T. Feeney1,2, S. Talutis1,2, M. Janeway1,2, P. Sridhar1,2, A. Gupta3, P. Knapp4, J. Moses5, D. McAneny1,2, F. T. Drake1,2 1Boston Medical Center,Surgical Endocrinology,Boston, MA, USA 2Boston University School of Medicine,Surgery,Boston, MA, USA 3Boston University School of Medicine,Radiology,Boston, MA, USA 4Boston University School of Medicine,Medicine,Boston, MA, USA 5Boston University School of Medicine,Pediatrics,Boston, MA, USA
Introduction: Incidental findings, including adrenal masses, are increasingly common, and their management is challenged by poor communication, determination of responsibility, the infrequency of clinical significant, and competing health considerations. Clear guidelines exist for the evaluation of incidental adrenal masses, but barriers to implementation are not well understood. The goal of the current study was to evaluate usual care practice patterns for follow-up of incidental adrenal masses at an urban Level 1 trauma and tertiary referral center.
Methods: A retrospective review of medical records for all patients with an incidentally-discovered adrenal mass at a tertiary medical center in Boston, MA and associated ambulatory care locations. All individuals ≥18 years old with a mass identified during 2016 were included. Patterns of evaluation, follow-up, and associated adrenal diagnoses were determined.
Results: 244 patients were identified from approximately 19,171 eligible scans. Median age = 63 years; median size = 1.5cm. Most patients (85%) had a single lesion, and 51% of imaging was performed during an ED evaluation. Of the 244 patients, 31 (12.7%) appropriately did not undergo adrenal evaluation due to severity of comorbid conditions. Among the remaining 213, 38 were lost to follow-up and only 20 had a PCP evaluation. Of those with an identifiable PCP, 118 (80%) had a PCP within our health system. Dedicated adrenal evaluation (imaging and/or labs) was performed by a PCP in only 9% of patients (16/175). Patients were more likely to undergo follow-up if the mass was characterized in the radiology report as “indeterminate” versus “benign” (65% vs 30% p<0.001). Of 130 patients with hypertension, only 2 (3.2%) underwent aldosterone/renin screening. Of 53 patients with co-morbid conditions potentially related to Cushing’s Syndrome, 0 patients had appropriate hormonal evaluation. Four patients (1.9%) had hormonal evaluation for pheochromocytoma. Among all 244 patients, our review yielded 71 patients with some diagnosis listed in the chart (including, simply, “adrenal nodule.”) including 1 cortisol secreting mass and 8 metastases.
Conclusion: Under usual care, most patients with an incidental adrenal mass do not undergo workup described in published guidelines. A potential contributing factor is detection during ED evaluations, which challenges follow-up. Nine of 213 adrenal masses (4.2%) were clinically significant; however, according to available literature, we would have expected up to 25%, or 53 masses, to be. This discrepancy suggests that published estimates are not necessarily generalizable to all healthcare settings or that usual care is inadequate to detect clinically significant lesions. This discrepancy between guidelines and usual care offers a clear quality improvement opportunity, and we have implemented a prospective initiative to facilitate communication and evaluation of incidental adrenal masses.