Introduction: Incidentally diagnosed adrenal masses represent an entity that is treated by a variety of medical and surgical specialities and can result in either long term follow up, surgical excision, or both. Understanding when and which adrenal masses are ultimately excised surgically is not well understood. We sought to understand the fate of these incidentalomas using a large population based dataset
Methods: The Optum De-identified Clinformatics® Data Mart database was queried from 2003 to 2017 to examine patients who had an incidentally diagnosed adrenal mass on CT scan. Those patients who were under 18 years of age, previously underwent adrenalectomy or nephrectomy, had a history of an adrenal condition, a previous history of malignancy or renal cell carcinoma were excluded. We evaluated temporal adoption trends for surgical approach (open, laparoscopic, or robotic) and we obtained descriptive statistics and utilized multivariable regression modeling to assess outcomes.
Results: A total of n=60,002 incidental adrenal masses were detected on CT imaging and ultimately 2653 of these masses underwent surgical excision. For the entire cohort, the majority of the patients were Caucasian (64%), female (63%), and the mean age was 60.3 years. Over the study period, approximately 25% of the adrenalectomies were performed with a robotic approach and the remaining 75% were evenly split between laparoscopic and open surgical approaches. The vast majority of adrenalectomies were not performed by urologists. The histologic subtype of the masses most likely to undergo excision rather than surveillance included aldosteronoma, functional adenoma causing Cushing’s disease, and adrenocortical carcinoma. Whereas adrenocortical carcinoma was more often resected after just one CT scan had been completed, the other histologic subtypes that underwent adrenalectomy did so more frequently after 2 or more follow up CT scans had been completed. On multivariable adjusted logistic regression, older patients (OR 1.01 (1.001 - 1.02)) were more likely to undergo resection and those with higher Charlson Comorbidity scores (CCI) (OR 0.85 (0.75-0.96) were less likely to undergo resection.
Conclusions: Adrenalectomy is most likely to be performed by non urologic surgeons and for adrenocortical carcinomas or biochemically active adrenal masses. The timing of surgery within radiologic follow up differs amongst histologic subtypes. In addition, younger patients and those with higher CCI scores are less likely to undergo adrenalectomy.