Specialist consultation improves underdiagnosis of surgical adrenal incidentaloma: a TriNetX database investigation

Objectives: Despite practice guidelines recommending hormonal testing for all cases of incidentally discovered adrenal adenomas (incidentalomas), only 30% of patients receive laboratory workup. This study sought to evaluate hormonal testing and adrenal surgery rates in incidentaloma patients seen by a specialist (endocrinologist, nephrologist, urologist, or general surgeon), compared to those not seen by a specialist. Methods: We identified incidentaloma cases by querying the TriNetX Research Network for all adult patients with an unspecified adrenal mass occurring within 1 month following abdominal imaging. We compared those seen by a specialist against those not following an incidentaloma diagnosis. Primary outcomes were rates of hormonal testing and adrenal gland surgery. Results: Of 132,217 incidentaloma patients, 1054 (0.7%) received a specialist consultation. Referral to a specialist was associated with increased hormonal testing (49.5% vs. 28.0%, p < 0.0001) and adrenal surgery (6.3% vs. 3.6%, p < 0.0001). Surgery rates were similar among those who received hormonal testing, regardless of specialist consultation (12.6% vs. 13.3%, p = 0.8445). Of all incidentaloma patients, 6765 (5.2%) proceeded to adrenal surgery. Conclusions: Patients receiving specialist services experienced more hormonal testing and treatment with surgery. Surgery rates did not differ among those undergoing any hormonal evaluation, regardless of specialist status, indicating that about 13% of incidentaloma patients will require adrenal surgery. Applying this rate suggests that nearly 14,000 incidentaloma patients in TriNetX did not receive surgery despite likely meeting criteria, a significant failure in treatment. Further, prospective studies are needed to investigate practice patterns and expose reasons for the lack of progression to evaluation or treatment.