Adrenal incidentaloma (adrenal mass found on imaging)
BioMG follows French guidelines. Adapt it to the guidelines and the tests available where you practise.
Initial hormonal work-up
Overnight dexamethasone suppression test
- Take 1 mg of dexamethasone between 23 h and midnight; cortisol sample the next day between 8 am and 9 am. If possible, stop combined oestrogen-progestogen pills and oral oestrogens 6 weeks before.
- 8 am serum cortisol after suppression with 1 mg of dexamethasone
Laboratory tests
- Serum potassium
- Fasting plasma glucose
- 24-hour urinary metanephrines with urinary creatinine (if mass not typical of a benign adenoma)if neededESE 2023: in all patients whose lesion does not have the typical appearance of a benign adenoma (density > 10 HU, heterogeneous), or when no unenhanced CT has been done [2]; the SFE proposed them for every incidentaloma [1].
- Plasma free metanephrines (if mass not typical of a benign adenoma and 24-hour urine collection impossible)if needednon-French guidelineESE 2023 accepts this measurement as it does urinary metanephrines [2], and a 2025 American review puts it first for its higher sensitivity [3]. In France, it has no NABM procedure, which leaves urinary metanephrines first-line [4].
- Aldosterone and renin, aldosterone/renin ratio (if hypertension or hypokalaemia)if neededHypertension or unexplained hypokalaemia [1,2]; sample under standardised conditions [5].
- DHEA-S (if adrenocortical carcinoma suspected)if neededImaging or clinical picture suggesting adrenocortical carcinoma: androgens and precursors, on specialist advice [1,2]. Covered in adrenal diseases [4].
Do not order
- Chromogranin A: poorly sensitive and poorly specific, not recommended routinely [1].
- Routine androgens and precursors (testosterone, DHEA-S, 17-hydroxyprogesterone): only if adrenocortical carcinoma is suspected [1,2].
- Hormone tests repeated every year when the initial tests are normal: not recommended, except for new signs [2].
- Urinary free cortisol or midnight cortisol to screen for autonomous cortisol secretion: poorly sensitive, the overnight dexamethasone suppression test is the screening test [1].
Abnormal suppression (cortisol > 50 nmol/L)
Laboratory tests (often prescribed by the endocrinologist)
- 8 am serum cortisol after suppression with 1 mg of dexamethasone (follow-up)
- Plasma ACTH (in the morning, EDTA tube, rapid transport)
Then once a year (without surgery)
- Fasting plasma glucose
- Lipid profile
Sources (8)
- Tabarin A, Bardet S, Bertherat J, Dupas B, Chabre O, Hamoir E, et al. Exploration and management of adrenal incidentalomas. French Society of Endocrinology Consensus. Ann Endocrinol (Paris). 2008;69(6):487-500 (texte français du consensus d'experts SFE, hébergé par la SFE).
- Fassnacht M, Tsagarakis S, Terzolo M, Tabarin A, Sahdev A, Newell-Price J, 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(1):G1-G42.
- Owei L, Wachtel H. The Landmark Series: evaluation and management of adrenal incidentalomas. Ann Surg Oncol. 2025;32(7):4712-4719.
- Assurance maladie. Nomenclature des actes de biologie médicale (NABM), version 105 : actes 0462 (cortisol), 0477 (métanéphrines urinaires), 0478 (catécholamines plasmatiques), 1802 (SDHEA), 0714 et 0776 (aldostérone, rénine), 1577 (HbA1c).
- Douillard C, Houillier P, Nussberger J, Girerd X. SFE/SFHTA/AFCE Consensus on Primary Aldosteronism, part 2: First diagnostic steps. Ann Endocrinol (Paris). 2016;77(3):192-201 (version française hébergée par la SFE).
- Nieman LK, Biller BM, Findling JW, Newell-Price J, Savage MO, Stewart PM, et al. The diagnosis of Cushing's syndrome: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2008;93(5):1526-40.
- Park SS, Kim JH. Recent updates on the management of adrenal incidentalomas. Endocrinol Metab (Seoul). 2023;38(4):373-380.
- Mayo-Smith WW, Song JH, Boland GL, Francis IR, Israel GM, Mazzaglia PJ, et al. Management of incidental adrenal masses: a white paper of the ACR Incidental Findings Committee. J Am Coll Radiol. 2017;14(8):1038-1044.