Less is more: cost-effectiveness analysis of surveillance strategies for small, nonfunctional, radiographically benign adrenal incidentalomas

Adrenal masses are mainly detected unexpectedly by an imaging study performed for reasons unrelated to any suspect of adrenal diseases. Such masses are commonly defined as "adrenal incidentalomas" and represent a public health challenge because they are increasingly recognized in current medical practice. Management of adrenal incidentalomas is currently matter of debate. Although there is consensus on the need of a multidisciplinary expert team evaluation and surgical approach in patients with significant hormonal excess and/or radiological findings suspicious of malignancy demonstrated at the diagnosis or during follow-up, the inconsistency between official guidelines and the consequent diffuse uncertainty on management of small adrenal incidentalomas still represents a considerable problem in terms of clinical choices in real practice. The aim of the present work is to review the proposed strategies on how to manage patients with adrenal incidentalomas that are not candidates to immediate surgery. The recent European Society of Endocrinology/European Network for the Study of Adrenal Tumors guidelines have supported the view to avoid surveillance in patients with clear benign adrenal lesions <4 cm and/or without any hormonal secretion; however, newer prospective studies are needed to confirm safety of this strategy, in particular in younger patients.

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“…In relation to this point, Chomsky-Higgins et al [52] developed a cost-effectiveness model, which evaluates different sur- Fig. 2.…”

Section: Discussionmentioning

confidence: 99%

Is Follow-up of Adrenal Incidentalomas Always Mandatory?

et al. 2020

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“…Our findings may also have implications for healthcare costs, as point-of-care clinical guidelines may reduce unnecessary follow-up studies. 9 For example, providers might be less likely to order a PET scan for a lung nodule, when a chest CT is sufficient for follow-up, or they may be less likely to order annual CT scans to 'follow' an adrenal mass if the initial battery of tests conclusively reveal the IAM to be a benign and nonfunctional adrenal adenoma.…”

Section: Discussionmentioning

confidence: 99%

Point‐of‐care access to clinical guidelines may improve management of incidental findings in the primary care setting

Annesi

Talutis

Goldman

et al. 2023

Evaluation Clinical Practice

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Rationale: Incidental radiographic findings are common, and primary care providers (PCPs) are often charged with the conducting or initiating an appropriate evaluation.Clinical guidelines are available for management of common 'incidentalomas' including lung and adrenal nodules, but guidelines-adherent evaluations are not always performed; for example, in the setting of incidental adrenal masses (IAMs), recent literature suggests that an evidence-based evaluation occurs in <25% of patients for whom it is warranted-a quality and safety concern. Aims and Objectives:The objective of this study was to examine whether point-ofcare access to concise clinical guidelines would promote appropriate evaluations of two common incidentalomas: IAMs and lung nodules.Method: This study was a survey-based, single-blinded, randomized experiment of decision-making within clinical vignettes. Respondents were PCPs in a variety of clinical practice settings, and half were randomly assigned to surveys that included concise clinical guidelines while the other half served as controls without access to guidelines. Scenarios involved patients with IAMs and lung nodules, and the scenarios included both higher-risk and lower-risk lesions. Our primary analysis examined safe versus inappropriate clinical decisions, while a secondary analysis compared guidelines-concordant versus guidelines-discordant responses.Results: For both the higher-risk IAM and higher-risk lung nodule scenarios, safe answer choices were selected at a similar rate by respondents regardless of whether they had access to guidelines or not. However, for the lower risk scenarios, inappropriate answer choices were chosen substantially more frequently by respondents without access to guidelines compared to those with the guidelines (lung: 29.3% vs. 4.5%, p = 0.003, adrenal: 31.6% vs. 7.0%, p = 0.01). There was less variation in the secondary analysis. Conclusion:Survey respondents were significantly more likely to make safe management decisions in lower-risk clinical scenarios when clinical guidelines were available. Point-of-care access to clinical guidelines for incidentalomas is an intervention that may reduce management errors and improve patient safety.

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“…Chomsky-Higgins et al performed a cost-effectiveness analysis of surveillance of adrenal masses 1–4 cm with an initial normal workup including non-contrasted CT showing a mass < 10 HU, no suspicious features, and negative hormonal evaluation. They determined it is most effective to perform a single follow up at one year with non-contrasted CT and biochemical evaluation [ 26 ]. It may be reasonable to consider excision in those adrenal masses with indeterminate radiologic features that grow at least 0.8 cm during 3–12 month follow-up [ 14 ].…”

Section: Discussionmentioning

confidence: 99%

Diagnostic dilemmas: a multi-institutional retrospective analysis of adrenal incidentaloma pathology based on radiographic size

et al. 2022

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Introduction/background Adrenal incidentalomas (AIs) are masses > 1 cm found incidentally during radiographic imaging. They are present in up to 4.4% of patients undergoing CT scan, and incidence is increasing with usage and sensitivity of cross-sectional imaging. Most result in diagnosis of adrenal cortical adenoma, questioning guidelines recommending removal of all AIs with negative functional workup. This retrospective study analyzes histological outcome based on size of non-functional adrenal masses. Material and methods 10 years of data was analyzed from two academic institutions. Exclusion criteria included patients with positive functional workups, those who underwent adrenalectomy during nephrectomy, < 18 years, and incomplete records. AI radiologic and histologic size, histologic outcome, laterality, imaging modality, gender, and age were collected. T-test was used for comparison of continuous variables, and the two-sided Fisher’s exact or chi-square test were used to determine differences for categorical variables. Univariate analysis of each independent variable was performed using simple logistic regression. Results 73 adrenalectomies met the above inclusion criteria. 60 were detected on CT scan, 12 on MRI, and one on ultrasound. Eight of 73 cases resulted in malignant pathology, 3 of which were adrenocortical carcinoma (ACC). Each ACC measured > 6 cm, with mean radiologic and pathologic sizes of 11.2 cm and 11.3 cm. Both radiologic and pathologic size were significant predictors of malignancy (p = 0.008 and 0.011). Conclusions Our results question the generally-accepted 4 cm cutoff for excision of metabolically-silent AIs. They suggest a 6 cm threshold would suffice to avoid removal of benign lesions while maintaining sensitivity for ACC.

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Less is more: cost-effectiveness analysis of surveillance strategies for small, nonfunctional, radiographically benign adrenal incidentalomas

Cited by 11 publications

References 22 publications

Is Follow-up of Adrenal Incidentalomas Always Mandatory?

Is Follow-up of Adrenal Incidentalomas Always Mandatory?

Point‐of‐care access to clinical guidelines may improve management of incidental findings in the primary care setting

Diagnostic dilemmas: a multi-institutional retrospective analysis of adrenal incidentaloma pathology based on radiographic size

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