Clinical Review: The Approach to the Evaluation and Management of Bilateral Adrenal Masses

This white paper provides practical guidance for clinicians encountering bilateral adrenal masses. Bilateral adrenal masses represent approximately 10-20% of incidentally discovered adrenal masses. The differential diagnosis and the approach to managing patients with bilateral adrenal masses are reviewed through a case-based approach and recommendations are given based on clinical guidelines. •Evaluating bilateral adrenal masses includes individual assessment of the imaging phenotype of the adrenal lesions to determine whether each one is benign, malignant, or indeterminate. •The patient's history, examination, and hormone assessment should focus on the signs and symptoms of malignancy, hormone excess, and, if indicated, adrenal insufficiency, as well as inherited syndromes or comorbidities that may be related to an adrenal lesion. •Most primary bilateral adrenal masses are benign - mainly bilateral adrenocortical adenomas (∼75%) and primary bilateral macronodular adrenal hyperplasia (∼13%). •Bilateral adrenal masses more commonly demonstrate hormone excess, most often from mild autonomous cortisol secretion, (in primary bilateral macronodular adrenal hyperplasia or adrenocortical adenomas) compared to solitary adrenal masses. •Primary adrenal insufficiency may occur with bilateral adrenal metastases, infiltrative disease or infection, or adrenal hemorrhage or infarction.