audit on adrenal incidentalomas p lang ping nam, msj wilson, a reid, sr aspinall northumbria...
TRANSCRIPT
Audit on Adrenal Incidentalomas
P Lang Ping Nam, MSJ Wilson, A Reid, SR AspinallNorthumbria Healthcare NHS Foundation Trust
Contents
• Background• Aims and Standard Measures• Method• Results
– 1. Prevalence and comorbidities– 2. Radiological analysis– 3. Referral and outcomes
• Interpretation• Summary
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)
Aims
• Establish prevalence of adrenal incidentalomas in Northumbria Trust
• Audit referral pathways, investigation protocols and end-point management
• Compare to published guidelines
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
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
Northumbria Healthcare NHS Foundation Trust
• Population of 500 000 to 600 000
• 3 district general hospitals
Image © 2012 NHS Northern Deanery
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
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)
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
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
2B. Radiological featuresTotal number patients 75
Total number incidentalomas
108
Location Bilateral Left Right Unspecified
3329121
Mean size (N = 40)
“Bulky” Unspecified
23 mm, SD 11 mm (range: 4 – 68 mm)
2119
Suspicious features (5, 6) ≥ 4cm ≥ 10 Hounsfield Units Calcification present Investigation/referral
124547
3A. Referral
Total = 75 Documented = 33
Not documented = 42 Referred/biochem = 15
Documented = 33 Not investigated = 18
Not investigated
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
3C. Outcomes Patients referred for work-up
Referred Did Not Attend
13 1
Reviewed in clinic- Surgery Phaeochromocytoma Cushing’s
12312
- Metastates Received CT-guided FNA Presumed
413
- Surveillance Presumed benign Pit. Hyperprolactinaemia
541
3C. Outcomes: Patients not referredNot ReferredBiochemistry done
622
1 metastasis + 1 no follow up
Outcome Malignancy Terminal/ Inoperable Cancer Surgical condition: Acute Chronic Respiratory condition: Acute Chronic Indeterminate No anomaly
3126 (of 31)
77
2447
Adrenal metastases (not referred) Received CT-guided FNA Presumed
918
75 patients with new masses
75 patients with new masses
42 No follow up
42 No follow up
33Noted33
Noted
5Surveillance
5Surveillance
4Metastases
4Metastases
3Surgery
3Surgery
Summary
18 No follow up
18 No follow up
1 DNA1
DNA
1 No follow up
1 No follow up15
Tested/referred15
Tested/referred
12Clinic12
Clinic
1Metastasis
1Metastasis
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
• 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
• 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
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
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