Endocrine Abstracts

Background: Adrenal incidentalomas (AI) are common, with approximately 40% of these demonstrating evidence of mild autonomous cortisol secretion (MACS). MACS has been associated with increased morbidity and mortality, and some patients with MACS may benefit from medical therapy or adrenalectomy, so all require further evaluation. Given the large numbers of patients involved, this has potentially significant resource implications for outpatient endocrinology services. To standardise and enhance the evaluation of patients with MACS, we developed a virtual pathway that systematically assesses symptoms, biochemistry, and end-organ impact of patients with MACS.

Methods: Retrospective data collection was conducted on 391 patients with AI and evidence of MACS (cortisol between 50-138 nmol/l on ONDST), before and after the introduction of a virtual ‘MACS testing’ pathway. Completion of relevant biochemistry (including ACTH and DHEAS), completion of HbA1c screening and DEXA scans conducted in each group were documented.

Results: A total of 391 patients were included (53% female, median age of 69±10 years (SD)). Mean cortisol on ONDST was 76.5±20 nmol/l. 53.2% of these were assessed via the virtual MACS pathway, whilst the rest had individualised clinician-led assessment in clinic. Both groups had comparable baseline demographic characteristics. Following implementation of the pathway, there was a significant increase in patients undergoing tests for ACTH (77% increase), DHEAS (76% increase), HbA1c (46% increase), and 24-h urinary cortisol (74% increase). Additionally, the referred group had a 3% higher utilisation of DEXA scans. Most patients following the MACS pathway did not require an endocrinology outpatient appointment.

Conclusions: Within our cohort of patients with AI and MACS, implementation of a systematic virtual pathway resulted in significant increase in completion of key diagnostic investigations. Such a pathway facilitated standardised assessment and virtual review of results, resulting in reductions in the need for clinic appointments for this large cohort of patients.