Dual-energy CT (DECT) has emerged as a novel imaging modality that offers a multiparametric approach for noninvasive adrenal lesion characterization. This narrative review examines recent advances in DECT—including virtual non-contrast imaging, iodine density quantification, spectral curve analysis, and material density mapping—for differentiating benign adrenal adenomas from metastases. Conventional CT techniques rely primarily on unenhanced attenuation measurements and contrast washout kinetics; however, these methods may be limited in evaluating lipid-poor adenomas, and in cases where imaging features overlap with metastatic lesions. Although virtual non-contrast imaging with DECT tends to overestimate attenuation relative to true non-contrast scans, the recalibration of diagnostic thresholds and integration with complementary parameters, such as the iodine density-to-virtual non-contrast attenuation ratio, can significantly enhance sensitivity and specificity. Additional parameters, including fat fraction analysis and the evaluation of attenuation changes across energy spectra, further refine tissue characterization by quantifying intracellular lipid content and vascularity. Material density analysis has demonstrated near-perfect diagnostic accuracy in select studies. By tailoring imaging evaluation to the unique spectral and compositional features of each adrenal lesion, DECT contributes to a more personalized diagnostic approach. This individualization allows for better differentiation between benign and malignant findings, potentially avoiding unnecessary interventions and enabling more targeted clinical management. Despite these promising developments, challenges remain regarding the standardization of acquisition protocols, optimization of diagnostic thresholds, and minimization of interobserver variability. Emerging radiomics and machine learning applications may further automate lesion classification and improve diagnostic accuracy. Thus, DECT holds considerable potential to improve diagnostic confidence, reduce radiation exposure, and streamline the management of patients with adrenal incidentalomas, although further multicenter validation is warranted.

Purpose: Lung cancer screening (LCS) by low-dose computed tomography (LDCT) demonstrated a 20–40% reduction in lung cancer mortality. National stakeholders and international scientific societies are increasingly endorsing LCS programs, but translating their benefits into practice is rather challenging. The “Model for Optimized Implementation of Early Lung Cancer Detection: Prospective Evaluation Of Preventive Lung HEalth” (PEOPLHE) is an Italian multicentric LCS program aiming at testing LCS feasibility and implementation within the national healthcare system. PEOPLHE is intended to assess (i) strategies to optimize LCS workflow, (ii) radiological quality assurance, and (iii) the need for dedicated resources, including smoking cessation facilities. Methods: PEOPLHE aims to recruit 1.500 high-risk individuals across three tertiary general hospitals in three different Italian regions that provide comprehensive services to large populations to explore geographic, demographic, and socioeconomic diversities. Screening by LDCT will target current or former (quitting < 10 years) smokers (> 15 cigarettes/day for > 25 years, or > 10 cigarettes/day for > 30 years) aged 50–75 years. Lung nodules will be volumetric measured and classified by a modified PEOPLHE Lung-RADS 1.1 system. Current smokers will be offered smoking cessation support. Conclusion: The PEOPLHE program will provide information on strategies for screening enrollment and smoking cessation interventions; administrative, organizational, and radiological needs for performing a state-of-the-art LCS; collateral and incidental findings (both pulmonary and extrapulmonary), contributing to the LCS implementation within national healthcare systems.

Background/Objectives: To provide an updated overview of adrenal incidentaloma evaluation, characterize the principal imaging mimics across pediatric and adult populations, and propose a clinically actionable approach integrating endocrine assessment with conventional and advanced imaging. Methods: A narrative review of recent evidence and major international recommendations was performed, focusing on epidemiology, endocrine work-up, non-contrast computed tomography (CT), washout CT, magnetic resonance imaging (MRI), and dual-energy CT (DECT). Results: The recent literature has questioned a uniformly washout-centered approach and has raised interest in more selective, risk-adapted strategies based on clinical context, endocrine profile, and lesion phenotype; however, these proposals should be distinguished from established guideline recommendations. Non-contrast CT remains the cornerstone of first-line characterization, particularly for identifying lipid-rich adenomas. However, the routine use of adrenal washout CT is increasingly questioned, especially in true incidentalomas, because many benign adenomas are lipid-poor and several non-adenomatous lesions may show overlapping washout behavior. In this setting, MRI maintains a key problem-solving role, mainly through chemical shift imaging. DECT represents the most promising technical advance, enabling multiparametric characterization through virtual non-contrast images, iodine quantification, and material decomposition, with the potential to improve the assessment of indeterminate lesions while reducing unnecessary multiphasic imaging and radiation exposure. Conclusions: Current management should remain grounded in established guideline recommendations. MRI may be selectively used as a problem-solving modality, while DECT and emerging strategies require further validation before they can be considered standards of care.