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Incidental Adrenal Mass Evaluation (ACR)

Incidental Adrenal Mass Evaluation (ACR): Incidental Adrenal Mass → Known Primary Malignancy? → Staging Workup.

Interactive Decision Tree

Mini Map

Algorithm Steps

  1. ▶
    Start

    Incidental Adrenal Mass

    Discovered on CT/MRI for unrelated indication

    1. ◆
      Decision

      Known Primary Malignancy?

      • Yes - staging workup
      • No - characterize
      1. ●
        Action

        Staging Workup

        PET/CT, consider biopsy for treatment planning

      2. ◆
        Decision

        CT Attenuation (Unenhanced)?

        • ≤10 HU (lipid-rich)
        • 10-30 HU
        • >30 HU
        1. ●
          Action

          Likely Benign Adenoma

          ≤10 HU highly specific for lipid-rich adenoma

          1. ◆
            Decision

            Size Assessment

            • <4cm - observe
            • ≥4cm - surgery consult
            1. ■
              End

              Annual Imaging x 1-2 Years

              Consider biochemical workup

            2. ■
              End

              Consider Adrenalectomy

              If growth or hormonal symptoms

        2. ●
          Action

          Washout CT or MRI

          APW >60% or RPW >40% suggests adenoma

          1. ●
            Action

            PET/CT or Biopsy

            PET if known malignancy; biopsy if isolated

        3. ●
          Action

          Suspicious Features

          >30 HU, no washout, irregular margins

Guideline Source

ACR Appropriateness Criteria: Incidentally Discovered Adrenal Mass

DOI: 10.1016/j.jacr.2017.02.016View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Does not address functional tumors in detail
  • Biochemical workup recommendations vary by institution
  • Size thresholds may differ internationally

Applicable Regions

USAUUKEU

EU: ENSAT guidelines with emphasis on functional screening

US: Endocrine Society recommends biochemical screen for all

Version 1Next review: 2028-01-01

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Frequently Asked Questions

What is the Incidental Adrenal Mass Evaluation (ACR)?

The Incidental Adrenal Mass Evaluation (ACR) is a diagnostic clinical algorithm for Radiology. It provides a structured decision tree to guide clinical decision-making, based on ACR Appropriateness Criteria: Incidentally Discovered Adrenal Mass.

What guideline is the Incidental Adrenal Mass Evaluation (ACR) based on?

This algorithm is based on ACR Appropriateness Criteria: Incidentally Discovered Adrenal Mass (DOI: 10.1016/j.jacr.2017.02.016).

What are the limitations of the Incidental Adrenal Mass Evaluation (ACR)?

Known limitations include: Does not address functional tumors in detail; Biochemical workup recommendations vary by institution; Size thresholds may differ internationally. Individual patient factors may require deviation from these recommendations.

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