01.14 Adrenal Referral Pattern: Management of Patients with Adrenal Incidentalomas

A. Allahwasaya1, R. Akhund1, S. Balachandra1, R. Wang1, B. Lindeman1, J. Fazendin1, A. Gillis1, J. McMullin1, H. Chen1  1University Of Alabama at Birmingham, Endocrine Surgery, Birmingham, Alabama, USA

Adrenal incidentalomas (AIs) are found in approximately 3–4% of abdominal computed tomography (CT) scans. Evaluating the functional status and malignant potential of AIs in a timely manner is necessary, as this directs appropriate non-operative surveillance or surgical intervention. This study aims to evaluate the adherence of referring services to the American Association of Endocrine Surgeons (AAES)/American Association of Clinical Endocrinologists (AACE) guidelines for the biochemical work-up of AIs at a single tertiary surgical clinic.


We did a retrospective study on 125 patients who were evaluated for AIs at the endocrine surgery clinic between November 2017 and January 2022.Information on patient demographics, referral source, and referral reason was collected. The appropriateness of the initial biochemical work-up conducted by the referring physicians for Cushing's syndrome, Aldosteronoma, and Pheochromocytoma was assessed. The number of days from referral to initial clinic visit and initial clinic visit to surgery was also collected. For statistical analysis chi-square and Kruskal-Wallis were performed. 


Adrenal incidentalomas referrals came from endocrinologists (44.8%), other sub-specialties (31.2%), and primary care physicians (PCPs; 19.2%). Patients referred by endocrinologists were more likely to receive a complete screening biochemical work-up for AIs compared to other sub-specialties and PCPs (76.8% vs. 28.2% vs. 8.3% respectively, P < 0.001). Among the 125 patients, 66 (52.8%) were diagnosed with benign adrenal masses, 20 (16%) with Cushing syndrome, 20 (16%) with pheochromocytoma, 10 (8%) with aldosteronoma, and 5 (4%) with metastatic masses. Out of the 50 patients diagnosed with functional tumors, 23 (46%) were referred to the surgery clinic without having undergone the recommended biochemical work-up for AIs.  Only 11 (55%) of the 20 patients with pheochromocytoma were assessed for elevated catecholamine levels by the referring physician. A total of 83 (66.4%) patients underwent adrenalectomy, and patients referred by endocrinologists were more likely to undergo surgery compared to other sub-specialties and PCPs (81.8%vs57.9%vs52.0%, p<0.05). There was no significant variation in time from referral to initial clinic visit by specialty. 

More than half of the patients with AIs referred to endocrine surgery clinic were by specialists other than endocrinologists. Familiarizing all referring physicians with AAES/AACE recommended screening guidelines for AIs may minimize undiagnosed cases of functional adrenal incidentalomas and facilitate timely surgical management when necessary.