Inside the UPMC Multidisciplinary Adrenal Program: How the Team Works Together on Complex Adrenal Disease

Featured in the article are:

• Divya Sistla, MD, FACP – Clinical Assistant Professor of Medicine, Division of Endocrinology and Metabolism
• Niveditha Manivannan, MD – Clinical Assistant Professor, Division of Endocrinology and Metabolism
• Alaa Sada, MD, MS, FACS– Assistant Professor, Department of Surgery
• Linwah Yip, MD, FACS – Professor of Surgery; Chief, Division of Endocrine Surgery

The UPMC Multidisciplinary Adrenal Program cares for patients with adrenal nodules, hormonal excess syndromes, and adrenal malignancy. Medical endocrinology and endocrine surgery work together, with patients moving between the two services as the workup and treatment require. When the case calls for it, oncology, radiology, nephrology and pathology can be brought in as part of the conversation, which is what allows the program to manage the full spectrum of adrenal disease in one place.

"Adrenal disease is uncommon enough that no single physician sees the full range of it in a typical practice," Dr. Yip says. "What we have built at UPMC is a program where the medical and surgical expertise is in the same room on the same case, working from the same information. That changes what we are able to offer patients, and it changes what we ask of the team that takes care of them."

A patient with an incidentally discovered adrenal nodule usually obtains a standard hormonal workup which is also guided by symptoms and other associated medical conditions. If the workup points to a functioning tumor or the imaging raises concern, surgery, or medication options in some cases, become a consideration.

UPMC sees one of the highest volumes of adrenal patients in the country. The program cares for patients with a variety of conditions, including incidentally discovered nonfunctioning adenomas, primary aldosteronism, cortisol-producing tumors, pheochromocytomas, and adrenocortical carcinoma. Each one calls for a different workup and a different treatment plan.

"Adrenal patients are complicated," Dr. Sada says. "Multiple specialties are involved, and we have the expertise and technology to manage the full range of what we see."

How Patients Reach the Program

Patients arrive at the program through several pathways. The most common is referral from primary care after an incidental adrenal nodule is identified on imaging. Nephrology is a significant secondary source, particularly for patients with difficult-to-control hypertension or hypokalemia, both of which can signal possible primary aldosteronism. Colleagues from a wide variety of specialties with difficult to interpret initial results or challenging clinical cases account for additional volume. Finally, cross-referral within the program occurs when adrenal lesions are being considered for surgery or when medical options are being considered for non-surgical candidates who have hormonally active adrenal masses.

"Most of the referrals I see come from primary care after an incidental finding, but a meaningful share come from nephrology when a patient has difficult-to-control hypertension or low potassium," Dr. Manivannan says. "We also see self-referrals from patients who have read about cortisol excess or Cushing's syndrome and want to be evaluated."

The Monthly Case Review Conference

Once a month, the program's endocrinologists and endocrine surgeons meet to review difficult cases. Dr. Mannivannan organizes the meeting and builds it around the fellows.

"I send out a call for interesting or difficult cases the medical or surgical group has encountered," Dr. Mannivannan says. "The fellows work through them, summarize them, and present them to the group. The format gives them ownership of the cases and exposes them to the full range of perspectives in the room."

The cases brought to the meeting have already been seen in clinic by either an endocrinologist or an endocrine surgeon. The conference is where the team works through the ones that are complex, instructive, or unresolved enough to benefit from a wider discussion. Other specialties join when a case calls for it. Interventional radiology came to a recent session to weigh in on imaging and procedural options. The attending physician who saw the patient usually attends so the discussion stays grounded in the actual clinical picture rather than an abstracted version of it.

"Once we get the initial recommendations and they are put in place, we bring the case back and walk through what changed," Dr. Manivannan says. "It is a learning experience for the fellows, and it is a check for the rest of us on whether the consensus we reached actually held up."

The discussion also gives the endocrinologists a clearer view of what the surgical side of the patients they refer actually involves.

"It is easy to say, 'Go ahead and take it out,' and then realize during the discussion how many steps are involved in actually doing that," Dr. Manivannan says. "That perspective changes how we think about the cases we send forward."

Not every case ends with a decision to operate.

"Not every adrenal tumor needs surgery," Dr. Sada says. "We discuss these cases together to figure out which ones need surgery, which ones can be watched, and which ones are completely benign."

The cases that need surgery are not always the ones that look concerning on imaging, and the cases that look concerning are not always the ones that turn out to matter. The hormonal evaluation tells the team whether a tumor is functioning, which hormones are involved, and what the patient's overall picture looks like. Those answers shape the management plan, the recovery plan, and sometimes the decision about whether to operate at all.

"Removing an adrenal gland is one part of the work, and not always the hardest part," Dr. Sada says. "Some patients need hormone replacement before they leave the operating room and have to be weaned off it over months. If the medical workup is not thorough, the postoperative period is where the surprises happen, and the surprises in these patients are not small ones."

A Wider Range of Patients

The patients reaching the program now are not the same mix the program saw a decade ago. Two clinical patterns account for much of the change. Adrenal nodules show up regularly on cross-sectional imaging ordered for other reasons, and many of them get worked up that would have gone unnoticed before. In addition, the Endocrine Society now recommends that every patient with hypertension be screened at least once for primary aldosteronism, where it used to recommend screening only for refractory cases on multiple agents or with hypokalemia.

"The old criteria were missing too many patients with treatable disease," Dr. Sistla says. "Once the broader recommendation took hold in clinical practice, the referral pattern shifted. We are seeing patients now who would have spent years on additional blood pressure medications before anyone considered an adrenal cause."

Patients with primary aldosteronism do better when they are caught early, which is the main reason the screening recommendation was broadened. The earlier these patients are identified and treated, the better their long-term outcomes, and the difference is substantial enough to be a primary argument for the wider screening net. Identifying these patients also changes what can be offered. Primary aldosteronism is one of the few causes of hypertension where surgery can be curative or can substantially reduce the medication burden, which makes the diagnosis more than a relabeling exercise.

The patients reaching the program through the broader screening recommendation are often earlier in their disease course than the patients the program traditionally saw, which means the team is working through different questions than it used to. Some of those patients are clear surgical candidates. Others benefit more from medical management given their overall clinical picture. Sorting which is which is part of what the conference exists to do.

“Current guidelines recommend hormonal evaluation for any adrenal lesion, regardless of symptoms,” Dr. Sistla says. “An incidentaloma is not something you can ignore. The workup needs to happen”

Communication With Referring Physicians

Communication with referring physicians is an important part of the adrenal program’s functionality. After every visit, the treating physician sends a letter to the primary care physician or referring provider summarizing findings and next steps. The same practice applies between the team members internally.

"I regularly receive notes from Dr. Sada with updates on how a patient did with surgery and what the postoperative plan looks like," Dr. Manivannan says. “These handoff notes keep medical endocrinology current on the surgical side of patient care.”

The program also offers an electronic consultation pathway for primary care and referring physicians who are uncertain whether a patient needs to be referred for a consult. The e-consult provides an opinion on whether a patient needs to be seen in person, what workup should be initiated, and whether the case is appropriate for medical management, surgical evaluation, imaging follow-up, or otherwise. Given the frequency with which adrenal nodules are identified incidentally on cross-sectional imaging ordered for other reasons, the e-consult is an efficient way to help referring providers take the next, most appropriate step for the patient.

Learn More and Information for Referring Physicians

For more information or to schedule an appointment with endocrine surgery, please call 412-647-0467, 8 a.m. to 4:30 p.m., Monday through Friday, or visit our website.

For more information or to schedule an appointment with endocrinology, please call 412-586-9700, 8 a.m. to 4:30 pm, Monday through Friday, or visit our website.