For patients with Cushing's syndrome and adrenal neoplasms, abdominal CT scanning is almost 100% accurate, and false-negative results in cases of biochemically proven Cushing's syndrome are rare. For these patients, normal adrenal morphologic patterns seen on CT scans suggest adrenal hyperplasia. When CT and MRI findings are nondiagnostic, adrenocortical scintigraphy using iodocholesterols is helpful.

For patients with biochemically proven primary hyperaldosteronism, abdominal CT scanning with contiguous 0.3- to 0.5-cm collimation of the adrenal is the localization procedure of choice. When a unilateral adrenal lesion is identified, no further imaging is necessary. When CT scanning is normal, equivocal, or depicts bilateral adrenal masses, adrenal venous sampling with aldosterone and cortisone testing should be done.

For patients with biochemically proven pheochromocy-tomas, abdominal CT scanning has nearly 100% accuracy. When intravenous contrast enhancement is required, patients must be prepared with a- and P-adrenergic blockade. For patients with negative studies or for patients with recurrent or metastatic disease, MIBG or MRI scanning is helpful. MIBG scanning is also the modality of choice for patients with MEN syndromes.

Incidentaloma discovered by US or CT

History, physical examination, and biochemical test to assess function

FIGURE 66-10. The flowchart shows the diagnostic procedures used in imaging incidentalomas. FNAC = fine-needle aspiration cytology; US = ultrasonography.

Hormone-secreting tumor

For further imaging refer to other algorithms

Hormonally silent tumor

Repeat or review CT

Cyst Adenolipoma Myelolipoma


Carcinoma Known malignancy




Observe Surgery

Incidentalomas are the most common adrenal tumors requiring evaluation by the clinician. Most masses are benign. When CT scanning fails to show a cyst, adenomyelolipoma, or carcinoma, biochemical studies are necessary to determine whether the tumor is functioning. All functioning adrenal tumors and most nonfunctioning adrenal tumors larger than 4 cm in the maximal diameter should be removed, especially if the tumor is heterogeneous and has an irregular contour.


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