Observation or laparoscopic adrenalectomy for adrenal incidentaloma? A surgical decision analysis.
BACKGROUND
The optimal strategy remains controversial for adrenal incidentaloma, 4 to 6 cm in size, nonfunctioning, and without malignant imaging characteristics. A decision analysis model was used to identify relevant variables for selecting the optimal management (observation versus adrenalectomy).


METHODS
Risk/benefit analysis in tertiary care center. The probabilities of each health outcome states were determined by a review of the literature from 1980 to 2002 (n=2844 patients); and from a retrospective review of experience at University of California San Francisco (UCSF).


RESULTS
The baseline probabilities of morbidity after laparoscopic unilateral adrenalectomy and a new indication developing during initial observation (hypersecretion, size increase, malignancy) were 7.8% and 3.1%, respectively. We found observation to be the preferred approach when using baseline probabilities and utilities. Laparoscopic adrenalectomy becomes the preferred approach however if: (1) The morbidity rate from laparoscopic unilateral adrenalectomy is < 3.0%, 2) The probability of a new indication developing for adrenalectomy during observation is > 7.5%, 3) A patient's perspective of observation has a utility of lower than 98.6%, and (4) A patient views having a complication from adrenalectomy is not much deleterious (utility > 88.1%).


CONCLUSIONS
This decision analysis model identifies the important variables for selecting the optimal management approach for adrenal incidentalomas. These results can be used to select the optimal management strategy based on individual patient preference and surgeon-specific complication rate.
Brunaud
Laurent
L
Department of Surgery, University California San Francisco and Mount Zion Medical Center, Mount Zion Medical Center, San Francisco, CA, USA. l.brunaud@chu-nancy.fr
Kebebew
Electron
E
Sebag
Frederic
F
Zarnegar
Rasa
R
Clark
Orlo H
OH
Duh
Quan-Yang
QY
D000310:Adrenal Gland Neoplasms / Q000401:mortality* / Q000601:surgery*; D000315:Adrenalectomy; D002140:California / Q000453:epidemiology; D003663:Decision Trees; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D012495:San Francisco / Q000453:epidemiology; D016019:Survival Analysis; D016896:Treatment Outcome