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Radiomic Characterization of Adrenal Incidentalomas on NECT: Retrospective Exploratory Study and Systematic Review.

Pasquale Frisina1, Paolo Ricci1, Filippo Valentini2

  • 1Department of Radiological, Oncological and Pathological Sciences, Sapienza University, 00161 Rome, Italy.

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|April 27, 2026
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Radiomics analysis of non-enhanced CT scans can help differentiate adrenal lesions. Increased heterogeneity metrics on CT scans may aid in characterizing indeterminate adrenal incidentalomas, complementing traditional methods.

Keywords:
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Area of Science:

  • Radiology
  • Medical Imaging
  • Oncology

Background:

  • Adrenal incidentalomas require accurate characterization to distinguish benign from malignant lesions.
  • Radiomics offers a noninvasive approach, but methodological heterogeneity limits reproducibility.
  • Standard computed tomography (CT) criteria can be insufficient for indeterminate adrenal lesions.

Purpose of the Study:

  • To evaluate radiomic features from baseline non-enhanced computed tomography (NECT) for discriminating benign from malignant/metastatic adrenal lesions.
  • To contextualize findings with a systematic review of existing CT radiomics literature.
  • To assess the potential of radiomics to improve the noninvasive characterization of adrenal incidentalomas.

Main Methods:

  • Retrospective, single-center study of 33 patients with 36 adrenal lesions (excluding myelolipomas).
  • Consensus 3D segmentation by two radiologists on NECT followed by feature extraction using LIFEx and IBSI definitions.
  • LASSO regression selected four heterogeneity descriptors for analysis; Vargha-Delaney A index (VDA) measured pairwise separability.

Main Results:

  • Radiomic heterogeneity increased significantly from lipid-rich adenomas to pheochromocytomas and malignant/metastatic lesions (p < 0.001).
  • Highest separability was observed between lipid-rich adenomas and malignant/metastatic lesions (VDA = 0.93).
  • Systematic review of 18 studies confirmed higher entropy/non-uniformity in pheochromocytomas and malignant lesions compared to lipid-rich adenomas.

Conclusions:

  • Global heterogeneity metrics derived from NECT radiomics show promise in characterizing indeterminate adrenal lesions.
  • These radiomic features may complement conventional CT criteria for improved diagnostic accuracy.
  • External validation in larger, multicenter cohorts with standardized methods is crucial for clinical implementation.