French AFU Cancer Committee Guidelines – Update 2024–2026 : Assessment of an adrenal incidentaloma and oncological management

The aim of this publication is to review the initial management procedure for adrenal incidentalomas, and where appropriate, to establish a carcinological management procedure for malignant adrenal tumours. The multidisciplinary working group updated the CCAFU 2022 recommendations for the carcinological management of adrenal incidentalomas on the basis of a comprehensive PubMed review of the literature. Although the majority of adrenal masses are benign and nonfunctional, it is important to investigate them because of their serious endocrine potential, and because of certain cancers. Malignant adrenal tumours (MCTs) are essentially adrenocortical carcinomas (ACCs), malignant pheochromocytomas (MPCs), and adrenal metastases (AMs). The work-up for the malignancy of an adrenal incidentaloma includes a full history, physical examination, and a biochemical/hormonal assessment to look for subclinical hormone secretion. Diagnostic hypotheses are sometimes available at this stage, but morphological and functional imaging and histological analysis enable the malignancy assessment to be completed, and a carcinological diagnosis to be made. SCC and MCC are mostly sporadic, but a hereditary origin is always possible. SCC is suspected preoperatively, but a diagnosis of certainty is histological. The diagnosis of PCM is more delicate and is based on clinical, biological, and imaging findings. The definitive diagnosis of MS requires a percutaneous biopsy. All cases must then be discussed within the COMETE adrenal cancer network.