrenal pathology</li>
  • +<li>referred for imaging for reasons unrelated to adrenal pathology</li>
  • -<li>Adrenal masses less than 1cm (short axis) do not require further investigation</li>
  • -<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>
  • +<li>adrenal masses &lt;1 cm do not require further investigation</li>
  • +<li>incidental masses should be categorised according to diagnostic imaging features, mass size, growth (cf. prior imaging if available) and cancer history</li>
  • +<li>dedicated adrenal CT is preferred to determine if a 1-4 cm mass, with density &gt;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 (e.g. chest CT, PET-CT, abdominal US, lumbar spine MRI)</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 ≥1 cm</p><h5>Diagnostic benign imaging features</h5><ul>
  • -<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>
  • +<li>density &lt;10 HU on non-contrast CT</li>
  • +<li>signal loss compared to the spleen on in-phase and opposed-phase images of a chemical-shift MRI sequence</li>
  • -<li>benign calcified mass eg old <a href="/articles/adrenal-haemorrhage">haematoma </a>or granulomatous infection</li>
  • +<li>benign calcified mass e.g. old <a href="/articles/adrenal-haemorrhage">haematoma</a> or granulomatous infection</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><h5>Indeterminate imaging features</h5><h6>Size 1 cm - 4 cm</h6><p>1. prior imaging</p><ul>
  • +<li>stable ≥1 year and no biochemical features of functioning adenoma or <a href="/articles/pheochromocytoma-2">phaeochromocytoma</a><ul><li>no follow-up</li></ul>
  • -<li>New or enlarging<ul>
  • -<li>No Cancer History<ul><li>Consider follow-up adrenal CT or resection</li></ul>
  • +<li>new or enlarging<ul>
  • +<li>no cancer history<ul><li>consider follow-up adrenal CT or resection</li></ul>
  • -<li>Cancer History<ul><li>Consider biopsy or PET-CT</li></ul>
  • +<li>cancer history<ul><li>consider biopsy or PET-CT</li></ul>
  • -</ul><p>2. No prior imaging, no cancer hostory</p><ul>
  • -<li>&lt;2cm<ul><li>probably benign, consider 12 month adrenal CT</li></ul>
  • +</ul><p>2. no prior imaging, no cancer history</p><ul>
  • +<li>&lt;2 cm<ul><li>probably benign, consider 12 month adrenal CT</li></ul>
  • -<li>2 - 4cm<ul><li>Adrenal CT</li></ul>
  • +<li>2-4 cm<ul><li>adrenal CT</li></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>
  • +</ul><p>3. no prior imaging, with cancer history and isolated adrenal mass</p><ul><li>adrenal CT</li></ul><h6>Size &gt;4 cm</h6><ul>
  • +<li>with no cancer history<ul><li>consider resection</li></ul>
  • -<li>with cancer history<ul><li>Consider Biopsy or PET-CT</li></ul>
  • +<li>with cancer history<ul><li>consider biopsy or PET-CT</li></ul>
  • -<li>Reduced dose non-contrast CT ≤10 HU and no biochemical features of functioning adenoma or pheochromocytoma<ul><li>benign adenoma, no follow-up</li></ul>
  • +<li>reduced dose non-contrast CT ≤10 HU and no biochemical features of functioning adenoma or phaeochromocytoma<ul><li>benign adenoma, no follow-up</li></ul>
  • -<li>NCCT &gt; 10 HU<ul><li>Adrenal CT washout<ol>
  • -<li>No enhancement (&lt;10HU) = cyst or haemorrhage<ul><li>benign, no follow-up</li></ul>
  • +<li>non-contrast CT &gt;10 HU<ul><li>
  • +<a title="Adrenal washout" href="/articles/adrenal-washout">adrenal CT washout</a><ol>
  • +<li>no enhancement (&lt;10 HU) = cyst or haemorrhage<ul><li>benign, no follow-up</li></ul>
  • -<li>APW/RPW ≥ 60/40%<ul>
  • -<li>(and no biochemical features of hyperfunctioning adenoma or pheochromocytoma)</li>
  • +<li>absolute percentage washout (APW) / relative percentage washout (RPW) ≥60/40%<ul>
  • +<li>and no biochemical features of hyperfunctioning adenoma or phaeochromocytoma</li>
  • -<li>APW &lt; 60/40%<ul><li>imaging follow-up, Biopsy, PET-CT or resection depending on clinical scenario</li></ul>
  • +<li>APW/RPW &lt;60/40%<ul><li>imaging follow-up, biopsy, PET-CT or resection depending on clinical scenario</li></ul>

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