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Suggested Reference
Wickramarachchi, B. N., Meyer-Rochow, G. Y., McAnulty, K., Conaglen, J. V., &
Elston, M. S. (2016). Adherence to adrenal incidentaloma guidelines is
influenced by radiology report recommendations. ANZ Journal of Surgery, 86(6), 483-486. doi:10.1111/ans.12799
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Adherence to Adrenal Incidentaloma Guidelines is Influenced by Radiology Report Recommendations
Journal: ANZ Journal of Surgery Manuscript ID: Draft
Manuscript Type: Original Article Date Submitted by the Author: n/a
Complete List of Authors: Wickramarachchi, Binula; Waikato Hospital, Department of Surgery Meyer-Rochow, Goswin; Waikato Hospital, Department of Surgery;
University of Auckland, Department of Surgery
McAnulty, Kim; Waikato Hospital, Department of Radiology Conaglen, John; Waikato Hospital, Department of Endocrinology;
University of Auckland, Faculty of Medicine
Elston, Marianne; Waikato Hospital, Department of Endocrinology;
University of Auckland, Waikato Clinical School General Key Words: Endocrine Surgery, General Surgery
Specialty Key Words: adrenal gland neoplasm, adrenal cortex neoplasms, adrenocortical adenoma, adrenalectomy
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Adherence to Adrenal Incidentaloma Guidelines is Influenced by Radiology Report Recommendations
Running head: Investigation of adrenal incidentalomas
Binula N Wickramarachchi MB ChB
1, Goswin Y Meyer-Rochow MB ChB, PhD
1,2, Kim McAnulty MB ChB, FRACR
3, John V Conaglen MB ChB, MD
2, Marianne S Elston MB ChB, PhD
2,41
Department of Surgery, Waikato Hospital, Hamilton 3240, New Zealand;
2Waikato Clinical School, University of Auckland, Hamilton 3240, New Zealand;
3Department of Radiology, Waikato Hospital, Hamilton 3240, New Zealand;
4Department of Endocrinology, Waikato Hospital, Hamilton 3240, New Zealand.
This work has previously been presented as an oral presentation at the Royal Australasian College of Surgeons 81
stAnnual Scientific Congress, Auckland, NZ, 6-10 May 2013
Word count – abstract 250
Manuscript (excluding references, figure legend) 2119 Figures – 1
Tables – 1
Corresponding author:
Dr Goswin Y Meyer-Rochow Department of Surgery Waikato Hospital Private Bag 3200 Hamilton 3240 New Zealand
Email: [email protected] Phone: +647 839 8899; Fax +647 839 8733
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Abstract
Introduction: Approximately 5% of all abdominal CT and MRI scans reveal an adrenal incidentaloma.
Whilst most adrenal incidentalomas are benign non-functioning adenomas, lesions may be hormonally active and/or malignant. The aim of this study was to determine adherence to recommended international guidelines and potential influencing factors when an adrenal incidentaloma is identified in routine clinical practice.
Methods: A retrospective study was performed of all CT and MRI reports from December 2009 to December 2011 using a key phrase search to identify patients with an incidental adrenal lesion.
Results: A total of 125 patients with incidental adrenal lesions were identified, of which 74 patients were considered appropriate for further endocrine/radiological work up. Of the 74 patients, only nineteen (26%) were initially referred to the endocrine service for investigation; 21/74 (28%) had complete biochemical work up and 24/74 (32%) had imaging follow up arranged. The reporting radiologist provided advice for follow up in 31/74 (42%) and action was more likely to be taken when this recommendation was given. Follow up of the patients who had not received investigation was attempted resulting in assessment of a further 23 patients. Of the 44 patients who have undergone full assessment, 4 patients were found to have clinically significant lesions (1 each of: Cushing's syndrome, phaeochromocytoma, Conn’s syndrome and plasmacytoma).
Discussion: This study suggests that the majority of adrenal incidentalomas may not be investigated according to current international guidelines. The recommendations by the reporting radiologist appear to influence whether a patient is referred for further investigation.
Abstract word count: 250
Keywords: Adrenal gland neoplasm; adrenal cortex neoplasms; adrenocortical adenoma; adrenalectomy;
quality assurance, health care 3
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Introduction
An adrenal incidentaloma (AI) is an adrenal lesion discovered incidentally by a radiologic examination performed for reasons other than to evaluate the adrenal gland. Given the widespread availability and use of highly sensitive imaging techniques, the number of AIs being discovered is increasing[1]. AIs are now found in approximately 5% of all computed tomography (CT) scans imaging the adrenal gland, with the prevalence increasing with age [1-3]. The prevalence of AIs is now approaching that reported from autopsy data (2-6%)[4,5], consistent with the advances in imaging.
Despite published international guidelines by both disciplines of radiology and endocrinology (ACR 2009 [6] and AACE/AAES 2009[7]), there remains debate regarding the extent of investigation and optimum length of follow up of patients with AI [1,2,8,9]. Following identification of an AI, the clinician not only needs to consider whether the lesion is likely benign or malignant but also whether the tumour is producing inappropriate quantities of the hormones cortisol, aldosterone, sex steroids or catecholamines.
The diagnostic challenge is to identify adrenal masses which are malignant and/or hyperfunctioning and that will require surgical intervention as opposed to benign non-functional tumours of no clinical consequence. Interval imaging or interventional management of an AI must be balanced against the cost and potential harm of repeated radiation exposure, repeat hospital visits or potential morbidity from unnecessary surgery.
The aims of the current study were to determine whether AIs at our institution were being investigated according to current international guidelines, the proportion of missed lesions which were clinically significant as well as assessing the factors influencing referral to the appropriate specialty service for evaluation.
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Methods
A retrospective study was performed of all patients who had an incidentally diagnosed adrenal lesion during the period 1 Dec 2009 to 30 November 2011 at Waikato Hospital, a 600-bed tertiary New Zealand hospital. Ethical approval was obtained in accordance with local ethics committee guidelines (approval NTY/12/EXP/001). Patients were identified using a key phrase search of CT and MRI reports on the Picture Archiving and Communication System (PACS) using the terms: adrenal nodule, adrenal lesion, adrenal adenoma, adrenal incidentaloma, adrenal carcinoma, adrenal cortical, adrenocortical, adrenal neoplasm, adrenal tumour and adrenal mass. Patients were excluded from the study if the scan was being performed for known or suspected adrenal disease or if follow up was considered unreasonable (patients with disseminated malignancy, death by other cause, in hospital level care or when domiciled outside of the region). For patients included in the study, demographic data, the radiological characteristics of the lesion, the specialty requesting the scan, the biochemical evaluation of the lesion, whether an endocrine referral was made, the reporting radiologist’s assessment and advice for follow up and patient outcome were all recorded. Whether the radiology report was acknowledged on the electronic system and by which level of medical officer was also noted. For those patients who had not undergone assessment of the adrenal lesion, a standard letter was sent to the primary care practitioner recommending referral to the endocrine service for follow up if clinically appropriate. Personalised repeat letters were sent to the primary care practitioner of those cases thought likely to have potentially significant pathology (based on lesion size and imaging characteristics). P-values were calculated using Chi-square tests.
Results 3
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A total of 125 patients with incidental adrenal lesions were identified over the 24 month period. Of these, 41 patients were excluded due to known metastatic disease. Follow up was deemed unlikely to be appropriate for an additional 10 (6 were deceased from unrelated causes, 3 patients were requiring hospital level residential care and 1 was living outside the region). After exclusion of these 51 patients, 74 patients were identified for whom further workup was considered appropriate. Of these patients, 69 were identified on the basis of a CT scan abnormality and 5 from MRI. Forty-five percent (n=33) were male. The median age was 66 years (range 32 – 89). The median diameter of lesions was 15mm with a range 7mm-45mm. Out of 69 CT scans evaluated, 15 were non-contrast scans. Of these, nodule density in Hounsfield Units (HU) was reported in 11. In those reports in which HU were not reported, the density was measured by the investigators. The median HU was 10 with a range from -10 to 40 HU.
Of the 74 patients, 19 (26%) had been referred to the endocrine service, with 18 of these receiving full biochemical and radiological work up (1 patient declined further investigation). Sixteen of these were diagnosed as having a non-functioning adrenal lesion with imaging characteristics consistent with a benign lesion and two patients were identified as having clinically significant lesions – one with Cushing’s syndrome and the other a malignant plasmacytoma. Of the 55 patients who were not referred to the endocrine service, 3 patients (5%) had biochemical work up and 6 (10%) had imaging follow up.
The reporting radiologist provided advice for follow up in 31/74 (42%) of cases. When radiological advice was given, follow up was much more likely to occur than when no recommendation was offered (17/31 (54%) vs 9/43 (21%); p = 0.003). When advice was given for referral to the endocrine service (n = 3), this was adhered to all three times. The type of advice given and consequent outcomes are detailed in Table 1. Out of the 43 patients for whom no advice was provided, 23 (53%) were reported to be consistent with a benign adrenal lesion and 16 (37%) were reported to be indeterminate. None were reported to appear malignant. Consequently, only one of these indeterminate lesions was referred on for specialist investigation.
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Approximately two thirds of radiology reports had been acknowledged on the PACS system (48/74; 65%) and most of these were by consultants and registrars (39/48; 81%; p = 0.00001). Similar proportions of reports were acknowledged in the patients who were investigated compared with the ones who were not investigated (73% vs. 62% respectively; p = 0.36).
A wide range of specialties had patients with AIs identified, with general surgery, urology and the emergency department initiating the imaging for the majority (Figure 1).
Letters were sent to the primary care practitioners for the 52 patients who had not received both biochemical and radiological workup recommending referral to the endocrine service for assessment. This resulted in assessment of an additional 26 patients (3 of whom are still under investigation). Of the 23 patients assessed, 21 had benign, non-functioning lesions and 2 had significant pathology (one phaeochromocytoma and one Conn’s syndrome). Of the remaining 26 patients: 3 were deceased, 1 had metastatic disease, 1 did not attend clinic and 21 were not referred despite the follow up letters to their family doctors.
Discussion
From this study it is clear that in our institution, the majority of patients discovered to have an AI are not investigated according to current international guidelines, with only 1 in 4 patients referred to a specialist service for assessment and less than 30% of patients undergoing biochemical workup. Our organisation is typical of other Australasian hospitals, therefore the results of this study is likely to be applicable to other centres.
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A number of factors may have contributed to the low rate of further investigation or referral. Firstly, these lesions are being discovered on scans performed to evaluate extra-adrenal disease, often in the acute setting. Management of the acute condition takes priority and it is possible that as a non-urgent problem the AI is overlooked. Secondly, there is possibly a lack of awareness by medical colleagues of the significance of AIs and of the investigations required. We identified that patients are more likely to receive radiological than biochemical follow up when investigations are requested by non- endocrinologists and it is likely that further education regarding the potential for an adrenal lesion to be secreting excess hormones would be beneficial.
The radiologist’s report appears to have an important impact on whether these patients were appropriately investigated, particularly if the scan was being performed by a service unfamiliar with the relevance of an adrenal lesion. When radiological advice for follow up was included in the report, action was more than twice as likely to be taken by the service who initiated the scan. Moreover, in those patients where advice for follow up was not provided, over a third had indeterminate lesions – suggesting that the radiologists expected the clinicians caring for the patient to be aware of the significance of adrenal nodules. In this group only one patient had follow up arranged, highlighting multiple failures to act on an AI which was not radiologically benign. A recent study from the United Kingdom reported similar issues in incidentally discovered adrenal enlargement [10].
Two thirds of all radiology reports had been acknowledged on the electronic PACS imaging system. The vast majority of those were acknowledged by senior clinicians – excluding inexperience of the junior medical staff as a cause for the low rate of follow up of these lesions. Furthermore, there was no significant difference in the proportion of acknowledged reports in those that were investigated compared with those that were not. This suggests that there was little association between whether a report was acknowledged and whether the patient was referred on for further assessment. It was of concern that over a third of reports had not been acknowledged. However this may be due to the reader of the report not indicating their acknowledgement rather than due to the report not being followed up.
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Most AIs were discovered by investigations requested by the General Surgery department. This is presumably due to the nature of presenting complaints to this speciality which results in imaging of the abdomen. Sample sizes were too small in most cases to comment regarding specialty specific investigation rates. The emergency medicine department only referred 1 out of 14 cases in whom it requested imaging, however it is likely that many of these patients were either referred to another service or discharged home prior to the formal report being available. General surgery and urology were found to be the specialities most likely to investigate, although these services did so in less than half of all cases.
Despite the fact that only 44 patients (including those seen after proactive identification by the investigators) were assessed, significant pathology was found in 10% (one each of Cushings, Conn’s, phaeochromocytoma and a plasmacytoma). Given the relatively high proportion of patients found in our study with a clinically significant lesion, it is concerning that so many AIs had no investigations performed. It is also unclear why a significant proportion of patients (45%) were still not referred for further workup despite the investigators contacting the primary care practitioner.
Despite comprehensive international guidelines being developed to manage AIs [6,7], the optimum approach to investigation and follow up of these patients remains debated[1,2,9]. There is a lack of level 1 evidence to support such recommendations and many of the guidelines are based on expert opinion and practice rather than firm evidence. The length of follow up patients with AIs and the frequency of imaging assessments vary widely between clinicians and institutions. Inappropriate investigation can result in expensive repeats of biochemical tests and imaging, exposing patients to repeated and potentially damaging doses of radiation as well as provoking anxiety. As most adrenal nodules are non-secreting adenomas, such extensive investigation over a number of years is discouraged by some[8]. Whilst it is possible that a lesion initially assessed as benign and non-functioning may transform into a malignant or functioning lesion, the risk of this occurring appears to be extremely low[8]. Although patients with AIs of clinical importance are potentially being missed, careful consideration must be given as to the extent of 3
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secreting adenoma. Extensive investigation over long periods of time not only burdens the health system with unnecessary costs, but may also cause harm to patients through repeated exposure to radiation and anxiety. Until more evidence is accrued, it is appropriate for patients with AIs to proceed to biochemical screening for excess hormone secretion as well as further imaging, individualised according to the baseline radiological findings and clinical picture. As demonstrated by our study, a significant proportion of these lesions were clinically important.
Conclusions
When compared to published current international guidelines, less than one-third of patients identified with an adrenal incidentaloma in this study underwent adequate investigation. The most important factor identified in determining whether a patient was referred for investigation was the advice provided by the reporting radiologist. We recommend that a standard comment by the radiologist should be included to highlight the presence of an AI and the recommendation of hormonal and radiological follow up as clinically appropriate with consideration of referral to an endocrine service.
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References
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405-19
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3. Bovio S, Cataldi A, Reimondo G, Sperone P, Novello S, Berruti A, et al. Prevalence of adrenal incidentaloma in a contemporary computerized tomography series. J Endocrinol Invest 2006; 29:
298-302
4. Kloos RT, Gross MD, Francis IR, Korobkin M, Shapiro B. Incidentally discovered adrenal masses. Endocr Rev 1995; 16: 460-84
5. Barzon L, Sonino N, Fallo F, Palu G, Boscaro M. Prevalance and natural history of adrenal incidentalomas. Eur J Endocrinol 2003; 149: 273-85
6. Choyke PL, ACR Committee on Appropriateness Criteria. ACR Appropriateness Criteria on incidentally discovered adrenal mass. J Am Coll Radiol 2006; 3: 498-504
7. Zeiger MA, Thompson GB, Duh QY, Hamrahian AH, Angelos P, Elaraj D, et al. American Association of Clinical Endocrinologists and American Association of Endocrine Surgeons Medical Guidelines for the Management of Adrenal Incidentalomas. Endocr Pract 2009; 15 Suppl 1:1-20
8. Cawood TJ, Hunt PJ, O'Shea D, Cole D, Soule S. Recommended evaluation of adrenal incidentalomas is costly, has high false-positive rates and confers a risk of fatal cancer that is similar to the risk of the adrenal lesion becoming malignant; time for a rethink? Eur J Endocrinol 2009; 161: 513-27
9. Young WF Jr Clinical practice. The Incidentally Discovered Adrenal Mass. New Engl J Med 2007; 356: 601-10
10. Tang YZ, Bharwani N, Micco M, Akker S, Rockall AG, Sahdev A. The prevalence of incidentally detected adrenal enlargement of CT. Clin Radiol 2014; 69: 37 - 42
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Figure Legends
Figure 1. Number of patients discovered with AIs and respective referrals made to an endocrine service by each specialty
Gen surg = general surgery; med spec = medical subspecialty; ED = emergency medicine department; GP
= general practitioner; O&G = obstetrics & gynaecology; CTS = cardiothoracic surgery; ICU = intensive care unit; ortho = orthopaedics; psych = psychiatry; rad onc = radiation oncology
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Table 1. Advice provided by radiologists and subsequent action taken by specialties requesting the scan
Advice Number of patients Actually done
Further imaging advised 20 Imaging 4 – 2 CT, 1 MRI
(20%)
Endo referral 6 (30%)
No action 11 (55%)
Endoa referral advised 3 Endo referral 3 (100%)
Biochemb advised 3 Biochem done 0 (0%)
Endo referral 2 (67%)
No action 1 (33%)
Biochem & imaging advised 5 Endo referral 2 (40%)
MRI 1 (20%)
No action 2 (40%)
No advice given 43 Endo referral 6 (14%)
MRI 1 (2%)
Biochem 2 (5%)
No action 34 (79%)
a Endo = endocrine 3
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Figure 1
0 5 10 15 20 25
G e n s u rg M e d s p e c E D U ro lo g y G P O & G C T S IC U O rt h o P sy ch R a d O n c
N u m b e r o f p a ti e n ts
Total
Endo referrals
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