Audit on Adrenal Incidentalomas

P Lang Ping Nam, MSJ Wilson, A Reid, SR AspinallNorthumbria Healthcare NHS Foundation Trust

Contents

• Background• Aims and Standard Measures• Method• Results

– 1. Prevalence and comorbidities– 2. Radiological analysis– 3. Referral and outcomes

• Interpretation• Summary

Background

• Definition – Adrenal mass found on imaging conducted

for another reason

• Prevalence– 1.65 - 4.4% (1,2) of Computed Tomography

(CT) and >6% in autopsy series (3, 4)

Aims

• Establish prevalence of adrenal incidentalomas in Northumbria Trust

• Audit referral pathways, investigation protocols and end-point management

• Compare to published guidelines

BAETS Guidelines 2003 (5)

• Clinical evaluation to assess for evidence of hormone overproduction

• Biochemical screening in all cases• Surgery if lesion is functioning, >3 cm or shows

rapid increase in size• Surveillance by repeat CT if lesion <3cm• Needle biopsy only if history of primary

malignancy elsewhere with no other metastases

BMJ Best Practice Guidelines 2011 (6)

• Clinical evaluation• Biochemical screening in all cases • Imaging with CT/magnetic resonance

imaging (MRI)– If attenuation > 10 Hounsfield Units on unenhanced

CT → contrast CT– If hormonally active → functional imaging

• Surveillance imaging at 6 – 12 months and annual biochemical assessment for 4 years

Northumbria Healthcare NHS Foundation Trust

• Population of 500 000 to 600 000

• 3 district general hospitals

Image © 2012 NHS Northern Deanery

Methods• Retrospective audit: 01 Jan 2010 - 31 Dec 2010

• CT scan reports commenting on new adrenal findings containing the search criteria– Adrenal mass, lesion, swelling, cyst, tumour, nodule,

incidentaloma or adenoma– Enlarged or bulky adrenals

• Case note review to establish:– Patient co-morbidities – Detailed radiological report– Referral pathways

Results

1A. Prevalence

Total number CT scans searched 4028

Scans matching search criteria 124

Pre-existing adrenal lesions 49

New adrenal incidentaloma 75

37 Males Mean age 71 (range: 41 – 89)

38 Females Mean age 66 (range: 45 – 93)

Co-morbidities associated with hormone over-production• Hypertension (HTN): > 140/90 mmHg

(NICE)

• Obesity: Body Mass Index (BMI) > 30

• Diabetes Mellitus Type 2 (DM2): diet, tablet or insulin controlled

• Osteoporosis (OP): as per DEXA scan

1C. Comorbidities (7)

Percentage

1C. Comorbidities: Malignancy

35, 46.7%

5, 6.7%

2A. Imaging requests

44 Outpatient requests 31 Inpatient requests

Cancer and/or staging CT 37

Acute abdomen 12

Acute respiratory 7

Non-acute abdo condition 15

Hyponatraemia 1

Respiratory surveillance

COPD

1

2B. Radiological featuresTotal number patients 75

Total number incidentalomas

108

Location Bilateral Left Right Unspecified

3329121

Mean size (N = 40)

“Bulky” Unspecified

23 mm, SD 11 mm (range: 4 – 68 mm)

2119

Suspicious features (5, 6) ≥ 4cm ≥ 10 Hounsfield Units Calcification present Investigation/referral

124547

3A. Referral

Total = 75 Documented = 33

Not documented = 42 Referred/biochem = 15

Documented = 33 Not investigated = 18

Not investigated

3B. Investigation

Patients with incidentaloma 75

Average CT to clinic time

(n = 11)

57 days

(Range: 6 – 249 days)

Patients referred for work-up

- Biochemical screen done

- Further imaging

13

10

9

Patients not referred

- Biochem done by team

62

2

3C. Outcomes Patients referred for work-up

Referred Did Not Attend

13 1

Reviewed in clinic- Surgery Phaeochromocytoma Cushing’s

12312

- Metastates Received CT-guided FNA Presumed

413

- Surveillance Presumed benign Pit. Hyperprolactinaemia

541

3C. Outcomes: Patients not referredNot ReferredBiochemistry done

622

1 metastasis + 1 no follow up

Outcome Malignancy Terminal/ Inoperable Cancer Surgical condition: Acute Chronic Respiratory condition: Acute Chronic Indeterminate No anomaly

3126 (of 31)

77

2447

Adrenal metastases (not referred) Received CT-guided FNA Presumed

918

75 patients with new masses

75 patients with new masses

42 No follow up

42 No follow up

33Noted33

Noted

5Surveillance

5Surveillance

4Metastases

4Metastases

3Surgery

3Surgery

Summary

18 No follow up

18 No follow up

1 DNA1

DNA

1 No follow up

1 No follow up15

Tested/referred15

Tested/referred

12Clinic12

Clinic

1Metastasis

1Metastasis

Interpretation

Discussion• Prevalence in this series (1.9%) consistent with

other published studies (1,2)

• National Guidelines are not being followed – Majority of incidentalomas (56%) were not commented

upon in case notes– Only a minority (20%) had biochemical screening or

referral for work-up

• Investigative protocols in those referred comply with National Guidelines

• 3 of 12 (25%) incidentalomas worked up were functioning lesions– All surgically managed– Histology: 2 benign adrenal cortical adenomas, 1

phaeochromocytoma

• 62 of 75 (83%) were not referred– 26 (42%) were diagnosed with metastatic/inoperable

cancer – 36 (58%) did not have co-morbidities that would

preclude incidentaloma work-up

Discussion

• A high incidence of co-morbidities associated with hormone over-production

• Are adrenal incidentalomas contributing to the high incidence of DM2 (37% or x5 regional value) and HTN (76% or x2 regional value) observed?

Discussion

Summary• Prevalence of adrenal incidentaloma in

Northumbria is 1.9%

• National Guidelines for their management are not being followed as the majority were not investigated

• Awareness of adrenal incidentalomas among clinicians needs to be raised

1) Price L, Munigoti S, Rees A (2011) Management of adrenal incidentaloma: are we getting it right? Endocrine Abstracts 25:54

2) Bovio S, Cataldi A, Reimondo G, Sperone P, Novello S, Berruti A, Borasio P, Fava C, Dogliotti L, Scagliotti GV, Angeli A, Terzolo M (2006) Prevalence of adrenal incidentaloma in a contemporary computerized tomography series Journal of Endocrinological Investigation 29(4):298-302

3) Young WFJr (2007) The Incidentally Discovered Adrenal Mass New England Journal of Medicine 356:601-10

4) Kloos RT, Gross MD, Francis IR, Korobkin M, Shapiro B (1995) Incidentally Discovered Adrenal Masses Endocrine Reviews 16 (4):460-84

5) BAETS (2003) Guidelines for the Surgical Management of Endocrine Disease

6) BMJ Evidence Centre (2011) Assessment of incidental adrenal mass Best Practice

7) The Network of Public Health Observatories Northumberland Health Profile (2012); Modelled estimates of prevalence (2011) www.apho.org.uk

• Image: Cybermedicine2000 – Adrenal Neoplasm

References