Clinical decision-making
adenoma
DISEASE, ADENOMA
Each study patient was discussed in an MDT meeting attended by principal investigators, radiologists and a surgeon. The MTO scan was presented and interpreted by the reporting radiologist, always without previous knowledge of the AVS results. For each investigation, the question posed was: ‘In the absence of any other information, would this result provide sufficient evidence for a referral for surgery?’. The MDT decision was not bound unconditionally to the criteria for diagnosis of unilateral PA as outlined above. The probability of unilateral disease could, by consensus, be reduced if data from the contralateral adrenal suggested bilateral disease (for example, adenoma in the contralateral adrenal with SUVmax higher than in the adjacent adrenal). Importantly, the agreed score for MTO was entered into the case report form before discussion of the AVS and could not be revised once the AVS results were revealed. The overall outcome of the MDT was a recommendation for either surgical or medical management. Surgery was recommended if either investigation was scored highly. In a small number of patients for whom both investigations indicated an intermediate probability of unilateral PA, surgery was recommended if there was a strong clinical indication to proceed. A decision for recommending surgery was deferred if MTO and AVS showed discordant results (lateralized to opposite sides). Such participants (two in total) were managed medically with a view to reviewing the results at the end of the study, when recommendations for surgery would be based on the outcomes from the study.