Methods: This IRB-approved minimal risk retrospective study included 253 patients aged 18-40 years with adrenal lesions identified on cross-sectional imaging (CT, MRI, and PET/CT). Radiology reports were reviewed to determine lesion descriptors, inclusion of the adrenal lesion in the report impression, and management recommendations. Logistic regression was used to identify factors associated with inclusion of adrenal lesions in the impression. 

 Results: Among 253 adrenal lesions, 194 (76.7%) were included in the report impression and 59 (23.3%) were omitted. Lesion size was the most frequently reported descriptor (83.7% of reports), whereas attenuation measurements were reported in only 14.3%. Overall, 57.9% of reports contained no management recommendation. Follow-up imaging was recommended in 39.2% of cases, hormonal evaluation in 2.8%, and endocrine referral in 0.8%. Inclusion of adrenal lesions in the impression was independently associated with larger lesion size (OR 1.46 per cm, p = 0.025) but was not associated with imaging context, prior malignancy, or mechanism of discovery. Among 162 incidental lesions in patients without prior malignancy or known genetic predisposition, 5 (3.1%) were non-metastatic pheochromocytomas, 115 (71.0%) were benign, and 42 (25.9%) remained non-characterized. 

 Conclusion: Adrenal lesions identified in younger adults are frequently omitted from radiology impressions and often lack key descriptors or management recommendations. Reporting practices appear to be influenced primarily by lesion size rather than clinical context, suggesting opportunities to improve the consistency and clinical utility of adrenal lesion reporting, particularly in younger patients where standardized evaluation strategies are less well established.