Table 2.

Summary of recommendations

	Recommendation	Strength of recommendation	Quality of evidence
1	Workup for an adrenal incidentaloma should include a focused history and physical examination aimed at identifying signs/symptoms of adrenal hormone excess, adrenal malignancy, and/or extra-adrenal malignancy.	Clinical principle
2	There should be a low threshold for a multidisciplinary review by endocrinologists, surgeons, and radiologists when the imaging is not consistent with a benign lesion, there is evidence of hormone hypersecretion, the tumor has grown significantly during followup imaging, or adrenal surgery is being considered.	Clinical principle
3	Patients found to have an indeterminate incidental adrenal mass should undergo a non-contrast CT as first-line imaging to distinguish benign lesions from those that require further radiological investigation.	Strong	Moderate
4	Patients who continue to have an indeterminate adrenal mass on non-contrast CT should undergo second-line imaging with either washout CT or chemical-shift MRI.	Weak	Moderate
5	Adrenal mass biopsy should not be performed routinely for the workup of an adrenal incidentaloma.	Strong	Moderate
6.1	All patients with adrenal incidentalomas should be screened for autonomous cortisol secretion.	Weak	Moderate
6.2	1 mg dexamethasone suppression testing is the preferred screening test for identifying autonomous cortisol secretion when clinically appropriate.	Strong	Moderate
7.1	Patients with adrenal incidentalomas and hypertension and/or hypokalemia should be screened for primary aldosteronism with an aldosterone-to-renin ratio.	Strong	Moderate
7.2	Adrenal vein sampling is recommended prior to offering adrenalectomy in patients with primary aldosteronism.	Strong	Moderate
8.1	We suggest against screening for pheochromocytoma in patients who have unequivocal adrenocortical adenomas confirmed on unenhanced CT (<10 HU) and no signs or symptoms of adrenergic excess.	Weak	Low
8.2	Patients with adrenal incidentalomas that display ≥10 HU on non-contrast CT or who have signs/symptoms of catecholamine excess should be screened for pheochromocytoma with plasma or 24-hour urinary metanephrines.	Strong	Moderate
9	In cases of suspected adrenocortical carcinoma and/or when clinical signs of virilization are present, serum testing of excess androgen testing should be performed.	Clinical principle
10.1	Patients with unilateral cortisol-secreting adrenal masses and clinically apparent Cushing’s syndrome should undergo unilateral adrenalectomy of the affected adrenal gland. Minimally invasive surgery should be performed when feasible for these procedures.	Clinical principle
10.2	Younger patients with mild autonomous cortisol secretion who have progressive metabolic comorbidities attributable to cortisol excess can be considered for adrenalectomy after shared decision-making. Patients not managed surgically should undergo annual clinical screening for new or worsening associated comorbidities.	Weak	Low
11	Adrenalectomy should be performed for patients with unilateral aldosterone-secreting adrenal masses and pheochromocytomas. Minimally invasive surgery should be performed when feasible for these procedures.	Clinical principle
12.1	Minimally invasive adrenalectomy can be offered to patients with suspected adrenocortical carcinomas that can be safely resected without rupturing the tumor capsule.	Weak	Low
12.2	Open adrenalectomy should be considered for patients with larger adrenocortical carcinomas or those presenting with locally advanced tumors, lymph node metastases, or tumor thrombus in the renal vein/inferior vena cava.	Strong	Low
13	Patients with benign non-functioning adenomas <4 cm, myelolipomas, and other small masses containing macroscopic fat detected on the initial workup for an adrenal incidentaloma do not require further followup imaging or functional testing.	Strong	Moderate
14.1	Patients with non-functioning adrenal lesions that are radiologically benign (<10 HU) but >4 cm should undergo repeat imaging in 6–12 months	Weak	Low
14.2	Adrenalectomy should be considered for patients with adrenal incidentalomas growing >5 mm/year after repeating a functional workup.	Weak	Low
14.3	No further imaging followup or functional testing is required for patients with adrenal lesions that grow <3 mm/year on followup imaging.	Weak	Low
15	Shared decision-making between patients and their clinicians should be used for the management of indeterminate non-functioning adrenal lesions. Management options include repeat imaging in 3–6 months vs. surgical resection.	Clinical principle

CT: computed tomography.