• Frederick-Anthony Farrugia, Evangelos Misiakos, Georgios Martikos, Panagiotis Tzanetis, Anestis Charalampopoulos, Nicolaos Zavras, Dimitrios Sotiropoulos, and Nikolaos Koliakos.
• Private practice.
• Rom J Intern Med. 2017 Dec 1; 55 (4): 188-197.

ObjectivesTo present a step by step approach for the diagnosis of adrenal incidentaloma (AI).MethodAn extensive review of the literature was conducted, searching the Pub-Med and Google Scholar using the Mesh terms; Adrenal; Incidentaloma; Adrenal tumours; Radiology; Diagnosis. We also did a cross-referencing search of the literature. Comments on the new European guidelines are presented.ResultsThe majority of the tumours are non-functioning benign adenomas. The most important radiological characteristic of an adrenal incidentaloma is the radiation attenuation coefficient. Wash out percentage and the imaging characteristics of the tumour may help in diagnosis.ConclusionDensity less than 10 HU is in most cases characteristic of a lipid rich benign adenoma. More than 10 HU or/and history of malignancy raise the possibility for cancer. 1 mg dexamethasone test and plasma metanephrines should be done in all patients. If there is history of hypokalemia and/or resistant hypertension we test the plasma aldosterone to plasma renin ratio (ARR). Newer studies have shown that tumours even nonfunctioning and less than 4 cm may increase the metabolic risks so we may consider surgery at an earlier stage.

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