. 2023 Aug 16;38(4):373–380. doi: 10.3803/EnM.2023.1779

Table 1.

Key Updates to the 2023 ESE Guideline

Remarks	2023 ESE guideline		2016 ESE guideline	2017 KES guideline
Category for serum cortisol after 1-mg DST	Recommend: MACS^a: patients without features of overt Cushing’s syndrome with serum cortisol after DST >50 nmol/L (>1.8 μg/dL)^a		Suggest: possible ACS^a: serum cortisol after DST between 51 and 138 nmol/L (1.9–5.0 μg/dL)	Similar to the 2016 ESE guidelines
	Confirm ACTH-independency, repeat DST, consider conditions that alter the results		ACS^a: serum cortisol after DST >138 nmol/L (>5.0 μg/dL)
	Additional biochemical tests to assess the degree of cortisol secretion might be useful^a.		Additional biochemical tests might be required^a.
Treatment for patients with MACS	Recommend^a: discussing surgery with the patient. Consider age, sex, general health, degree and persistence of non-suppressible cortisol after dexamethasone, severity of comorbidities, and patient’s preference. The proposal to perform surgery should be established within an expert MDT^a		Suggest^a: an individualized approach for adrenal surgery. Consider age, degree of cortisol excess, general health, comorbidities, and patient’s preference. In all patients considered for surgery, ACTH-independency of cortisol excess should be confirmed.	NA
Measurement of sex hormone and steroid precursors	Suggest: ideally, use multi-steroid profiling by tandem mass spectrometry^a in patients in whom an adrenocortical carcinoma is suspected.		Suggest^a: in patients with clinical or imaging features suggestive of adrenocortical carcinoma	Recommend^a: all patients suspected of having adrenal cancer.
Benign criteria for no further imaging	Recommend^a: homogeneous appearance and ≤10 HU on non-contrast CT		Suggest^a: homogeneous appearance, smaller than 4 cm and ≤10 HU on non-contrast CT	Homogeneous appearance, smaller than 4 cm^a and ≤10 HU on non-contrast CT+contrast washout in delayed images of contrast CT
Management of indeterminate adrenal nodules	(1) Adrenal mass with unenhanced HU between 11 and 20 and <4 cm^a		Three options^a:	Recommend: follow-up imaging in 3–6 months after the initial study and continuing for 1–2 years^a
		Suggest: immediate additional imaging to avoid any follow-up imaging.	(1) Immediate additional imaging with another modality
		Optional: interval imaging in 12 months by non-contrast CT (or MRI)	(2) Interval imaging in 6 to 12 months (non-contrast CT or MRI)
	(2) Adrenal mass ≥4 cm and unenhanced >20 HU^a		(3) Surgery without further delay.	Consider adrenalectomy^a if the mass enlarges by 1 cm^a or more and/or changes its appearance during observation
		Suggest: MDT, immediate surgery/staging
		Optional: follow-up imaging in 6–12 months
	(3) Adrenal mass ≥4 cm with unenhanced HU 11–20; or <4 cm with unenhanced HU >20; or tumor size <4 cm with heterogeneous appearance
		Suggest: individualized approach in MDT
Surgical treatment	Recommend: surgery by an expert high-volume adrenal surgeon^a in patients suspicious of malignancy		NA	NA
Surgical treatment	Suggest: surgical resection if indeterminate adrenal mass on imaging in children, adolescents, pregnant women and adults <40 years of age^a.		NA	NA
Hormone follow-up of nonfunctioning tumors at initial evaluation	Recommend: against^a repeated hormonal work-up unless new clinical signs of endocrine activity appear or comorbidities worsen		Suggest: against^a repeated hormonal work-up unless new clinical signs of endocrine activity appear or comorbidities worsen	Recommend^a: annual hormone tests for 4–5 years
Follow-up of patients with MACS	Recommend: only annual re-assessment of comorbidities potentially attributable to cortisol.		Suggest: annual clinical re-assessment for comorbidities potentially related to cortisol excess. Based on the outcome of this evaluation the potential benefit of surgery should be considered.	Recommend: annual hormone tests for 4–5 years
Follow-up of patients with MACS	If these comorbidities develop or worsen, referral to an endocrinologist.			Recommend: annual hormone tests for 4–5 years
Approach to bilateral adrenal incidentaloma	Suggest following four-option schema^a (1) bilateral (macronodular) hyperplasia, (2) bilateral adrenal adenomas, (3) two morphologically similar, but non-adenoma-like adrenal masses, (4) two morphologically different adrenal masses.		The same applies to the assessment of comorbidities that might be related to ACS.	Similar to the 2016 ESE guideline
	Bilateral (macronodular) hyperplasia or bilateral adenomas: recommend assessment of comorbidities attributable to MACS^a		Bilateral hyperplasia without ACS: 17-hydroxyprogesterone
	Otherwise, similar to the 2016 ESE guideline		Bilateral metastases, lymphoma, infiltrative inflammatory disease and hemorrhages: recommend assessment for adrenal insufficiency
Treatment for bilateral adrenal incidentaloma	(1) Bilateral hyperplasi^a or bilateral adenomas with MACS: suggest individualized treatment options^a		Suggest^a: the same recommendations for patients with unilateral adrenal incidentalomas	NA
Treatment for bilateral adrenal incidentaloma	(2) Suggest against bilateral adrenalectomy^a in patients without clinical signs of overt Cushing’s syndrome		Suggest that bilateral adrenalectomy is not performed^a without clinical signs of overt Cushing’s syndrome.	NA

Modified from Fassnacht et al. [7].

ESE, European Society of Endocrinology; KES, Korean Endocrine Society; DST, dexamethasone suppression test; MACS, mild autonomous cortisol secretion; ACTH, adrenocorticotropic hormone; ACS, autonomous cortisol secretion; MDT, multidisciplinary team; NA, not available; HU, Hounsfield unit; CT, computed tomography; MRI, magnetic resonance imaging.

Relevant changes.