SAT-373 Adrenal Incidentaloma Unidentified Case Load: Are We Dealing Only with the Tip of the Iceberg?

Background: Adrenal incidentalomas (AI) are incidentally identified lesions whilst scanning for other purposes. They are mostly benign and hormonally inactive but about 20% are hormonally-active or malignant, requiring prompt intervention. The overall reported AI prevalence is 3-5% but increases with age (up to 7% of those above 70 years). Guidelines stipulate that patients with AI should be investigated, but only a small proportion of patients are referred for an endocrine work up.. We are not aware of any work that systematically looked at the proportion of missed cases of AI. Aim: To identify the proportion of missed cases with AI.Methods: Data on adrenal lesions reported on CT scans were collected, utilising pre-agreed key phrases to identify AI. These included the terms: Adrenal adenoma, Adrenal incidentaloma, Adrenal lesion, Adrenal mass, Adrenal nodule, Incidental adrenal, Indeterminate adrenal. These data were collected from 2014-2016, focusing on the referral for the month of November each year as a representative sample. Patients with known cancer were excluded and those with genuine AIs were then checked (based on MDT note entry and/or review of endocrinology letters) to confirm whether they were appropriately identified and then referred to endocrinology for further assessment or not.Results: November 2014: Out of a total 57 cases, identified using the key phrases, 30 had previously known malignancies and hence were excluded. This left a net of 27 genuine AI cases. Out of those, only 8 (29.6%) were referred for further assessment. November 2015: Out of a total 76 cases, 35 had genuine AIs (with 41 cases of known malignancy). Only 10 AIs were referred on (28.6%) November 2016: Out of a total 77 cases, 62 had genuine AIs (with 15 cases of known malignancy). Only 20 AIs were referred on (32.3%) The missed cases are equivalent to approximately one third of the endocrinology workload for our unit. Conclusion: Despite an established and dedicated MDT, only a third of cases are referred for further evaluation, with 70% are being overlooked. The potential for missing functional or malignant cases is a serious patient safety risk. Paradoxically, the financial implication for managing this work load is - to our knowledge - significant and has never been considered in a systematic way.