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American Journal of  Medical 
Science and Innovation (AJMSI) 

Adrenal Incidentaloma Prevalence and Clinical Management- A Retrospective Study
Waleed Abdalrazig Dosogi Elzain1*, Abdullah Mohammed Alshalaan1, Mohammed Mana Mohammed Al Qahtani1

Hind Ali Abdullah Al Qahtani1, Dawlah Hadi Assiri1, Halimah Hussain Alshehri1, Eman Mohammed Alsultan1

Fahad Obaid Mohammed Alnamshah1, Mohammed Abdullah Salem Alshehri1

Volume 3 Issue 1, Year 2024
ISSN: 2836-8509 (Online)

DOI: https://doi.org/10.54536/ajmsi.v3i1.2332
https://journals.e-palli.com/home/index.php/ajmsi

Article Information ABSTRACT

Received: December 17, 2023
Accepted: January 22, 2024
Published: January 24, 2024

This study aims to investigate the characteristics and prevalence of  adrenal incidentalomas 
and subsequent clinical practice among patients in Armed Forces Hospital Southern Region 
-Saudi Arabia, 2021. An observational retrospective study was conducted in Armed Forces 
Hospital Southern Region -Saudi Arabia on the medical records of  383 consecutive patients. 
Patients with incidental adrenal tumors who underwent abdominal CT scans with intravenous 
contrast during the period from January 2013 and December 2021. A total of  300 patients 
were included in this study.  However, the data were analyzed using statistical tests. The 
results revealed that most patients with adrenal incidentalomas were above 60 (53.3%%). The 
gender distribution was nearly equal, with 50.3% females and 49.7% males. Most observed 
tumors were unilateral (96.0%), while a small percentage was bilateral (4.0%). In terms of  
size, the majority were less than 1 cm (59.0%), followed by sizes greater than 4 cm (31.0%) 
and 1-4 cm (10.0%). Further analysis indicated that 49.3% were found to have functioning 
tumors, while 50.7% had non-functioning tumors. The specific types of  functioning tumors 
included non-functioning adrenal adenoma (50.7%), pheochromocytoma (16.9%), Cushing’s 
syndrome (5.8%), and other functional tumor types (28.0%). Most of  these patients were 
not referred to endocrine clinics. Adrenal incidentalomas are prevalent in the above-60 age 
group, with most tumors being non-functional. Further research into adrenal incidentalomas 
associated with diabetes and hypertension is required.

Keywords
Adrenal Incidentaloma, Adrenal 
Gland, Cushing’s Syndrome, 
Diagnosis, Imaging, Surgery, 
Tumor

1 Armed Forces Hospital, Southern Region KSA, Tamniah, Saudi Arabia
* Corresponding author’s e-mail: Waleeddosogi@yahoo.com

INTRODUCTION
An Adrenal Incidentalomas (AIs) is an unexpected tumor 
in one or both adrenal glands. These tumors can be benign 
(non-cancerous) or malignant (cancerous) (Nieman et al., 
2013; Terzolo et al., 2011). These include adrenal cysts, 
hematomas, adrenal cortical carcinomas, adenomas, 
pheochromocytomas, myelolipomas, ganglioneuromas, 
metastases from various cancers, and other rare forms 
(Grumbach et al., 2003). An AIs describes detecting an 
adrenal asymptomatic mass or tumor during imaging 
examinations such as Computed Tomography (CT) 
scans or Magnetic Resonance Imaging (MRIs) used for 
unrelated purposes (Francis & Mayo-Smith, 2023; Jason 
& Oltmann, 2019). Usually, these tumors are identified in 
people without symptoms or indicators associated with 
the adrenal gland. Abdominal CT scan has been widely 
used since the late 1970s and has proven highly effective 
in detecting adrenal pathology in individuals suspected of  
having adrenal disease. It is a valuable diagnostic tool for 
identifying abnormalities in the adrenal glands (Chatzellis 
& Kaltsas, 2019; Kim et al., 2013). Furthermore, the first 
laparoscopic adrenalectomy was reported by Michel 
Gagner in 1992, marking a significant milestone in the 
field. This minimally invasive surgical technique quickly 
became the preferred approach for treating benign 
adrenal diseases (Serra, 2023).
The adrenal glands or suprarenal glands are small 
endocrine glands in each kidney. Despite their small size, 
these glands play a crucial role in hormonal regulation 

(Kebebew, 2021). Each adrenal gland is divided into two 
main parts: the adrenal cortex (outer cortex) and the 
adrenal medulla (inner medulla), which have different 
functions and produce distinct hormones (Van Slycke 
et al., 2022). These glands synthesize several necessary 
hormones, such as cortisol, aldosterone, and adrenaline. 
The hormones are essential for maintaining homeostasis, 
responding to stress, regulating metabolism, and 
influencing various bodily functions. Any dysfunction or 
abnormalities in the adrenal glands can lead to hormonal 
imbalances and various health conditions (Lyraki & 
Schedl, 2021). Most adrenal incidentalomas are non-
functioning, meaning they do not generate abnormally 
high levels of  hormones and manifest as symptoms 
(Francis & Mayo-Smith, 2023). In many cases, adrenal 
incidentalomas do not cause symptoms and are non-
functioning. However, some adrenal incidentalomas may 
exhibit certain symptoms and characteristics (Imbroll et 
al., 2020; Kim et al., 2013).

LITERATURE REVIEW
Adrenal Incidentalomas Symptoms
Adrenal incidentalomas often do not cause specific 
symptoms directly related to the adrenal gland (Jabarkhel, 
2019). However, if  the mass is large or functioning, it can 
cause symptoms related to hormone overproduction or 
local compression of  nearby structures. These symptoms 
may include: Hypertension (high blood pressure), 
excessive sweating, unexplained weight gain or weight 



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loss, palpitations or rapid heart rate, anxiety or panic 
attacks, abdominal or back pain (if  the mass is large 
and causing compression), changes in menstrual cycles 
(in women), muscle weakness, and sleep disturbances 
(Nieman et al., 2013). Moreover, the characteristics of  
adrenal incidentalomas can be assessed through imaging 
studies, such as CT scans or MRI (Yilmaz et al., 2021). 

Prevalence of  AIs
The prevalence of  adrenal incidentalomas has increased 
with the widespread use of  imaging techniques (Ichijo 
et al., 2020). These masses are often benign, but a small 
percentage can be cancerous. Therefore, when an adrenal 
incidentaloma is detected, further evaluation is necessary 
to determine its nature and potential impact on health 
(Sconfienza et al., 2023). Due to limited population-based 
research, determining AI’s exact prevalence and incidence 
is challenging. The available data primarily comes from 
retrospective postmortem and radiological investigations, 
which lack comprehensive clinical information, may be 
biased in referrals, and involve varying patient selection 
criteria (Chatzellis & Kaltsas, 2019). The prevalence of  
adrenal incidentalomas in the general population ranges 
from approximately 1% to 6%, with the incidence 
increasing with age (Kebebew, 2021). While these masses 
are rare in childhood, they affect around 3% of  individuals 
over 50 and over 7% of  those over 70 (Jackson, 2023; Jing 
et al., 2022) and even less frequently in individuals who are 
under 40 years old (Sherlock et al., 2020). 

Adrenal Incidentalomas Insights
In 2018, a significant number of  CT and MRI scans 
were performed, with 6 million CT scans and 3.8 million 
MRI scans (in any anatomical region) reported by the 
National Health Service (NHS) Diagnostic Imaging 
Datasets (Cuthbertson et al., 2023; Kebebew, 2021). 
Most adrenal incidentalomas are benign, but about 2% 
represent primary adrenal malignancies. Morphological 
and functional status are the 2 key issues with an 
adrenal incidentaloma. AIs are often benign adenomas 
with a malignancy incidence of  between 1.9% and 
4.7% (Fassnacht et al., 2016). The majority of  adrenal 
incidentalomas (80%) are nonfunctioning adenomas. 
Autonomous cortisol secretion is the primary cause of  
adrenal hypersecretion, which accounts for 1%–29% 
of  cases. Pheochromocytomas account for 1.5%–14% 
of  cases, and aldosterone-secreting tumors account for 
1.6%–3.3% of  cases (Jackson, 2023). 

Key Considerations in Managing AIs
Adrenal incidentaloma (AI) is a hormonally functional 
or malignant tumor, (Griffing, 2022) with 14% being 
functional tumors secreting excessive hormone levels 
(Bancos & Prete, 2021). The diagnosis and treatment of  
AI are significantly influenced by their size (Aron et al., 
2012) with adrenal masses less than 1 cm considered not 
real AI unless there are clinical symptoms of  increased 
adrenal hormone production. (Terzolo et al., 2011). The 

National Institute of  Health (NIH) consensus in 2002 
categorized adrenal tumors into low risk, uncertain, and 
high risk (Şenoğlu et al., 2022). Moreover, ;arger than 6 cm 
tumors are generally considered surgically indicated due to 
the increased risk of  malignancy (Zeiger et al., 2011). The 
decision regarding surgical intervention is individualized 
for those measuring 4-6 cm, considering factors such 
as the patient’s overall health, symptoms, radiological 
characteristics, and the likelihood of  malignancy 
(Jackson, 2023; Kahramangil et al., 2022).  Techniques 
like laparoscopic or retroperitoneoscopic adrenalectomy 
are commonly employed, offering advantages like smaller 
incisions, reduced postoperative pain, shorter hospital 
stays, and faster recovery compared to traditional open 
surgery (Sada & McKenzie, 2023; Sancho et al., 2012).
Therefore, this study aims to identify the prevalence of  
adrenal incidentaloma and subsequent clinical practice 
among 383 consecutive patients in Armed Forces 
Hospital. 

MATERIALS AND METHODS
Study Design
An observational and retrospective study approach was 
employed. 

Ethical Approval 
Approval for the study was granted by the research ethics 
committee of  Armed Forces Hospital Southern Region, 
Saudi Arabia (AFHSRMREC/2022/INTERNAL 
MEDICINE/636). A written informed consent form 
from each participant was obtained. Moreover, the study 
was carried out in conformity with the 1964 Declaration 
of  Helsinki and any subsequent revisions, or with 
comparable ethical standards.

Study Setting and Period
The study was conducted in Armed Forces Hospital 
Southern Region - Saudi Arabia, during the period from 
January 2013 and December 2021.

Study Sample and Population Size
The study examined the medical records of  383 
consecutive adult patients who had undergone abdominal 
CT scans with intravenous contrast at the Armed 
Forces Hospital Southern Region in Saudi Arabia. The 
researchers specifically focused on patients who were 
found to have adrenal incidentalomas during the study 
period, resulting in a total of  300 patients included in the 
study. 

Inclusion and Exclusion Criteria
The study’s inclusion criteria encompassed male and 
female adult patients aged 18 years or older who had 
undergone abdominal CT scans with intravenous contrast 
and were diagnosed with adrenal incidentalomas. The 
exclusion criteria depend on benign lesions, additional 
diagnostic workup, diagnostic clarity, urgent need for 
intervention, patient age, incomplete data, ethical or 



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legal considerations, radiological characteristics and other 
medical conditions. A total of  83 patients were excluded 
from the study who did not meet inclusion criteria.

Data Collection
The primary researchers used specific sampling methods 
to gather data from human participants, including 
recruitment, inclusion/exclusion criteria, and selection, 
while considering potential risks and benefits.

Data Analysis
The study used SPSS 25.0 version for data analysis, 
utilizing descriptive statistics and bivariate analysis to 
determine associations between outcome variables and 
influencing factors. Categorical variables were analyzed 
using the Chi-square test, while quantitative variables 
were analyzed using the t-test. A p-value of  0.05 or less 
was considered statistically significant.

RESULTS
The results section displays data analysis and statistical 
interpretations based on sampling methods and collected 
data. Frequencies and percentages were used for statistical 
analysis. The demographic characteristics of  participants 
are shown in Table 1. The adenoma discovery and 
referral correlation are represented in Table 2 and Table 
3, respectively. 
Table 1 shows that out of  the 300 patients with incidental 
adrenal tumors, 53.3% were above 60 years, 30% were 

between 41 and 60 years, and 16.7% were between 20 
and 40 years. Among the patients, 50.3% were females, 
and 49.7% were males, resulting in an almost equal 
male-to-female ratio (1:1). The majority of  the patients, 
96.3%, were of  Saudi nationality.  Non-Saudi patients 
represented a smaller proportion, comprising only 3.7% 
(11 patients) of  the total population.
Figure 1 presents information on patients’ frequency 
and percentage distribution based on three demographic 
factors: age, gender, and nationality. A total of  300 
patients were included in the analysis.
Table 2 shows adrenal incidentalomas characteristics 
in a population of  300 patients. Most were unilateral, 
with 59.0% measuring less than 1 cm. The remaining 
31.0% had tumors larger than 4 cm. Functioning tumors 
associated with hormonal secretion were 49.3%, while 
non-functioning tumors did not produce hormones.
Table 3 shows a significant association between referral 
to endocrine clinic, requesting doctor, and abdominal CT 
utilization, with a correlation between requesting doctors 
and endocrinologist referrals.
Figure 2 shows that 44.0% of  abdominal CT scan requests 
were made by Endocrinologists, with the remaining 
56.0% made by other doctors, involving 300 patients.
Figure 3 demonstrates the distribution of  unilateral 
and bilateral cases among the patients with adrenal 
incidentalomas. According to the data, 96.0% of  the 
cases were unilateral, while only 4.0% were bilateral.
Figure 4 displays the distribution of  adrenal incidentalomas 

Table 1: The demographic data of  the patients with incidentaloma 
Factors Frequency Percent
Age 20 - 40 years 50 16.7%

41 - 60 years 90 30.0%
Above 60 years 160 53.3%

Gender Male 149 49.7%
Female 151 50.3%

Nationality Saudi 289 96.3%
Non - Saudi 11 3.7%

Figure 1: The demographic data of  the patients with incidentaloma



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Table 3: The correlation between the referral to the endocrine clinic with the requesting doctor and abdominal CT 
using the chi-square test

Refer to the Endocrine clinic Total P value
Yes No

Requesting doctor Endocrinologist 115 17 132 0.00*
50.0% 24.3% 44%

Others 115 53 168
50.0% 75.7% 56%

Abdominal CT Unilateral 230 66 296 0.382
100.0% 94.3% 98.7%

Bilateral 0 4 4
0.0% 5.7% 1.3%

*Significant correlation

Figure 2: The frequencies of  the specialty of  requesting 
a doctor of  CT

Figure 3: The distribution of  the findings of  adrenal 
incidentaloma in abdominal CT

Figure 4: The frequencies of  the lesion size in abdominal CT 

Table 2: The finding of  incidental adenoma from abdominal CT and further workup
Frequency Percent

Site Unilateral 288 96.0%
Bilateral 12 4.0%

Size < 1 cm 177 59.0%
1 – 4 cm 30 10.0%
>4 cm 93 31.0%

Activity Functioning 148 49.3%
Non-functioning 152 50.7%



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based on their sizes. According to the data, 59.0% of  the 
incidentalomas were smaller than 1 cm, 31.0% were larger 
than 4 cm, and 10.0% measured between 1-4 cm.
Figure 5 shows that 50.0% of  patients with adrenal 
incidentalomas were referred for further evaluation or 
management, while 24.3% were not referred.
Figure 6 shows that 50.0% of  patients with adrenal 
incidentalomas were referred to others for further 
evaluation or management, while 75.7% were not referred.
Figure 7 shows that 30.2% of  patients with adrenal 

incidentalomas underwent additional investigations, while 
69.8% did not undergo further work-up.
Figure 8 shows patients with adrenal incidentalomas, with 
49.3% having functioning tumors and 50.7% having non-
functioning ones, after additional investigations.
Figure 9 shows that out of  18 patients with available 
findings, 50.7% had non-functioning adrenal adenoma, 
16.9% had pheochromocytoma, 5.8% had Cushing’s 
syndrome, and 28.0% had other functional adrenal 
tumors.

Figure 5: The distribution of  the patients according to the referral to an endocrinologist after the incidental finding 
in abdominal CT

Figure 6: The distribution of  the patients according to the requesting doctors to others after the incidental finding 
in abdominal CT

Figure 7: The distribution of  the patients according to 
the further workup for the patients after the incidental 
finding in abdominal CT 

Figure 8: The distribution of  the patients according to 
the findings of  further workup



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DISCUSSION
An adrenal incidentaloma is an adrenal lesion incidentally 
detected during a radiological examination for reasons 
unrelated to suspected adrenal disease (Rowe et al., 
2023; Shaikh et al., 2023; Zeiger et al., 2011). Moreover, 
the evaluation of  adrenal incidentaloma can be done 
by medical history, review of  the patient’s symptoms, 
physical examination, body weight, pulse rate, blood 
pressure, genetic tests, and blood or urine testing to 
measure hormone levels and rule out pheochromocytoma 
(Nieman et al., 2013). 
The present study examined 300 patients who underwent 
abdominal CT scans at the Armed Forces Hospital 
Southern Region in Saudi Arabia to determine the 
prevalence and features of  incidental adrenal tumors. 
The results showed that age significantly influences the 
formation of  these tumors, with an increased prevalence 
observed in older age groups. The ratio of  male to female 
cancers was almost equal, indicating no gender difference 
in the incidence. The majority of  patients were Saudi 
nationals, possibly due to the demographic characteristics 
of  the population or the unique healthcare setting. 
Unilateral tumors were more prevalent than bilateral 
ones, and most were small, measuring less than 1 cm. 
A significant number of  tumors were non-functional, 
while a smaller portion secreted hormones. The study 
also found a significant correlation between the doctor’s 
request and the patient’s referral to the endocrine clinic. 
These findings can help in clinical decision-making and 
patient care.
Moreover, Secreting syndromes can be diagnosed using 
various criteria, including Cushing’s syndrome, primary 
aldosteronism, pheochromocytoma, and androgen or 
estrogen excess. Cushing’s syndrome is diagnosed by 
elevated cortisol levels, confirmed by UFC measurements 
and salivary cortisol testing. Primary aldosteronism 
involves tests like the aldosterone-to-renin ratio (ARR) 
test, saline infusion test, captopril challenge test, and 
confirmatory salt-loading test. Pheochromocytoma 
is diagnosed by measurements of  plasma or urinary 

metanephrines or catecholamines, with imaging studies 
like CT or MRI scans.
Adrenal gland disorders can be caused by various factors, 
including excessive hormone production, leading to 
functional tumors (Yilmaz et al., 2021) like Cushing’s 
syndrome, hyperaldosteronism, pheochromocytoma, 
congenital adrenal hyperplasia, and adrenal gland cancer 
(Terzolo et al., 2012). Conversely, non-functional tumors, 
such as adenomas, cysts, and less common conditions like 
fatty or blood cell tumors, can result from these conditions. 
It’s crucial to differentiate between hormonally active and 
non-functional tumors for better diagnosis and treatment 
(Nieman et al., 2013).
Diabetes and hypertension are associated with adrenal 
incidentalomas, non-functional tumors that do not 
produce hormones (Reimondo et al., 2020). Some of  
them produce cortisol, which causes increased cortisol 
levels that might result in hypertension (Szychlińska et al., 
2023). Adrenal incidentalomas that produce aldosterone 
can cause primary aldosteronism, leading to hypertension 
(Hiraishi et al., 2011; Vilela & Almeida, 2017). Severe 
hypertension can be caused by pheochromocytomas, 
which produce too much noradrenaline and adrenaline 
(Zuber et al., 2011). Adrenal incidentalomas and diabetes 
possess a less direct link than they do with hypertension. 
Adrenal tumors can occasionally impact how the body 
processes glucose (Higgs et al., 2022; Muscogiuri et al., 
2011). For example, cortisol-producing tumors can cause 
insulin resistance, which in certain people can progress 
to type 2 diabetes (Higgs et al., 2022; Sydney et al., 2019). 
However, not all incidentalomas of  the adrenal gland are 
linked to either diabetes or hypertension. Patients with 
adrenal incidentalomas need a complete evaluation, which 
should include hormonal testing, to identify if  the tumor 
is overproducing hormones and contributing to these 
symptoms (Arnaldi & Boscaro, 2012; Terzolo et al., 2012).
Moreover, the distribution of  pathological origins in 
adrenal incidentalomas varies depending on important 
clinical factors, such as cancer history and tumor size 
(KHALIL & ASA, 2023). When considering patients 

Figure 9: The distribution of  the patients according to the lab diagnosis of  the patients



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with a history of  cancer, including lung, breast, kidney, 
and melanoma carcinomas, it has been observed that 
up to 75% of  incidentalomas are metastases (Samsel et 
al., 2023). However, in cases with no identified primary 
cancer site, the prospect of  a metastatic lesion causing 
the adrenal incidentaloma is very low (Dunn et al., 2022). 
Instead, primary adrenocortical carcinoma becomes 
a more probable cause of  a malignant adrenal tumor 
(Demidowich et al., 2019). Therefore, patients with an 
adrenal incidentaloma must undergo a comprehensive 
clinical evaluation (Calissendorff  et al., 2023). This 
evaluation should include a thorough assessment of  
medical history and a physical examination to exclude 
the presence of  a functional tumor or an underlying 
malignancy (Spartalis et al., 2019).
The symptoms experienced by individuals with adrenal 
tumors can vary depending on whether the tumor is 
functional or nonfunctional, as well as the specific 
hormones being overproduced Excessive cortisol 
production can lead to weight loss, skin stretch marks, 
acne, muscle weakness, depression, anxiety, fatigue, and 
sleep disturbances  (Nieman et al., 2013). Women may 
experience hair growth, irregular menstrual periods, and 
elevated cortisol levels, leading to high blood pressure, 
blood sugar, and decreased bone density. Excessive 
norepinephrine or epinephrine can cause symptoms like 
heartbeat irregularity, sweating, headaches, trembling, and 
pale complexion (Nieman et al., 2013; Terzolo et al., 2012).
In patients with adrenal incidentalomas, the diagnostic 
approach should address two key questions: determining 
whether the lesion is malignant and assessing its 
hormonal activity (Crafa et al., 2022). Radiological 
assessment, utilizing computed tomography (CT) with 
both non-contrast and contrast phases, is the most 
effective method for distinguishing between benign and 
malignant adrenal masses by analyzing attenuation values 
expressed in Hounsfield units (Korivi & Elsayes, 2013). 
Surgical excision is recommended for adrenal tumors with 
suspicious radiological findings, most functional tumors, 
and all tumors larger than 4 cm without typical features 
of  benign masses (Zeiger et al., 2011). In addition, it is 
important to conduct hormonal evaluations for subclinical 
Cushing’s syndrome and pheochromocytoma in all 
patients, and those with hypertension should be evaluated 
for hyperaldosteronism. Initial hormonal assessments can 
include a combined 1-mg dexamethasone suppression 
test, plasma metanephrines, and aldosterone/plasma 
renin activity measurements for hypertensive patients 
(Schumm et al., 2023; Terzolo et al., 2012). 
Consequently, the size of  adrenal tumors plays a 
significant role in distinguishing between benign and 
malignant adrenal adenomas (Farrugia et al., 2017). 
Typically, tumors smaller than 3 cm are more likely 
benign, while malignant lesions are usually larger than 6 
cm. Different cutoff  values, ranging from 4 to 6 cm, have 
been suggested for surgical removal of  adrenal masses. 
However, a 5-cm homogenous adrenal mass with a 
non-contrast attenuation value of  less than 10  

Hounsfield units (HU) has a very low risk of  malignancy 
(Wale et al., 2017). Studies have shown that 5 to 25% 
of  nonfunctioning adrenal masses can increase in size 
by at least 1 cm during follow-up, suggesting that size 
stability does not guarantee an adrenal tumor’s benign 
nature (Bhat & Tiyadath, 2017). Furthermore, with the 
advancement of  modern CT scanners, it has become 
easier to identify and differentiate both adrenal glands 
(Suvannarerg et al., 2018). In some cases, it is even 
possible to distinguish between the cortex and medulla 
of  the glands using CT scans. Three key imaging criteria 
are crucial when distinguishing between benign and 
malignant adrenal lesions. These criteria include the 
lesion size, the CT attenuation value observed on an 
unenhanced CT scan, and the pattern of  enhancement 
and de-enhancement, commonly called washout (Zeiger 
et al., 2011). By assessing these criteria, radiologists can 
make a more accurate determination regarding the nature 
of  the adrenal lesion (Albano et al., 2019).
During the time specified, a total of  383 consecutive 
patients underwent abdominal CT scans with intravenous 
contrast. However, this observational study involved 
300 cases of  incidental adrenal tumors to identify 
the prevalence of  Adrenal incidentaloma. According 
to Abdurrahman C. et al., 2010, the most common 
radiological intervention used to detect adrenal masses 
is CT imaging (Comlekci et al., 2010). Their study also 
found that the age group most frequently affected by 
adrenal masses was above 60, slightly higher than that 
reported by Bhargav P. et al.,2008 (Bhargav et al., 2008). 
Regarding gender distribution, the current study revealed 
that 50.3% of  the patients were females and 49.7% were 
males, indicating a nearly equal male-to-female ratio. This 
finding aligns with the study conducted by Bhargav P. et 
al.,2008  (Bhargav et al., 2008). However, Abdurrahman 
C. et al., 2010 (Comlekci et al., 2010) reported a female 
predominance of  approximately 70%, which differs from 
the current study. Interestingly, a study by Seong H. et 
al., 2018 reported a higher male predominance. These 
variations in gender distribution among different studies 
suggest that gender preferences may not be specific 
or consistent and could vary based on region-specific 
factors (Ahn et al., 2018). The study revealed that only 
44% of  the CT scans were requested by endocrinologists, 
indicating a lack of  awareness or consideration of  adrenal 
incidentalomas by other healthcare providers. Most 
adrenal incidentalomas were found to be unilateral (96%), 
with only (4%) of  cases being bilateral. Most of  these 
tumors were small, measuring less than 1 cm (59.0%). 
However, Bhargav P. et al., 2008 reported larger tumor 
sizes; in 91% of  cases, the adrenal tumors were larger 
than 3 cm, while in 70% of  cases, the tumors were larger 
than 6 cm (Bhargav et al., 2008).
Further work-up was conducted for only 30% of  the 
cases in the current study. Among those who underwent 
further evaluation, 49.3% had functional adenomas, 
consistent with the findings of  Bhargav P. et al.,2008 who 
reported functional tumors in about 41.5% of  cases. 



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Moreover, Seong H. et al., 2018 reported that most of  the 
tumors were non-functional. Although generally benign 
with small sizes and slow progression, functional tumors 
may be associated with developing conditions like diabetes 
mellitus and hypertension, particularly in individuals over 
60 (Ahn et al., 2018). Furthermore,  laboratory diagnosis 
revealed that 50.7% of  the cases were non-functioning 
adrenal adenomas, 16.9% were pheochromocytomas, 
5.8% were associated with Cushing syndrome, and 28.0% 
were classified as other types. A significant correlation 
was observed between the requesting doctors and referral 
to endocrinologists. This finding suggests that patients 
referred by doctors other than endocrinologists are 
less likely to be directed to endocrine clinics, indicating 
potential neglect or management with other medical 
disciplines. 
In summary, the study highlights the underutilization 
of  endocrinologists in evaluating and managing adrenal 
incidentalomas, primarily due to the prevalence of  
unilateral and small-sized tumors. Functional tumors 
and referral patterns contribute to understanding the 
management of  adrenal incidentalomas. Surgery may 
be necessary for 85% of  non-functioning tumors, and 
hormone treatment may be necessary for hormonal 
imbalances. Consultation with a medical team, genetic 
counseling, and regular follow-up appointments are 
recommended. Further, the study emphasizes the 
need for a multidisciplinary approach in assessing and 
treating diseases, especially in individuals aged 60 or older, 
and highlights no gender disparity in their occurrence. It 
underscores the importance of  diligent surveillance in the 
elderly population for improved patient care.

CONCLUSION
In conclusion, The study highlights the higher prevalence 
of  adrenal incidentalomas in older individuals, with 
functional tumors in most cases, emphasizing the need for 
careful evaluation and monitoring. Further research and 
guidelines are needed to understand the natural history, 
optimal evaluation strategies, and long-term outcomes of  
adrenal incidentalomas. Patient education is important 
to facilitate their participation in decision-making and 
adherence to follow-up protocols. By implementing 
these recommendations, healthcare providers can enhance 
the management and outcomes of  patients with adrenal 
incidentalomas, improving their overall care and well-being. 

Strengths and Limitations
• It emphasizes the importance of  a multidisciplinary 

approach involving endocrinologists, radiologists, and 
other specialists, to evaluate and manage these tumors. 

• However, the data was collected from a single center, 
which may limit generalizability to other settings or 
populations.

RECOMMENDATIONS
Based on the study’s findings, recommendations, as 
follows, can be made:

• Conduct more studies on AI prevalence and the 
association between HTN and AI with DM, as well as 
further research on the relationship between HTN and AI.

• To maintain and enhance the recording system of  the 
hospital.

• Healthcare professionals should be aware of  the high 
prevalence of  adrenal incidentalomas, particularly among 
individuals aged over 60 years. 

• Long-term monitoring is essential to detect any 
changes in size or hormonal activity over time.

• Individualized treatment approaches should be 
tailored to each patient’s age, comorbidities, tumor size, 
and functional status.

Acknowledgments
The authors thank the Armed Forces Hospital Southern 
Region, Saudi Arabia, for their continuous support 
throughout the study. 

Trial Registration Number
Approval for the study was granted by the Research 
Ethics Committee of  Armed Forces Hospital Southern 
Region, Saudi Arabia and the registeration number is 
(AFHSRMREC/2022/INTERNAL MEDICINE/636). 

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