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Adrenal lesions with calcification are uncommon and surgical indication remains controversial. We evaluate rational indications for surgical intervention of adrenal lesions with calcification. From 2013 to 2021, 75 adrenal lesions with calcification managed with surgery had necessary studies for evaluation of rational surgical indication. Clinical benefit was defined as relief of symptoms or/and removal of the malignant tumors. Influencing factors for clinical benefit were evaluated by logistic regression. During the past 8-year period, 5057 patients received adrenal surgery in our center and 75 (1.5%) patients were accompanied with calcification, including 34 males and 41 females with a median age of 54 years (IQR = 41–63 years). The median maximum diameter of calcified adrenal lesions on preoperative CT imaging was 4.2 cm (IQR = 3.0–5.9 cm). Clinical benefit was achieved in 22 cases, including 4 cases of malignant tumors and 18 cases of relieved clinical symptoms. Correlation analysis indicated that maximum diameter of the lesion was significantly correlated with clinical benefit ( p  = 0.025). The maximum diameter in benefit group  vs.  non-benefit group was 5.5 cm (IQR = 3.7–7.4 cm)  vs.  3.7 cm (IQR = 2.8–5.4 cm). AUC of the maximum diameter ROC curve of adrenal lesions was 0.662. The diameter, sensitivity and specificity corresponding to the maximum Youden index value were 4.5 cm, 0.682 and 0.623, respectively. Clinical benefit was not significantly correlated with calcification distribution (peripheral or internally scattered) ( P  = 0.106), calcification area ≥ 50% ( P  = 0.617) and internal enhancement of the lesion ( P  = 0.720). Adrenal lesions with calcification are mostly benign. Clinical benefit is significantly correlated with the maximum diameter of the lesion and 4.5 cm may be considered as the cutoff point of surgical intervention.

An 8-year clinical experience with diagnosis and treatment of adrenal lesions with calcification