MANAGEMENT OF ENDOCRINE DISEASE: Differential diagnosis, investigation and therapy of bilateral adrenal incidentalomas

Eur J Endocrinol. 2018 Aug;179(2):R57-R67. doi: 10.1530/EJE-18-0296. Epub 2018 May 10.


The investigation and management of unilateral adrenal incidentalomas have been extensively considered in the last decades. While bilateral adrenal incidentalomas represent about 15% of adrenal incidentalomas (AIs), they have been less frequently discussed. The differential diagnosis of bilateral incidentalomas includes metastasis, primary bilateral macronodular adrenal hyperplasia and bilateral cortical adenomas. Less frequent etiologies are bilateral pheochromocytomas, congenital adrenal hyperplasia (CAH), Cushing's disease or ectopic ACTH secretion with secondary bilateral adrenal hyperplasia, primary malignancies, myelolipomas, infections or hemorrhage. The investigation of bilateral incidentalomas includes the same hormonal evaluation to exclude excess hormone secretion as recommended in unilateral AI, but diagnosis of CAH and adrenal insufficiency should also be excluded. This review is focused on the differential diagnosis, investigation and treatment of bilateral AIs.

Publication types

  • Review

MeSH terms

  • ACTH Syndrome, Ectopic / diagnosis
  • Adrenal Cortex Hormones / blood
  • Adrenal Cortex Hormones / metabolism
  • Adrenal Gland Neoplasms / diagnosis*
  • Adrenal Gland Neoplasms / pathology
  • Adrenal Gland Neoplasms / physiopathology
  • Adrenal Gland Neoplasms / therapy
  • Adrenal Glands / diagnostic imaging*
  • Adrenal Glands / metabolism
  • Adrenal Glands / pathology
  • Adrenal Hyperplasia, Congenital / diagnosis
  • Combined Modality Therapy
  • Diagnosis, Differential
  • Humans
  • Pheochromocytoma / diagnosis
  • Pituitary ACTH Hypersecretion / diagnosis
  • Practice Guidelines as Topic
  • Tumor Burden


  • Adrenal Cortex Hormones

Supplementary concepts

  • Adrenal incidentaloma