Adrenal incidentalomas: are they being worked up appropriately?

Abstract

IntroductionAdrenal incidentalomas are defined as masses picked up on imaging studies that were done for apparently different reasons. With frequent use of imaging modalities, incidental adrenal masses are commonly encountered in clinical practice. Guidelines are currently available for the diagnosis and management of adrenal incidentalomas, but the appropriateness of initial work-up and subsequent follow-up of incidental adrenal masses in the community hospital setting is unknown.ObjectiveWe studied the appropriateness of initial work-up and follow-up of incidental adrenal masses discovered on abdominal computerized tomography (CT).MethodsIn our retrospective study, we reviewed sequential CT scans of the abdomen performed in the month of January 2010 at a community hospital. Once patients with one or more adrenal masses were identified, outpatient charts for initial biochemical testing and follow-up imaging were obtained either through directly accessing the electronic medical records or through contacting primary care physician's offices. Patient charts were reviewed to assess the data for the next 2 years following the discovery of an adrenal abnormality.ResultsTwenty adrenal masses were incidentally discovered on 723 abdominal CTs performed within the month of January 2010 resulting in an overall incidence of 2.76%. Of the patients with incidentally discovered adrenal masses, appropriate biochemical and follow-up imaging were only performed in patients referred to an endocrinologist (2 of 20 patients). Thirty percent of patients with incidental masses received a repeat CT scan for non-adrenal reasons, and no change in the mass size was noted.ConclusionDespite published guidelines, the initial work-up and follow-up of patients with an incidentally discovered adrenal mass is unsatisfactory. There is a desperate need for education of providers regarding appropriate work-up of incidental adrenal masses.

The impact of an adrenal incidentaloma algorithm on the evaluation of adrenal nodules

“…We concluded that more education was needed for primary care clinicians about the appropriate evaluation and follow-up of these nodules. Other studies, both within the USA and in other countries, performed in community hospitals and university centers, have also confirmed low rates of hormone testing and imaging follow up for adrenal incidentalomas [8] , [9] , [10] . This study is a follow up to our 2008 study.…”

Incidental Adrenal Masses: Adherence to Guidelines and Methods to Improve Initial Follow-Up: A Systematic Review

“…Fifteen studies reported data on follow-up adrenal imaging and met our inclusion criteria [22][23][24][25][26][27][28][29][30][31][32][33][34][35][36] . Imaging follow-up was performed more frequently than biochemical work-up.…”

“…Imaging follow-up was performed more frequently than biochemical work-up. Appropriate imaging follow-up ranged from 6% to 55%, [23][24][25][26][27][28] although there were also 2 outliers (comparatively weak study design) that reported 76% 29 and 100% follow-up adrenal imaging. 30 Among all 15 studies, the median proportion of imaging follow-up was 34% with an inter-quartile range (IQR) of 20%-50%.…”

“…Not all of the studies included data as to whether follow-up imaging was done specifically to evaluate an IAM. 1 small case series found that 5 of 11 patients who underwent repeat imaging had the follow-up study specifically for an IAM evaluation, 24 but most other studies did not capture indications for repeat imaging, which would suggest that over-estimations are being reported. Moreover, some IAMs can be judged benign adenomas on the index scan (e.g., a noncontrast CT chest that detects an IAM with Hounsfield units [HU] < 10).…”

Diagnosing and managing adrenal incidentalomas

“…Only a minority of patients with adrenal masses undergo appropriate hormonal workup 4,13,14. Notably, up to 50% of patients with adrenal incidentalomas demonstrate mild autonomous cortisol secretion (MACS).…”