Evaluation of Adrenal Incidentaloma

Adrenal incidentalomas require a comprehensive history and physical examination, with a focus on identifying evidence of excess adrenal hormonal secretion. Biochemical testing is needed to exclude mild autonomous cortisol excess, a pheochromocytoma, and/or primary hyperaldosteronism (in patients with hypertension and or hypokalemia). A patient with inconclusive biochemical testing should undergo confirmatory testing (mild autonomous cortisol excess and primary hyperaldosteronism). All patients with a pheochromocytoma should be offered an adrenalectomy (minimally invasive if there is no suspicion of a malignant tumor). Patients with mild autonomous cortisol excess and associated metabolic complications should also be offered an adrenalectomy because most patients have reversal of the metabolic complications and reduced long-term risk of cardiovascular disease. Patients who have primary hyperaldosteronism benefit from an adrenalectomy if they have unilateral hypersecretion. If the patient has a nonfunctional tumor less than 4 cm with indeterminate imaging features, then clinical follow-up is recommended.