Predicting Biochemical Activity in Incidentally Discovered Adrenal Masses

incompletely understood.Prior studies have suggested that certain clinical and radiographic features-such as tumor size >3 cm, longstanding hypertension, and Hounsfield units (HU) <10-may be associated with hyperfunctional tumors. 6 -8 Conversely, nonfunctioning adrenal lesions have been linked to older age and the presence of metabolic syndrome. 9However, these associations are not well established, and their predictive accuracy remains limited. IntroductIonThe prevalence of incidentally discovered adrenal masses commonly referred to as adrenal incidentalomas has increased nearly tenfold over the past two decades.This rise is largely attributed to advances in imaging technology and the growing use of cross-sectional imaging modalities such as computed tomography (CT) and magnetic resonance imaging (MRI). 1 An adrenal incidentaloma is defined as an adrenal mass identified incidentally during imaging performed for reasons unrelated to suspected adrenal disease. 2 These lesions are detected in approximately 1-10% of the population, with prevalence increasing with age. 3 Most adrenal incidentalomas are benign and nonfunctional, requiring no further intervention.However, hyperfunctional adrenal tumors-those associated with autonomous hormone secretion-are identified in up to 20% of cases. 3Current guidelines recommend an initial evaluation with imaging to assess for radiographic features concerning for malignancy, followed by biochemical testing to screen for hormone excess.This typically includes serum or urinary assays for cortisol, catecholamines, or metanephrines, and plasma aldosterone with renin activity to evaluate for Cushing's syndrome, pheochromocytoma, and primary hyperaldosteronism, respectively. 4,5espite standardized diagnostic pathways, the factors that predict hormonal activity in adrenal incidentalomas remain