General remarks

Assessment of the risk of malignancy

Assessment for hormone excess

Surgical treatment

Follow-up of patients not undergoing adrenal surgery after initial assessment

Special circumstances

Document Overview

Design and created by Guideline Central in participation with the European Society of Endocrinology.

Management of Adrenal Incidentalomas

European Society of Endocrinology

Publication Date: Jun 15, 2023

Page Last Updated: May 5, 2026

GRADE Classification of Guideline Recommendations, Strength of Recommendation Classifications and Interpretation

GRADE Classification of Guideline Recommendations

Certainty of Evidence	Interpretation
High ⊕⊕⊕⊕	We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate ⊕⊕⊕o	We are moderately confident in the effect estimate; the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low ⊕⊕oo	Our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of the effect.
Very Low ⊕ooo	We have very little confidence in the effect estimate; the true effect is likely to be substantially different from the estimate of effect.

Reprinted from Eds. Schünemann H, Brożek J, Guyatt G, and Oxman A. GRADE Handbook: Handbook for grading the quality of evidence and the strength of recommendations using the GRADE approach. Updated October 2013.

GRADE Strength of Recommendation Classifications and Interpretation

Strength of recommendation	Criteria	Interpretation by patients	Interpretation by health care providers	Interpretation by policy makers
1 – Strong recommendation for or against	Desirable consequences CLEARLY OUTWEIGH the undesirable consequences in most settings (or vice versa).	Most individuals in this situation would want the recommended course of action, and only a small proportion would not.	Most individuals should receive the recommended course of action. Adherence to this recommendation according to the guidelines could be used as a quality criterion or performance indicator. Formal decision aids are not likely to be needed to help individuals make decisions consistent with their values and preferences.	The recommendation can be adopted as policy in most situations.
2 – Conditional recommendation for or against	Desirable consequences PROBABLY OUTWEIGH undesirable consequences in most settings (or vice versa).	The majority of individuals in this situation would want the suggested course of action, but many would not.	Clinicians should recognize that different choices will be appropriate for each individual and that clinicians must help each individual arrive at a management decision consistent with the individual’s values and preferences. Decision aids may be useful to help individuals make decisions consistent with their values and preferences.	Policy-making will require substantial debate and involvement of various stakeholders.

Adapted from Schünemann HJ et al. Blood Adv, 2018; 2(22) © by The American Society of Hematology.

Document Overview

Document Title: Management of Adrenal Incidentalomas

Authoring Society: European Society of Endocrinology

Document Publication Date: Jun 15, 2023

Page Last Reviewed/Updated: May 5, 2026

Document Type: Guideline

Country of Publication: European

Full Text Freely Available: Yes

Full Text Guideline: academic.oup.com/ejendo/article/189/1/G1/7198474

Source Citation: Martin Fassnacht and others, 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, European Journal of Endocrinology, Volume 189, Issue 1, July 2023, Pages G1–G42, https://doi.org/10.1093/ejendo/lvad066

Supplemental Implementation Resources

Slide Set

Document Scope, Criteria, and Use Cases

Document Objectives: Adrenal incidentalomas are adrenal masses detected on imaging performed for reasons other than suspected adrenal disease. In most cases, adrenal incidentalomas are nonfunctioning adrenocortical adenomas but may also require therapeutic intervention including that for adrenocortical carcinoma, pheochromocytoma, hormone-producing adenoma, or metastases. Here, we provide a revision of the first international, interdisciplinary guidelines on incidentalomas. We followed the Grading of Recommendations Assessment, Development and Evaluation system and updated systematic reviews on 4 predefined clinical questions crucial for the management of incidentalomas: (1) How to assess risk of malignancy?; (2) How to define and manage mild autonomous cortisol secretion?; (3) Who should have surgical treatment and how should it be performed?; and (4) What follow-up is indicated if the adrenal incidentaloma is not surgically removed?

Scope: Assessment and Screening, Diagnosis, Management, Treatment

Keywords: Adrenal Incidentalomas

Inclusion Criteria: Male, Female, Adolescent, Adult, Child, Older Adult

Health Care Settings: Ambulatory, Operating and Recovery Room, Outpatient

Intended Users: Nurse, Nurse Practitioner, Physician, Physician Assistant

Recommendation Development Processes & Methodology

Number of Source Documents: 291

Literature Search End Date: Sunday, July 31, 2022

Includes peer/external review process?: Yes

Includes public comment process?: No

Methodologist involvement?: Yes

Patient involvement?: No

Includes multi-disciplinary group?: Yes

Includes systematic review?: Yes

Grades quality of strength of evidence?: Yes

Grades quality of strength of recommendation?: Yes

Discloses funding source?: Yes

Discloses conflicts of interest?: Yes

Includes benefits/harms analysis with recommendations?: Yes

Management of Adrenal Incidentalomas

General remarks

R.1.1

Figure 4

Figure 5

Figure 6

Figure 7

Figure 9

Assessment of the risk of malignancy

R.2.1

R.2.2

R.2.3

R.2.4

R.2.5

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R.2.8

Figure 1. Diagnostic performance of unenhanced CT in adrenal incidentaloma

Figure 2. Diagnostic performance of FDG-PET/CT in adrenal incidentaloma

Figure 3. Morbidity in patients with mild autonomous cortisol secretion (MACS)

Assessment for hormone excess

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Surgical treatment

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Follow-up of patients not undergoing adrenal surgery after initial assessment

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Special circumstances

Patients with bilateral adrenal incidentalomas

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Adrenal incidentalomas in young or elderly patients

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Patients with newly diagnosed adrenal mass and a history of extra-adrenal malignancy

R.6.3.1

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R.6.3.5

R.6.3.6

GRADE Classification of Guideline Recommendations, Strength of Recommendation Classifications and Interpretation

GRADE Classification of Guideline Recommendations

GRADE Strength of Recommendation Classifications and Interpretation

Document Overview

Supplemental Implementation Resources

Document Scope, Criteria, and Use Cases

Recommendation Development Processes & Methodology