1. Audit on Adrenal Incidentalomas
P Lang Ping Nam, MSJ Wilson, A Reid, SR Aspinall
Northumbria Healthcare NHS Foundation Trust

2. Contents Background Aims and Standard Measures Method Results
1. Prevalence and comorbidities
2. Radiological analysis
3. Referral and outcomes
Interpretation
Summary

3. Background Definition Prevalence
Adrenal mass found on imaging conducted for another reason
Prevalence
% (1,2) of Computed Tomography (CT) and >6% in autopsy series (3, 4)

4. Aims
Establish prevalence of adrenal incidentalomas in Northumbria Trust
Audit referral pathways, investigation protocols and end-point management
Compare to published guidelines

5. 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

6. 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

7. Northumbria Healthcare NHS Foundation Trust
Population of to
3 district general
hospitals
Image © 2012 NHS Northern Deanery

8. 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

9. Results

10. 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)

12. 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

13. 1C. Comorbidities (7)
Percentage

14. 1C. Comorbidities: Malignancy
35, 46.7%
5, 6.7%

15. 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

16. 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

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

19. 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

20. 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

21. 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

22. 75 patients with new masses42
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

23. Interpretation

24. 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

25. 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

26. 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?

27. 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

28. 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):
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)
Image: Cybermedicine2000 – Adrenal Neoplasm