Presentation and management of patients with adrenal masses: a large tertiary centre experience

Background: Adrenal masses are found in up to 5-7% of adults. The 2016 European guidelines on the management of adrenal incidentalomas have standardised the workup of these patients, but evidence of their impact on clinical practice is lacking.
Methods: Retrospective review of clinical presentation, radiological characteristics, and final diagnosis of a large cohort of patients with adrenal masses referred to a tertiary care centre 1998 to 2022. Sub-analysis compares outcomes before and after implementing the 2016 guidelines.
Results: 1397 patients (55.7% women; median age 60 years [interquartile range, IQR, 49-70]) were included. Incidental discovery was the most frequent mode of presentation (63.7%) and 30.6% of patients had masses ≥4 cm (median 2.9 cm [IQR, 1.9-4.7]). Unenhanced computed tomography (CT) Hounsfield Units (HU) were available for 763 patients; of these, 32.9% had heterogeneous masses or >20 HU. The most common diagnoses were adrenocortical adenoma (ACA, 56.0%), phaeochromocytoma (12.7%), adrenocortical carcinoma (10.6%), and metastases (5.7%). At multivariable analysis, significant predictors of malignancy included HU >20 or heterogeneous density (Odds Ratio, OR 28.40), androgen excess (OR 27.67), detection during cancer surveillance (OR 11.34), size ≥4 cm (OR 6.11) and male sex (OR 3.06). After implementing the 2016 guidelines, the number of adrenalectomies decreased (6.1% pre-2016 vs. 4.5% post-2016) and the number of patients discharged increased (4.4% pre-2016 vs. 25.3% post-2016) for benign non-functioning adrenal masses.
Conclusion: Implementing the 2016 guidelines positively impacted clinical practice, reducing unnecessary surgeries and increasing the discharge rate for benign adrenal masses, thereby preserving healthcare resources and patient burden.