Introduction: Incidental indeterminate adrenal nodules discovered on imaging in patients under the care of University Hospitals of Derby and Burton Foundation Trust are discussed in Urology MDT. MDT cases were reviewed for a 12 month period before an endocrinologist joined the MDT in January 2018 and 12 months afterwards, to review the compliance of local practice with European Society of Endocrinology (ESE) Guidelines for the management of adrenal incidentalomas.
Results: 45 patients had adrenal nodules (12160 mm in maximum diameter) discovered on abdominal imaging; CT (n=41), MRI (n=2), MRCP (n=1), CTA (n=1), with HU >10 in 84% of cases (n=38). 39 patients had a unilateral nodule (Right n=14, Left n=25) with bilateral adrenal nodules in 6 patients. Adrenal nodule was associated with malignancy in 27% (n=12) of these patients, with metastatic disease diagnosed from primary lung (n=3), RCC (n=1) and DLCBC Lymphoma (n=1) as well as primary adrenal malignancy; sarcoma (n=1) and adrenocortical carcinoma (n=1). Investigation of hormone excess was carried out (Table 1). Non-functioning incidentaloma were diagnosed (n=21), the most common active nodule found was Phaeochromocytoma (n=6), Aldosterone secreting (n=2) and Cortisol secreting (n=1). 27% (n=12) of patients were scheduled for, or had undergone adrenalectomy.
|Differential Diagnosis||Assessment||2017 (%)||2018 (%)|
|Clinical evidence of hormone excess||Outpatient Clinic review by endocrinologist||6 (29)||19 (79)|
|Phaeochromocytoma||Plasma or Urine Metadrenalines||12 (57)||18 (75)|
|Cushings||9AM ACTH, Overnight Dexamethasone Suppression or 24 hr Urine Cortisol||5 (24)||15 (63)|
|Adrenocortical Carcinoma||Steroid precursors-DHEAS, 17-OHP||3 (14)||11 (46)|
|Conns||Renin and Aldosterone||5 (24)||10 (42)|
Conclusion: Local review of adrenal incidentaloma cases, following introduction of an Endocrinologist to MDT, argues for an improved and comprehensive assessment with particular reference to functional lesions. Implementation of a structured local guideline, may improve ESE adherence, to optimise management of functional adrenal incidentalomas.