Incidentaloma Biopsies of Scant Diagnostic Benefit

CHICAGO — Needle biopsy of an incidentally discovered adrenal mass is unlikely to be informative, diagnostic, or of assistance in clinical decision making, according to Dr. Frank J. Quayle.

Nonetheless, the procedure continues to be done, and at considerable risk to patients, Dr. Quayle said at the annual meeting of the Central Surgical Association.

In a chart review of 347 patients referred to the endocrine surgery service, 22 had undergone fine-needle aspiration biopsy before referral, said Dr. Quayle of Washington University, St. Louis.

Fifteen of these 22 patients had been referred for incidentally discovered adrenal masses, or incidentalomas, four for suspected metastases, and three for symptomatic masses.

Of particular concern was the fact that 10 of the biopsies were performed before biochemical testing was done to exclude pheochromocytoma, despite the existence of well-established guidelines on biochemical evaluation for this potentially lethal tumor, Dr. Quayle said.

Biopsy results were either nondiagnostic or noninformative in 17 patients, or 77% of the cohort, including 13 of the 15 referred for incidentalomas.

Following resection and pathologic analysis, six of the incidentalomas were found to be adenomas and four were pheochromocytomas, with the remainder having various diagnoses including paragangliomas and organizing hematomas.

In three of the incidentalomas the biopsy results were discordant with the final pathology, showing normal tissues where the final diagnosis was pheochromocytoma in two and organizing hematoma in one.

Two of the four patients with suspected metastases had noninformative biopsies, while in one the biopsy was diagnostic for metastatic melanoma and one was diagnostic for renal cell carcinoma. All four of these patients underwent resection, and in the patients whose biopsies had been nondiagnostic the final diagnoses were renal cell metastasis and organizing hematoma, he said.

Two of the three biopsies for patients with symptomatic masses were nondiagnostic, with the third demonstrating a poorly differentiated malignant neoplasm.

Biopsy-related complications that required hospitalization—such as hemothorax—occurred in three patients. There were no hemodynamic complications, although these have been described in the literature, Dr. Quayle said.

In the operating room, resection had to be converted to an open procedure in one patient, with a key factor being inflammation relating to the biopsy, he said.

“Perhaps the most important finding was that biopsy results did not change clinical management in any of the patients,” he said.

All of the incidentalomas had biochemical and imaging findings that directed management, and all those with symptomatic masses and suspected metastases were candidates for resection regardless of biopsy results, he said.

“We therefore conclude that the risk-benefit ratio for adrenal biopsy in incidentally discovered adrenal masses is unacceptably high. The decision to perform a biopsy should be made by specialists who understand the limitations of the procedure and exactly how the results will be used to direct patient care,” Dr. Quayle said.

After Dr. Quayle's presentation, a member of the audience, Dr. Herbert Chen, said that often, “we are asked [as surgeons] to evaluate patients with incidentally discovered masses, and we generally do not consider an invasive biopsy unless it will change our management. Unfortunately this is not the case among nonsurgeons.”

“It was all risk with no benefit for these patients,” added Dr. Chen, of the University of Wisconsin, Madison.

Another member of the audience, Dr. Christopher McHenry of MetroHealth Medical Center, Cleveland, said that it is also important to emphasize that microscopic features cannot be used to distinguish benign from malignant tumors.

“Our pathologists can't make the diagnosis of malignancy even if they have the entire tumor,” he said.

“It's the presence of local invasion and metastases, either lymph node or systemic, that makes these diagnoses,” Dr. McHenry said.

CHICAGO — Needle biopsy of an incidentally discovered adrenal mass is unlikely to be informative, diagnostic, or of assistance in clinical decision making, according to Dr. Frank J. Quayle.

Nonetheless, the procedure continues to be done, and at considerable risk to patients, Dr. Quayle said at the annual meeting of the Central Surgical Association.

In a chart review of 347 patients referred to the endocrine surgery service, 22 had undergone fine-needle aspiration biopsy before referral, said Dr. Quayle of Washington University, St. Louis.

Fifteen of these 22 patients had been referred for incidentally discovered adrenal masses, or incidentalomas, four for suspected metastases, and three for symptomatic masses.

Of particular concern was the fact that 10 of the biopsies were performed before biochemical testing was done to exclude pheochromocytoma, despite the existence of well-established guidelines on biochemical evaluation for this potentially lethal tumor, Dr. Quayle said.

Biopsy results were either nondiagnostic or noninformative in 17 patients, or 77% of the cohort, including 13 of the 15 referred for incidentalomas.

Following resection and pathologic analysis, six of the incidentalomas were found to be adenomas and four were pheochromocytomas, with the remainder having various diagnoses including paragangliomas and organizing hematomas.

In three of the incidentalomas the biopsy results were discordant with the final pathology, showing normal tissues where the final diagnosis was pheochromocytoma in two and organizing hematoma in one.

Two of the four patients with suspected metastases had noninformative biopsies, while in one the biopsy was diagnostic for metastatic melanoma and one was diagnostic for renal cell carcinoma. All four of these patients underwent resection, and in the patients whose biopsies had been nondiagnostic the final diagnoses were renal cell metastasis and organizing hematoma, he said.

Two of the three biopsies for patients with symptomatic masses were nondiagnostic, with the third demonstrating a poorly differentiated malignant neoplasm.

Biopsy-related complications that required hospitalization—such as hemothorax—occurred in three patients. There were no hemodynamic complications, although these have been described in the literature, Dr. Quayle said.

In the operating room, resection had to be converted to an open procedure in one patient, with a key factor being inflammation relating to the biopsy, he said.

“Perhaps the most important finding was that biopsy results did not change clinical management in any of the patients,” he said.

All of the incidentalomas had biochemical and imaging findings that directed management, and all those with symptomatic masses and suspected metastases were candidates for resection regardless of biopsy results, he said.

“We therefore conclude that the risk-benefit ratio for adrenal biopsy in incidentally discovered adrenal masses is unacceptably high. The decision to perform a biopsy should be made by specialists who understand the limitations of the procedure and exactly how the results will be used to direct patient care,” Dr. Quayle said.

After Dr. Quayle's presentation, a member of the audience, Dr. Herbert Chen, said that often, “we are asked [as surgeons] to evaluate patients with incidentally discovered masses, and we generally do not consider an invasive biopsy unless it will change our management. Unfortunately this is not the case among nonsurgeons.”

“It was all risk with no benefit for these patients,” added Dr. Chen, of the University of Wisconsin, Madison.

Another member of the audience, Dr. Christopher McHenry of MetroHealth Medical Center, Cleveland, said that it is also important to emphasize that microscopic features cannot be used to distinguish benign from malignant tumors.

“Our pathologists can't make the diagnosis of malignancy even if they have the entire tumor,” he said.

“It's the presence of local invasion and metastases, either lymph node or systemic, that makes these diagnoses,” Dr. McHenry said.

CHICAGO — Needle biopsy of an incidentally discovered adrenal mass is unlikely to be informative, diagnostic, or of assistance in clinical decision making, according to Dr. Frank J. Quayle.

Nonetheless, the procedure continues to be done, and at considerable risk to patients, Dr. Quayle said at the annual meeting of the Central Surgical Association.

In a chart review of 347 patients referred to the endocrine surgery service, 22 had undergone fine-needle aspiration biopsy before referral, said Dr. Quayle of Washington University, St. Louis.

Fifteen of these 22 patients had been referred for incidentally discovered adrenal masses, or incidentalomas, four for suspected metastases, and three for symptomatic masses.

Of particular concern was the fact that 10 of the biopsies were performed before biochemical testing was done to exclude pheochromocytoma, despite the existence of well-established guidelines on biochemical evaluation for this potentially lethal tumor, Dr. Quayle said.

Biopsy results were either nondiagnostic or noninformative in 17 patients, or 77% of the cohort, including 13 of the 15 referred for incidentalomas.

Following resection and pathologic analysis, six of the incidentalomas were found to be adenomas and four were pheochromocytomas, with the remainder having various diagnoses including paragangliomas and organizing hematomas.

In three of the incidentalomas the biopsy results were discordant with the final pathology, showing normal tissues where the final diagnosis was pheochromocytoma in two and organizing hematoma in one.

Two of the four patients with suspected metastases had noninformative biopsies, while in one the biopsy was diagnostic for metastatic melanoma and one was diagnostic for renal cell carcinoma. All four of these patients underwent resection, and in the patients whose biopsies had been nondiagnostic the final diagnoses were renal cell metastasis and organizing hematoma, he said.

Two of the three biopsies for patients with symptomatic masses were nondiagnostic, with the third demonstrating a poorly differentiated malignant neoplasm.

Biopsy-related complications that required hospitalization—such as hemothorax—occurred in three patients. There were no hemodynamic complications, although these have been described in the literature, Dr. Quayle said.

In the operating room, resection had to be converted to an open procedure in one patient, with a key factor being inflammation relating to the biopsy, he said.

“Perhaps the most important finding was that biopsy results did not change clinical management in any of the patients,” he said.

All of the incidentalomas had biochemical and imaging findings that directed management, and all those with symptomatic masses and suspected metastases were candidates for resection regardless of biopsy results, he said.

“We therefore conclude that the risk-benefit ratio for adrenal biopsy in incidentally discovered adrenal masses is unacceptably high. The decision to perform a biopsy should be made by specialists who understand the limitations of the procedure and exactly how the results will be used to direct patient care,” Dr. Quayle said.

After Dr. Quayle's presentation, a member of the audience, Dr. Herbert Chen, said that often, “we are asked [as surgeons] to evaluate patients with incidentally discovered masses, and we generally do not consider an invasive biopsy unless it will change our management. Unfortunately this is not the case among nonsurgeons.”

“It was all risk with no benefit for these patients,” added Dr. Chen, of the University of Wisconsin, Madison.

Another member of the audience, Dr. Christopher McHenry of MetroHealth Medical Center, Cleveland, said that it is also important to emphasize that microscopic features cannot be used to distinguish benign from malignant tumors.

“Our pathologists can't make the diagnosis of malignancy even if they have the entire tumor,” he said.

“It's the presence of local invasion and metastases, either lymph node or systemic, that makes these diagnoses,” Dr. McHenry said.