Audit on Adrenal Incidentalomas P Lang Ping Nam, MSJ Wilson, A Reid, SR Aspinall Northumbria 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 Prevalence 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 Enhanced CT if lesion > 10 HU MRI if indeterminate FDG-PET if malignancy suspected NP-59 scintigraphy if previous malignancy

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 Where referral was made: Analysis of investigations conducted Time to endocrinologist review Whether managed medically, surgically or discharged

Results

Total number CT scans searched 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%

Cancer and/or staging CT Non-acute abdo condition 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

2B. Radiological features Total number patients 75 Total number incidentalomas 108 Location Bilateral Left Right Unspecified 33 29 12 1 Mean size (N = 40) “Bulky” 23 mm, SD 11 mm (range: 4 – 68 mm) 21 19 Suspicious features (5, 6) ≥ 4cm ≥ 10 Hounsfield Units Calcification present Investigation/referral 4 5 7 Suspicious features on CT: Presumed mets: 2 No further input: 3

3A. Referral Not investigated Total = 75 Documented = 33 Not documented = 42 Referred/biochem = 15 Not investigated = 18

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 Those referred but didnt have biochem done: 1 urgent transfer to another centre, 1 advanced lung ca with only osteoporosis as comorbidity Those referred but didnt have imaging done: 1 urgent transfer, 1 died before investigation concluded, 1 unknown (HTN as only comorbidity, benign appearance on inital CT) One referred but DNA’d appointment

3C. Outcomes Patients referred for work-up Did Not Attend 13 1 Reviewed in clinic - Surgery Phaeochromocytoma Cushing’s 12 3 2 - Metastates Received CT-guided FNA Presumed 4 - Surveillance Presumed benign Pit. Hyperprolactinaemia 5

3C. Outcomes: Patients not referred Biochemistry done 62 2 1 metastasis + 1 no follow up Outcome Malignancy Terminal/ Inoperable Cancer Surgical condition: Acute Chronic Respiratory condition: Indeterminate No anomaly 31 26 (of 31) 7 4 Adrenal metastases (not referred) Received CT-guided FNA Presumed 9 1 8

75 patients with new masses 42 No follow up 33 Noted 5 Surveillance 4 Metastases 3 Surgery Summary 18 No follow up 1 No follow up 15 Tested/referred 1 Metastasis 1 DNA 12 Clinic

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

Discussion 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?

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

References 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 BAETS (2003) Guidelines for the Surgical Management of Endocrine Disease BMJ Evidence Centre (2011) Assessment of incidental adrenal mass Best Practice The Network of Public Health Observatories Northumberland Health Profile (2012); Modelled estimates of prevalence (2011) www.apho.org.uk Image: Cybermedicine2000 – Adrenal Neoplasm