Melanie Cole: Welcome to UAB MedCast. I'm Melanie Cole. And today, we're giving an update on a previous podcast that we did on adrenal evaluation and treatment in this thought leader conversation and physician round table. We have Dr. Jessica Fazendin, she's an Assistant Professor, an endocrine surgeon and the Medical Student Clerkship Director in the Department of Surgery; Dr. John Porterfield, he's a professor and an endocrine surgeon; and Dr. Brenessa Lindeman, she's the Section Chief and Fellowship Director for Endocrine Surgery, and they're all at UAB Medicine.

Doctors, thank you so much for joining us today. And as we're hearing about adrenal nodules and being increasingly identified on imaging studies obtained for other reasons, we were all just discussing that a bit off the air, Dr. Porterfield, I'd like to start with you. If you could tell us about the current state of adrenal evaluation, treatments, what are you seeing in the trends?

Dr. John Porterfield: Thank you, Melanie. What we see now with adrenal tumors is that we are often identifying these, as you said, at times when we're not looking for them. And there is a term that we call incidentalomas and that is any tumor that we identify in the adrenal gland that is larger than one centimeter. And these types of tumors, most of them are benign, most of them are non-functional, but they can be worrisome in the hormones that they can create. That can be aldosterone, cortisol. They can also make the adrenaline hormones from tumors, such as pheochromocytomas. And for most physicians, this is an uncommon finding. And what we want to do is be a resource at UAB, so that when these tumors are identified, that we're able to consult with physicians so that we can direct which patients need to be observed and which patients need to move on to surgery.

Melanie Cole: Then, Dr. Fazendin, based on what Dr. Porterfield has just spoken about, do you want to speak about screening and really what had been the thought previously regarding these incidental findings? Tell us a little bit about that.

Dr. Jessica Fazendin: Thank you so much, Melanie. And just to echo as to what Dr. Porterfield has already mentioned, I think it's so important for referring providers and anyone who is looking at the CT scans to know what adrenal is important for next steps and next steps for the patient most importantly. So the way that we really teach this is any adrenal incidentaloma or any nodule that you see on the adrenal that's between one and four centimeters, we really want to know if it's growing or if it's functional, just as Dr. Porterfield said.

So if any of those nodules are above one centimeter in size, we need to test for hormonal production. And those are easy tests to do that we can perform same day when they're referred to our office here in endocrine surgery. The other important number to remember is any nodule that's above four centimeters, we start to worry about a potential malignancy. So four is really that magic number where we start to not only care about hormonal production, but also the risk of cancer as it increases in size.

The other thing that I think we'd all like to emphasize is that once these adrenal nodules are identified, it's important to not look at them as one snapshot in time, but to realize that these patients all need screening and surveillance. So what we usually recommend is every six months, these patients get a repeated scan where we check that the nodule is not growing in size. And oftentimes the recommendation is that any growth more than a half a centimeter in size in half a year or six months is also an indication for surgical removal.

Dr. Brenessa Lindeman: And I just want to add on to what Dr. Fazendin has very eloquently described is that what we're really looking for or as we're marching through the evaluation of these patients with incidentally discovered adrenal masses, is we're asking three questions. One, could this be a functional mass? And so we want to test all the various hormones that we've been discussing.

The second is whether or not the mass represents a primary adrenal malignancy. And so there are mechanisms that we can utilize based on CT perfusion characteristics that can help us to determine how concerned we should be about primary adrenal cancer within an adrenal nodule. But as Dr. Fazendin said, the primary marker of concern is size. And so any large mass, those more than four centimeters in size, should be taken out.

And the third question that we often want to answer is whether or not this adrenal nodule represents metastatic disease. There's some excellent literature recently published that we were privileged to participate in demonstrating that patients with an underlying cancer that have an isolated metastasis to the adrenal gland actually have a benefit in their overall survival if that adrenal metastasis is removed surgically as compared to other forms of treatment modalities.

And so for anyone that may be listening on the call, any suspicion to those three questions, whether it might be functional or malignant or metastatic, we would encourage you to seek advice from your friendly neighborhood endocrine surgeon, either reaching out to our offices or, if you're at UAB already, we can also be reached via the eConsult process.

Dr. John Porterfield: I think that's exactly right, Brenessa. And one of the things that, you know, we see with patients having complex cancer evaluations is the advent and the such high utilization of PET scans. And so, as Dr. Fazendin mentioned, you know, size and growth, those types of things, the providers also want to know that we're looking at PET positivity in adrenal nodules as something that is suspicious for future concerns.

Melanie Cole: Well, thank you all. This is really fascinating. And Dr. Lindeman, you mentioned to me the reason, one of the reasons, that we're updating this podcast is that there are new guidelines coming out. Can you tell us a little bit about those?

Dr. Brenessa Lindeman: Yes. Thank you so much. It is interesting that the American Association of Endocrine Surgeons jointly with the American Association of Clinical Endocrinologists had gotten together to publish guidelines about management of these adrenal incidentalomas last in 2009. So it's been more than a decade since the guidelines had been revised. And we anticipate those to be released hopefully by the end of 2021, if not in early 2022.

What we expect to see is more of an emphasis on these functional adrenal disorders that we have been describing and particularly related to studies demonstrating that there are many patients that are going undiagnosed with functional adrenal disorders, specifically related to patients that have potentially surgically curable hypertension. It's actually estimated that up to 15% of all patients with high blood pressure have an underlying surgically correctable cause that is of adrenal origin specifically hyperaldosteronism or hypercortisolism. And so we anticipate that the guidelines are going to suggest that we need to do more to be screening patients for hyperaldosteronism when they are seen in primary care clinics and that the absence of hypokalemia, so even patients that have a normal potassium level, if they have high blood pressure that needs more than two agents to manage, that those patients should be screened with renin and aldosterone.

Dr. John Porterfield: Yeah, Brenessa, I think that's exactly right. And I think one of the other things that goes along with the screening that we have to offer at UAB is that we have a spectacular relationship with our interventional radiologists and several of which I almost consider as endocrine interventional radiologist in that they're extremely skilled with adrenal venous sampling, which we primarily use for aldosterone-secreting tumors because I found a fair number of patients that have not been referred to us, because they had hyperaldosteronism and they were thought that this was coming from both adrenal glands. But in reality, when we tested them, we actually did find that they did lateralize to either the right or the left side, even with very small tumors that can be in the order of three or four millimeters that could be barely detected on a high resolution CT scan. But yet, if the suspicion is high that they have hyperaldosteronism and that the opportunity for it to be localized to one side or the other, it changes people's lives to be able to have their hypertension surgically correctable.

And I think as endocrine surgeons, you know, I know the three of us have talked about it, that this is one of the reasons we went into endocrine surgery was so that we could take out these small tumors, but be able to have a big impact in patient's lives. And so just because someone has hyperaldosteronism and their CT scan is normal, it doesn't mean that they might not have an opportunity for surgically correctable hypertension.

Dr. Jessica Fazendin: I could not agree more with Dr. Porterfield and Dr. Lindeman on this issue, it is incredibly satisfying to treat a patient with a biochemically-proven hyperaldosteronism and just to emphasize how important that early referral is, because the sooner that that patient can undergo a surgical cure, the more likely they are to be able to be weaned off of those anti-hypertensive medications and to receive the most clinical benefit.

Melanie Cole: Well, Dr. Fazendin, I was just getting to you with that question. So tell us, as we're speaking about evaluation, there's some confusion on timing of referral. And should all identified adrenal nodules be evaluated to determine whether they might harbor that malignancy? Tell us what the diagnostic approach in patients with adrenal nodules that other providers should focus on and why you feel the timing of referral is so important.

Dr. Jessica Fazendin: Melanie, it's a great question. Again, I think it's so important to just remember those numbers. So anything above one centimeter seen on imaging should really undergo that biochemical workup. Because again, it's been shown that the sooner that we can intervene, if it is in fact a hormone-producing nodule, the sooner that we can get that out, the greater clinical benefit our patients will experience. And then, not only that growth at the six-month mark where it has been shown to grow at least half a centimeter, but then also the number four being really what to remember as where the risk of malignancy really does jump much higher.

So the only other thing that I would really like to emphasize is I often get asked this almost on a weekly basis, what's the best test to order if you do suspect an adrenal module or you want to better characterize it? And a CT scan with adrenal protocol is really the most ideal scan as opposed to an MRI if that is not contraindicated in the patient population.

Dr. John Porterfield: Yeah, absolutely. And I would add to that, that it's unfortunate whenever we see patients that have a delay in referral, because they felt like the primary care doctor felt like that they were too old or too sick for adrenal surgery. And historically, adrenal surgery was an open procedure. Patients were in the hospital for multiple days and the preparation was complex. The inpatient stay was intense with complications. And, now adrenal surgery has really moved to be in line with so many other outpatient procedures that we do now, that patients are able to be well-prepared and coached to be able to have their procedure, which routinely the surgical time from skin incision until close can be an hour or an hour and 15 minutes. And then the patients are able to leave the hospital within two hours of the surgery. So the opportunity to lower the impact and to truly make this minimally invasive surgery has opened up the opportunity to operate on patients that are older and sicker than we would have in years past.

Dr. Brenessa Lindeman: Dr. Porterfield, that is such an important point. And I'm glad that you raised it. I want to emphasize what he said in that here at UAB in Endocrine Surgery, we are leading the nation in advancing techniques for outpatient adrenal surgery. At present, we are one of three centers I'm aware of that routinely allows patients to go home the day of surgery following a minimally invasive adrenalectomy.

And so that's one of the areas that we have a laser focus on is how to advance these techniques and also innovate around the patient experience, ensuring that patients are well-prepared in advance of surgery. They know what to expect on the day of surgery, as well as following discharge. And our recent studies have shown that is associated with improved patient satisfaction, such that patients undergoing outpatient adrenalectomy are equally, if not more satisfied with their operative course than patients who stayed overnight in the hospital.

Melanie Cole: Well, UAB is certainly at the top of the heap. And you all, I can hear the passion for what you do. I'd like to give you all a chance for a final thought. So, Dr. Lindeman, starting with you. As Dr. Porterfield just spoke about some changes in surgery and the timing, can you speak about any other treatment modalities? Is there an update on where things are as far as medication or radio-iodine therapy, nutrition? Anything else you'd like to bring into this discussion?

Dr. Brenessa Lindeman: Thank you so much, Melanie. The one other point that I wanted to make today for our physician population out there is to be increasingly on the lookout for something called subclinical Cushing syndrome. You know, in Alabama, the Southeastern United States and beyond, we know that obesity and metabolic syndrome are another parallel pandemic. And literature is also demonstrating that many patients with this metabolic syndrome-type profile actually have an underlying adrenal nodule that's making not an overwhelming amount of cortisol that presents with the classic Cushing syndrome features, but just a little bit that contributes to hypertension, hyperlipidemia, diabetes, and poor glucose control. And that those patients benefit much more from surgical adrenalectomy as compared to any medical therapy. And so if anyone has questions about that, we would love to tell you more about it either one-on-one or through discussion of a specific patient.

Melanie Cole: Dr. Fazendin, onto you, as this condition has so many aspects as we've discussed today of treatment modalities. Can you expand a little on that multidisciplinary approach that's so important for these patients and how other providers can help their patients deal with some of the physical and social, emotional side effects and how at UAB you're working with so many providers to help with that whole person picture?

Dr. Jessica Fazendin: That's a great question, Melanie. And I will say this, that any provider that sends an adrenal patient to here at UAB for endocrine surgery can be sure that this patient will be discussed at a multidisciplinary tumor board. This patient will have the opportunity to be presented multimodality treatments and different surgical approaches either through the abdomen or the back where oftentimes the biggest incision is going to be the size of your thumb.

And so as Dr. Porterfield had said earlier in the podcast, these patients, and Dr. Lindemann had mentioned, you know, have great outcomes with outpatient surgery and being able to leave the hospital same day, that's so important, especially in this day and age, trying to get out of the hospital during a pandemic.

And so oftentimes our patients, we're really lucky to be able to treat them as such. Give them between three and four tiny little incisions, to heal from this often as they would from a gallbladder surgery and to have a great functional outcome. And so we work with great endocrinologists here and around the state to work up these patients. And I think that my partners and I just really feel excited about these new ventures and being able to treat these patients with minimally invasive adrenalectomy.

Melanie Cole: Certainly an exciting time to be in your field. And Dr. Porterfield, last word to you. Do you have any promising new therapies for adrenal deficiency syndromes or adrenal gland nodules? Looking forward if you had to, to the next 10 years in the field, where do you feel the most important areas of research will be? And what would you like other providers to take away from this podcast today and the message about your team at UAB Medicine?

Dr. John Porterfield: Yeah, that's a great question. I think like a lot of things in medicine, I think that we will see more patient-specific diagnostic tools that will come out as we are able to more specifically test. We've been testing these hormones very consistently for 60 to 70 years, and I hope to see some more innovation and more specialized approach to individual patients that we may be able to pick up on even more surgically correctable adrenal disorders over the next few years.

But I think the thing to really highlight as I was listening to Dr. Fazendin and Dr. Lindeman was that at UAB, we do have this complete wrap around the patient, if you will. And we would be remiss to not mention our anesthesia colleagues that do a spectacular job managing these patients intraoperatively as we're dealing with patients that have labile blood pressures, they have labile blood sugars and all of the hemodynamics that go into place as we're doing these specialized minimally invasive approaches to remove adrenal tumors. They really are one of the keys to us being able to do these procedures and being able to have them leave in an outpatient setting.

So I think in the next 10 years, I think that if we could push for anything, we would all push for every tumor larger than a centimeter to be evaluated. And for any provider that has a question, just to go ahead and send them to us. We can answer questions and they can order the tests. But honestly, we would really love to just have them come to us so that we could be able to line up the most cost-effective and the most comprehensive biochemical and imaging evaluation that would get these patients ready for a safe minimally invasive adrenalectomy if that's what they need.

Melanie Cole: What a great conversation this was. Thank you all for sharing your expertise in this physician round table. It was really an informative episode. And a physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST or you can always visit our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. I'm Melanie Cole. Thanks so much for joining us today.