Ppt

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
– 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)

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

7. Northumbria Healthcare NHS
Foundation Trust
• Population of 500 000 to
600 000
• 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

9. Results

10. 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)
0 20 40 60 80
HTN
DM2
BMI > 30
Osteoporosis
2+ Comorbidities
NE England
N = 75
48%
76%
37%
19%
20%
7.5%
32%
27%
Percentage

14. 1C. Comorbidities: Malignancy
0 10 20 30 40 50 60 70 80
Established Previous Ca
Established current Ca
Total, N = 75
35, 46.7%
5, 6.7%

15. 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

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”
Unspecified
23 mm, SD 11 mm
(range: 4 – 68 mm)
21
19
Suspicious features (5, 6)
≥ 4cm
≥ 10 Hounsfield Units
Calcification present
Investigation/referral
12
4
5
4
7

18. 3A. Referral
56%
45%
55%
44%
No written documentation Referral Not referred
Total = 75 Documented = 33
Not documented = 42 Referred/biochem = 15
Documented = 33 Not investigated = 18
Not investigated

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

20. 3C. Outcomes
Patients referred for work-up
Referred
Did Not Attend
13
1
Reviewed in clinic
- Surgery
Phaeochromocytoma
Cushing’s
12
3
1
2
- Metastates
Received CT-guided FNA
Presumed
4
1
3
- Surveillance
Presumed benign
Pit. Hyperprolactinaemia
5
4
1

21. 3C. Outcomes: Patients not referred
Not Referred
Biochemistry done
62
2
1 metastasis + 1 no follow up
Outcome
Malignancy
Terminal/ Inoperable Cancer
Surgical condition:
Acute
Chronic
Respiratory condition:
Acute
Chronic
Indeterminate
No anomaly
31
26 (of 31)
7
7
2
4
4
7
Adrenal metastases (not referred)
Received CT-guided FNA
Presumed
9
1
8

22. 75 patients with
new masses
42
No follow up
33
Noted
5
Surveillance
4
Metastases
3
Surgery
Summary
18
No follow up
1
DNA
1
No follow up
15
Tested/referred
12
Clinic
1
Metastasis

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. • 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

26. • 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

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. 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