Incidental Adrenal Masses: Adherence to Guidelines and Methods to Improve Initial Follow-Up: A Systematic Review

Abstract

Incidental adrenal masses (IAMs) are detected in approximately 1%-2% of abdominal computed tomography (CT) scans. Recent estimates suggest that more than 70-million relevant CT scans are performed annually in the United States; thus, IAMs represent a significant clinical entity. Most clinical guidelines recommend an initial follow-up evaluation that includes imaging and biochemical testing after index IAM detection. Systematic review of literature in the PubMed, EMBASE and Web of Science databases to determine whether guidelines regarding IAM evaluation are followed and to identify effective management strategies. Our initial search was in January 2018 and updated in November, 2019. 31 studies met inclusion criteria. In most institutions, only a minority of patients with IAMs undergo initial follow-up imaging (median 34%, IQR 20%-50%) or biochemical testing (median 18%, IQR 15%-28%). 2 interventions shown to improve IAM evaluation are IAM-specific recommendations in radiology reports and dedicated multi-disciplinary teams. Interventions focused solely on alerting the ordering clinician or primary care provider to the presence of an IAM have not demonstrated effectiveness. Patients who are referred to an endocrinologist are more likely to have a complete IAM evaluation, but few are referred. Most patients with an IAM do not have an initial evaluation. The radiology report has been identified as a key component in determining whether IAMs are evaluated appropriately. Care teams dedicated to management of incidental radiographic findings also improve IAM follow-up. Although the evidence base is sparse, these interventions may be a starting point for further inquiry into optimizing care in this common clinical scenario.