Catching Adrenal Disease Earlier: Incidentalomas, Updated Screening Guidance, and Making Earlier Referral a Priority

Featured in the article are:

• Divya Sistla, MD, FACP – Clinical Assistant Professor, 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

Adrenal disease is systematically underdiagnosed. Two clinical patterns account for most of the gap. The first is the incidental adrenal nodule identified on cross-sectional imaging ordered for unrelated reasons, which may then go without further workup. The second is a finding of primary aldosteronism in patients with hypertension, which has historically been screened for only in narrow circumstances despite societal guidelines urging physicians to screen broadly.

Incidental Adrenal Nodules

Adrenal nodules are encountered frequently on imaging performed for non-adrenal indications, including emergency department evaluations and primary care workups for unrelated symptoms. Many of these findings do not receive the basic hormonal evaluation and imaging follow-up that current practice requires.

"Primary care physicians are managing multiple medical issues and are often the first to note an incidental adrenal nodule," Dr. Sistla says.

The program's position is that every adrenal lesion should receive evaluation, and the threshold for involving endocrinology or endocrine surgery should be low.

"The PCP does not need to be certain a referral is needed before reaching out," Dr. Sada says. "If there is a question about whether a finding needs to be evaluated, the answer is to contact us. The patients we worry about most are the ones who never get that call. When an adrenal condition is diagnosed late, the workup is harder, the surgical decision is harder, and the outcome is more variable. Determining which lesions require follow-up and which do not is exactly the kind of decision our team is equipped to make. Early involvement means referring physicians get a clear answer quickly, rather than uncertainty about whether to act."

Updated Hyperaldosteronism Screening Guidance

The Endocrine Society has revised its guidance on screening for primary aldosteronism. Previous recommendations limited screening to patients with difficult-to-control hypertension on multiple agents, hypokalemia, or other specific clinical features. Current guidance recommends that every patient with hypertension be screened at least once.

"The narrower screening criteria were missing too many patients with treatable disease," Dr. Manivannan says. "Once we caught up with the broader recommendation, the referral pattern in clinic shifted. We are seeing patients now who would have spent years on additional antihypertensives before anyone considered an adrenal cause."

The clinical case for catching these patients earlier is supported by outcomes data. Patients with primary aldosteronism identified and treated earlier in their disease course have better long-term cardiovascular and renal outcomes than patients diagnosed after years of unrecognized disease, and the difference is substantial enough to be a primary argument for the broadened screening recommendation.

The shift matters clinically because primary aldosteronism is managed differently from essential hypertension, and the difference is not marginal.

"Hypertension is one of the most common conditions in the country and one of the least often curable," Dr. Sada says. "Primary aldosteronism is among the few causes where surgery can resolve the hypertension entirely or improve it enough that the medication burden drops substantially.”

Practical Guidance for Referring Physicians

The UPMC Multidisciplinary Adrenal Program offers referring physicians three practical guidelines when dealing with patients in whom an adrenal issue has been uncovered. Any incidentally identified adrenal lesion should have hormonal evaluation and, in most cases, imaging follow-up. Any patient with hypertension should be screened at least once for primary aldosteronism, which is consistent with the current Endocrine Society guidelines. When there is uncertainty about whether a finding requires formal referral, the program has an e-consult pathway for referring physicians.

"What changes when patients are referred earlier is what we are operating on and optimizing patients for best outcomes,” Dr. Yip says. "A small, well-characterized tumor in a patient who has had a complete hormonal workup is a different operation than a larger tumor in a patient whose physiology has been adapting to the disease for years. The surgical outcome is based on how we can best prepare patients for the surgery and this is in part shaped by how early in the course of disease the patient was identified."

The e-consult provides an endocrinology or endocrine surgery 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.

"A quick and cost-effective way to get endocrinologist's expert opinion is to consider an e consult. We are often able to recommend initial investigations and triage the cases that need more complex care,” Dr. Sistla says.

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.