Introduction/Background The prevalence of incidental adrenal nodules is 4%. Although the majority of incidental adrenal nodules are benign (85%) and non-functional, malignant and hormone-secreting nodules (excess cortisol, aldosterone or catecholamines) require timely investigation and management. Currently, there is limited literature on their management in the pre-operative oncology setting and further investigation is time consuming and often causes significant delays to the planned gynaecological oncology surgical treatment.
Methodology Retrospective single cohort observational study undertaken at a tertiary cancer centre in UK. Patients undergoing major gynaecology oncology surgery who had incidental adrenal pathology reported on pre-operative imaging over a one year period (July 2019 – July 2020) were identified. Patient demographics, endocrine investigations and delays in treatment pathways were reported using descriptive statistics.
Results Incidental finding of adrenal pathology were reported in 9 of the 346 cases (2.6%). Patient age ranged from 30–73 years old. The primary sites of malignancy included ovarian (4/9), endometrial (4/9) and cervical (1/9). All adrenal pathology was identified on preoperative CT; the reports did not categorise these into benign or malignant/functioning. The size of the adrenal pathologies ranged from 11 mm – 70 mm (median = 26 mm). PET CT was used to further evaluate an adrenal nodule (1/9).
In those cases that had further investigations, initial tests included both urinary and plasma metanephrines 1/9, plasma metanephrines (2/9) and urinary metanephrines (5/9). Additional tests were undertaken in two cases; a dexamethasone suppression test (1/9) and serum renin/aldosterone (2/9). From these, 2/9 had abnormal urinary metanephrines. 1/9 was a false positive result and the other had endocrinology review for a raised methotyramine only which was not felt to be clinically significant. An adrenal malignancy or phaemochromocytoma was not identified within the cohort. (2/9) had no investigations or endocrinology input. The planned gynaecological surgical date was postponed in 4/9 cases to allow for investigation of the adrenal pathology to rule out a functioning or malignant lesion. The delay to surgery ranged 0–56 days (median 21 days). There was no progression of disease or change to the original management plan as a result of the delay.
Conclusion There is heterogeneity in the investigation and management of incidental adrenal pathology and significant delays to the surgical treatment of the patients’ primary gynaecology malignancy. We recommend adopting the European Society of Endocrinology guidelines to develop a local pathway with input from our endocrinology and radiology colleagues to ensure these patients are investigated in a timely and standardised manner and avoid undue delays to surgical treatment for the patient’s gynaecological malignancy.
Disclosures None of the authors wish to disclose any potential conflict of interest.
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