Evaluation of incidental adrenal masses at a tertiary referral and trauma center

Background: Incidental adrenal masses are those that are found on imaging performed for any nonadrenal evaluation. Published guidelines define accepted follow-up criteria for incidental adrenal masses; however, adherence to these guidelines and barriers to appropriate follow-up are not well understood. We aimed to describe practice patterns for the discovery, evaluation, and follow-up of incidental adrenal masses.

Methods: Medical records of patients with an incidental adrenal mass underwent retrospective review at a tertiary referral and level-1 trauma center, as well as regional ambulatory care locations. Individuals ≥18 years of age with an incidental adrenal mass identified during 2016 were included. Patterns of evaluation, follow-up, and associated adrenal diagnoses were determined.

Results: From a total of 19,171 cross-sectional imaging procedures (computed tomography and magnetic resonance imaging), 244 patients with new incidental adrenal masses were identified. A majority (52%) were discovered as part of an evaluation in the emergency department. Of 153 patients with an identifiable primary care provider, approximately 75% had an in-network primary care provider, and 12 (7.8%) had both follow-up imaging and biochemical evaluation. Twenty-three percent of patients with an in-network primary care provider underwent an appropriate cross-sectional imaging procedure in follow-up compared to 29% for a non-network primary care provider (P = .54). Patients with a mass described with benign terminology were less likely to undergo follow-up imaging compared to those with indeterminate terminology (5% vs 37%, P < .001). Patients with imaging ordered as an outpatient were more likely to receive follow-up with imaging (22.8% outpatient vs 11.5% inpatient, P = .042). There was no difference between any groups regarding biochemical evaluation, which inappropriately was performed in only 15% of patients with an incidental adrenal mass.

Conclusion: To optimize follow-up of incidental adrenal masses, efforts should be made to assure and prioritize inpatient/emergency department incidental findings and to communicate to the appropriate primary care provider the necessary next steps for evaluation. Further, efforts to increase biochemical testing should be pursued.