Challenges in Differentiating Adrenal Incidentalomas

Introduction Adrenal incidentaloma is endocrine diagnosis at times requiring a multidisciplinary approach. Each case demands a personalized evaluation based on imaging, hormone testing, clinical symptoms. Adrenal adenomas make up 54% to 75% of incidentalomas, bringing challenges with the diagnosis and management of autonomous cortisol secretion [1, 2]. Case Presentation A 67 year old man was referred for endocrinologist consultation in 2024 due to bilateral adrenal masses >5 cm, first identified on a chest CT in 2022 possibly related to trauma the patient experienced in 2021. The patient was feeling well, no signs of adrenals hyperactivity. Lab tests revealed elevated chromogranin A (217.54 µg/l), nephrines levels (MN 0.63 nmol/l; NMN 1.53 nnmol/l), increased cortisol in 24-hour urine (428.80 nmol/24h) and saliva (3.05 nmol/l), DST was pathological, but normal ACTH, aldosterone, renin. Aldosterone-to-renin ratio was 20.1. The patient was discussed at the Adrenal Diseases MDT, at first where it was noted that the adrenal masses had grown and showed signs of malignancy. A subsequent PET/CT scan showed metabolically inactive masses, biopsy revealed fibrin and red blood cells, suggesting hemorrhagic adenoma. Repeated chromogranin A and CEA were normal. The MDT after repeated MRI concluded that the masses are adenomas with haemorrhagic features. Summarizing the adrenal hormone tests, the data points to autonomous cortisol secretion. An endocrinology consultation and follow-up MRI were recommended after 1 y. Observation was chosen as no other conditions associated with hypercortisolism were identified, and there were no indications for surgical treatment. Discussion It is recommended that an imaging procedure, hormones check-up should be performed at the time of initial incidentaloma detection [3,4]. Patients with autonomous cortisol secretion have a higher incidence of cortisolrelated comorbidities such as hypertension, obesity, glucose intolerance or type 2 diabetes mellitus, dyslipidaemia, therefore, careful examination and monitoring is necessary [5]. On rare occasions, cortisol-producing adrenal adenomas and pheochromocytomas occur simultaneously [6]. Conclusions This case highlights the challenges in differentiating and managing adrenal incidentalomas with haemorrhagic features when autonomous cortisol secretion is present.