Estimated reading time: 4 minutes
Found an Adrenal Mass By Accident? Here is What to Do Next
For most people, the term “incidentaloma” is completely unfamiliar, until it shows up on their imaging report. An adrenal incidentaloma is simply an adrenal mass discovered accidentally during imaging performed for a completely unrelated reason. It was not the target of the scan, it was not suspected. It just appeared.
With the widespread use of high-resolution CT and MRI imaging, adrenal incidentalomas are now detected in approximately 1–4% of all abdominal CT scans, and the detection rate increases with age. By age 70, roughly 7% of the population has an adrenal nodule of some kind.
The central question is almost never “What is this?” In most cases, it’s a benign adrenal adenoma, a non-cancerous growth. The central question is: “Does this particular nodule, in this particular patient, require surgery?” Answering that correctly requires expertise.
Table of contents
How Adrenal Incidentalomas Are Classified
Endocrine surgeons and endocrinologists evaluate adrenal incidentalomas along two independent axes:
1. Functional Status: Is it making hormones?
- Non-functioning adenoma: makes no excess hormones (the most common type), approximately 70–80% of incidentalomas
- Mild autonomous cortisol secretion (MACS): produces slightly elevated cortisol without overt Cushing features; associated with increased cardiovascular risk
- Pheochromocytoma: produces catecholamines (adrenaline-like hormones); can be life-threatening if unrecognized before surgery
- Primary aldosteronism (Conn syndrome): produces excess aldosterone causing hypertension and low potassium
2. Radiologic Features: Does it look benign or malignant?
- Lipid-rich adenoma (most common): appears dark on non-contrast CT, measuring ≤10 Hounsfield units (HU)
- Lipid-poor adenoma: higher HU values; requires contrast-enhanced CT to assess washout characteristics
- Adrenocortical carcinoma (ACC): typically large (>6 cm), irregular, heterogeneous (rare but aggressive)
- Metastasis: if the patient has a history of another cancer, the adrenal gland is a common metastatic site
The Evaluation Process: What to Expect
When you are referred to Dr. Neychev for an adrenal incidentaloma, the workup typically involves:
- Review of all available imaging (CT, MRI, PET scan if relevant)
- Biochemical testing to screen for pheochromocytoma, Cushing syndrome, and primary aldosteronism
- A shared decision-making conversation about whether your nodule’s characteristics favor surgery, monitoring, or discharge
When Surgery Is the Right Choice
Dr. Neychev recommends laparoscopic adrenalectomy (minimally invasive removal of the adrenal gland) when:
- The nodule is ≥4 cm in diameter
- Imaging features suggest possible malignancy
- The nodule is proven to be a pheochromocytoma or functional adenoma causing clinical symptoms
- There is significant growth on follow-up imaging
- The patient is young (under 40) with an indeterminate mass
When Active Surveillance Is the Right Choice
Not every adrenal incidentaloma needs surgery. When a nodule is small (<4 cm), has reassuring imaging features, and shows no hormonal excess, the appropriate management is often watchful waiting with scheduled reimaging and periodic hormonal reassessment (typically at 6–12 months, then annually for several years).
Dr. Neychev’s role in these cases is to coordinate monitoring between surgery and endocrinology, ensure the follow-up plan is individualized, and re-evaluate if anything changes.
- Bulgarian
- English
- Russian
- Serbian
Frequently Asked Questions
Benign adrenal adenomas do not typically resolve on their own, but they also rarely cause harm if they are small and non-functioning. The purpose of monitoring is to detect any change in size or function over time.
An adenoma is a benign (non-cancerous) growth. Adrenocortical carcinoma (adrenal cancer) is rare, accounting for fewer than 5% of adrenal incidentalomas, but requires prompt surgical treatment. Imaging characteristics and size help distinguish between the two.
Possibly. Both pheochromocytoma and primary aldosteronism (Conn syndrome) can cause hypertension, and mild cortisol excess can cause fatigue, weight gain, and mood changes. These should be ruled out with biochemical testing.
Laparoscopic adrenalectomy is a well-established, minimally invasive procedure with low complication rates in experienced hands. Dr. Neychev’s fellowship training at the NIH National Cancer Institute specifically included high-volume adrenal surgery.
Most patients go home within 1–2 days after laparoscopic adrenalectomy and return to light activity within 1–2 weeks. Recovery is significantly shorter than with open adrenal surgery.
Post Tags
- adrenal incidentaloma adrenal mass incidentaloma surgeon surgery