Adherence to Clinical Guidelines in the Radiographic and Biochemical Evaluation of Adrenal Incidentalomas Detected on Diagnostic Imaging: An Open Access Observational Analysis

Abstract Background: Adrenal incidentalomas (AIs) are adrenal masses discovered incidentally on imaging studies performed for unrelated indications. Clinical guidelines recommend a standardized radiographic and biochemical evaluation to distinguish benign from malignant lesions and identify hormonally active tumors. Objective: To evaluate adherence to guideline-recommended radiographic and biochemical workup in patients with adrenal incidentalomas detected on diagnostic imaging and assess factors influencing compliance. Methods: We conducted a multicenter, observational study of 312 adult patients with adrenal incidentalomas identified between 2020 and 2025. Adherence to international guidelines, including imaging characterization (CT/MRI), biochemical evaluation (cortisol, catecholamines, aldosterone), and follow-up protocols, was analyzed. Demographic, clinical, and institutional factors influencing adherence were assessed. Results: Complete adherence to radiographic and biochemical recommendations was observed in 62% of cases. Imaging characterization using non-contrast CT or MRI was performed in 94% of patients, while complete biochemical screening was documented in 70%. Factors associated with higher adherence included tertiary care centers, endocrinology consultation, and multidisciplinary team involvement. Non-adherence was frequently due to lack of standardized protocols or incomplete follow-up. Conclusions: Despite established guidelines, significant gaps exist in the evaluation of adrenal incidentalomas. Implementation of structured, clinic-based protocols and multidisciplinary management improves adherence, potentially optimizing early detection of malignancy and hormonally active tumors. Keywords: Adrenal incidentaloma, guideline adherence, biochemical evaluation, radiographic workup, CT, MRI, endocrinology