A comprehensive approach to the CT detection and evaluation of large adrenal masses part 2: malignant adrenal lesions and future directions.

Large adrenal tumors have traditionally been associated with high risk of malignancy; however, recent studies challenge this assumption, highlighting that a significant proportion of large adrenal lesions are benign. With increasing detection of incidental adrenal lesions, there remains a clinical dilemma in their appropriate management. Malignant adrenal lesions include adrenal cortical carcinoma, lymphoma, metastasis, and rare tumors such as adrenal sarcomas. These often exhibit overlapping imaging features with benign lesions, complicating treatment planning. Therefore, accurate radiologic characterization, supported by clinical and laboratory correlation, is essential to avoid unnecessary surgical interventions while ensuring timely identification of aggressive pathology. This part two of the two-part pictorial essay focuses on the CT evaluation of malignant adrenal lesions with an emphasis on key imaging features and differential diagnosis.