Multimodal Imaging for Adrenal Tumor Characterization: Clinical Impact of the 2023 European Guidelines - A Single-Center Retrospective Study.

BACKGROUND: Adrenal lesions are becoming increasingly common with the advent of abdominal imaging. Although mostly benign and nonfunctional, some cases may be malignant or secretory and justify adrenalectomy. The 2023 European guidelines propose a more conservative approach (focused on simple radiological criteria) to limit unnecessary surgery. However, the impact of this strategy on the management of malignant lesions remains to be assessed. METHODS: We conducted a single-center retrospective study including all patients who underwent adrenalectomy between 2017 and 2024. The aim was to investigate the potential impact of the new iconographic criteria of the 2023 European recommendations. Patients aged over 18 years with at least one preoperative imaging examination and a histopathology report were included. RESULTS: Among 259 patients, 75% had benign lesions, and 25% had malignant lesions. Based on the 2016 guidelines, 71% of the patients would have undergone surgery, whereas 31% would have undergone surgery according to the 2023 criteria. With respect to malignant lesions, 98% of the patients would have received surgery according to the 2016 criteria, whereas 60% would have received surgery according to the 2023 criteria. The inclusion of hypersecretion increased this rate to 93%, and the addition of complementary imaging ensured the detection of all malignant cases. CONCLUSION: The 2023 guidelines may substantially reduce unnecessary adrenalectomies for benign lesions. The risk of missing malignant tumors remains low when hormonal evaluation and multimodal imaging (such as MRI and FDG-PET) are used, particularly in indeterminate cases.