肾上腺意外瘤指南Adrenal Incidentaloma guidelines

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,Adrenal,Incidentaloma,guidelines,AACE/AAES,Outline,Definition,Prevalence,Anatomy and Physiology Review,Diagnostic Workups,Conclusions,Definition,“,Mass lesion greater than 1 cm in diameter discovered “accidentally” during a radiographic examination performed for indications other than an evaluation for adrenal disease.”,Management of the clinically,inapparent,adrenal mass (,incidentaloma,). NIH State-of-the-Science Conference Statement Feb 4-6, 2002.,Prevalence,Autopsies: 87,065 cases:,6%,with adrenal adenomas,Abdominal CT (61,054 CT scans reviewed):,4%,with adrenal adenomas,Now approaches the,8.7%,incidence reported in autopsy series,Incidence Increases with Age,Endocrine and Metabolism Clinics of North America . 2000; 29(1):159-185,T,hree,Main Questions,Is the adrenal mass hormonally active?,Is the mass benign or malignant?,Does the patient have a history of a previous malignant lesion?,Is it metastatic?,Anatomy,http:/,shutterbug.ucsc.edu/sealion/view_photo.php?set_albumName,=album265&id=Adrenal,Anatomy,http:/,shutterbug.ucsc.edu/sealion/view_photo.php?set_albumName,=album265&id=Adrenal,Anatomy,Primary,Aldosteronism,Cushings Syndrome,DHEA-s,Pheochromocytoma,Frequency of Findings,Multicenter study of 1096 cases,Nonfunctioning adenoma: 85%,Subclinical Cushings syndrome: 9%,Pheochromocytoma,: 4%,Aldosteronomas,: 2%,Mantero,et al. 85 (2): 637. (2000),Frequency of Findings,Allolio, B., Adrenal,Incidentalomas,.,Adrenal Disorders, ed. C.G.,Margioris,AN. 2001, Totowa: Humana Press Inc.,A summary of the literature,Nonfunctioning adenoma Approximately 80%,Subclinical Cushing syndrome (SCS), 5%,Pheochromocytoma,5%,Aldosteronoma,1%,adrenocortical,carcinoma (ACC) 5 %,Metastatic lesion 2.5%,Ganglioneuromas,myelolipomas,or,benign cysts,考虑是否手术治疗之前准确的功能诊断非常必要,嗜铬细胞瘤要进行认真的术前准备以避免术中和术后的发作和死亡。,原发性醛固酮增多症的患者需要明确是否存在肾上腺皮质增生及无功能的肾上腺腺瘤。肾上腺源性,Cushing,综合征的患者在行切除术后可能发生肾上腺皮质功能不全，激素的替代以及增减治疗需要非常仔细。亚临床,Cushing,综合征的患者是否需要手术治疗仍存在争议。,肾上腺皮质癌的患者手术前需要外科医师和内分泌科医师或肿瘤科医师共同协商决定切除的方式，因为首次切除的效果是生存率的主要预测因素。,超过,4cm,的肾上腺无功能瘤可以考虑切除。小的髓脂肪瘤或良性的囊肿一般影像学检查即可确诊，通常不需要治疗，除非有症状可以考虑手术治疗。,Algorithm for the evaluation and management of an adrenal,incidentaloma,*,Reimage in 3 to 6 months and annually for 1 to 2 years; repeat functional studies annually for 5,years.If,mass grows more than 1cm or becomes hormonally active, then,adrenalectomy,is recommended.,Hyperfunctioning,Hormonal Evaluation,Subclinical Cushings Syndrome,Pheochromocytoma,Primary,Aldosteronism,Sex hormone-secreting,adrenocortical,tumors,Subclinical Cushings Syndrome,Hypercortisolism,without clinical manifestations of Cushings syndrome,Most frequent hormonal abnormality in adrenal,incidentalomas,Subclinical Cushings Syndrome,Central obesity,Facial rounding,Buffalo hump,Easy bruising,Purple,striae,Proximal muscle weakness,Emotional/cognitive changes,Subclinical Cushings Syndrome,Increase risk for:,Hypertension,Dyslipidemia,Impaired glucose tolerance,Type 2 DM,Atherosclerosis,Osteoporosis?,Tauchmanova,L, et. al. Patients with subclinical Cushings syndrome due to,adrenal adenoma have increase cardiovascular risk. JCEM 2000; 85:1440.,Subclinical Cushings Syndrome,Biochemical abnormalities,Elevated urine free,cortisol,Low or suppressed ACTH,Blunted diurnal variation,No,cortisol,suppression after 1 mg overnight,dexamethasone,suppression test-,BEST SCREENING TEST!,1.,Mantero,F, et al.,Hormone Res,47:284289, 1997,2.,Montwill,J, et al. The O/N DST is the procedure of choice for screening for Cushings syndrome.,Steroids,1994; 59:2296,Dexamethasone,Suppression Test,1 mg,dexamethasone,at 11PM,Measure,cortisol,at 8 AM the next morning,Normal:,cortisol, 30 and PAC 20,ng/dL,90% spec and sensitivity for PA,If screening test is positive- need to confirm with saline suppression test, adrenal venous sampling and imaging,midnight salivary,cortisol, or a 2-,day low-dose,dexamethasone,suppression test,midnight salivary,cortisol, or a 2-,day low-dose,dexamethasone,suppression test,Hyperfunctioning,Hormonal Evaluation,Subclinical Cushings Syndrome,Pheochromocytoma,Primary,Aldosteronism,Sex hormone-secreting,adrenocortical,tumors,Sex hormone-secreting,Adrenocortical,Tumors,Rare,Typically occur in the presence of clinical manifestations (,hirsutism,or,virilization,),Hirsutism,Sex hormone-secreting,Adrenocortical,Tumors,Rare,Typically occur in the presence of clinical manifestations (,hirsutism,or,virilization,),Routine screening for excess androgens and estrogens is not warranted,Hormonal Workup Summary,3 hormonal tests necessary for workup of adrenal,incidentaloma,:,1 mg overnight,dexamethasone,suppresion,test,Plasma or urinary fractionated,metaneprines,Plasma,aldosterone,concentration and plasma,aldosterone,concentration/plasma,renin,activity ratio (PAC/PRA).,Treatment,All patients with documented,pheochromocytoma,and primary,aldosteronism,should undergo surgery,No prospective, randomized trials for Subclinical Cushings Syndrome but,concensus,is to proceed with surgery if the patient is young,T,hree,Main Questions,Is the adrenal mass hormonally active?,Is the mass benign or malignant?,Does the patient have a history of a previous malignant lesion?,Is it metastatic?,Primary Adrenal Carcinoma,Very rare: 5 cases per 1 million population,Small size corresponds to better prognosis,5 year survival,Overall: 16%,Localized disease (stage I and II): 42%,Metastases: 5.3%,Imaging,complex solid and,cystic, calcified mass,Patient with Known Malignancy,10-40% of patients with known malignancy have adrenal metastases at autopsy,Most common primary,Breast,Lung,Kidney,Melanoma,Lymphoma,Assessment of Malignant Potential,Size,Imaging Phenotype (features),Size,Probability of malignancy increases with size,In a study involving 887 patients with adrenal,incidentalomas, 90% of patients with adrenal carcinomas has tumor 4 cm,(,National Italian Study Group, 1997),adrenal carcinomas,2%(6cm),Size,Mayo Clinic Study,342 Patients with adrenal,incidentaloma,retrospectively evaluated,Tumor diameter averaged 2.5 cm,Most malignant tumors measured 5 cm,Incidentally discovered adrenal tumors: an institutional perspective. Herrera MF; Grant CS; van,Heerden,JA;,Sheedy,PF;,Ilstrup,DM. Surgery 1991 Dec;110(6):1014-21,Size,Consensus Statement,Mass 6 cm should be removed,Mass 4 cm can be monitored,Mass between 4-6 cm: Criteria other than size should be used to dictate surgery vs. monitoring,Management of the clinically,inapparent,adrenal mass (,incidentaloma,).,NIH State-of-the-Science Conference Statement Feb 4-6, 2002.,Assessment of Malignant Potential,Size,Imaging Phenotype,Image Phenotype- CT Scan,Hounsfield unit (HU)-,semiquantitative,method for measuring x-ray attenuation,Water= 0 HU,Adipose tissue= -20 to -150 HU,Kidney= 20 to 50 HU,Bone= 1000 HU,Lipid rich mass are benign,HU10 on unenhanced CT= benign adenoma 100%,Image Phenotype- CT Scan,Retrospective analysis of 151 patients with adrenal masses,HU10 or a combination of tumor size 4cm and HU 60% at 10 min= no cancer,Wash out 60% at 10 min= high risk for malignant lesion,Imaging- metastases,MRI,Equally effective as CT,Adenomas are,isointense,with the liver on T2 weighted images,Carcinomas are,hyperintense,compared to the liver on T2 weighted images,FNA,Cytology from FNA cannot distinguish benign adrenal mass vs. malignant,It can distinguish adrenal tissue from metastases,FNA is useful only in distinguishing adrenal tumor from metastasis and infection,Need to rule out,pheochromocytoma,before FNA,Follow Up,Will the mass become,hypersecretory,?,Will the mass become malignant?,Conclusions,All patients with an,incidentaloma,should have a 1-mg,dexamethasone,suppression test, a plasma/urinary fractionated,metanephrines,and a,aldosterone/renin,level,A homogenous mass with low attenuation value (HU6 cm need to have the tumor removed, those with tumor 4 cm are typically monitored,Tumors between 4 to 6 cm need to consider other criteria other than size,Conclusions(3),In patients with tumors that remain stable on two imaging studies done at least 6 months apart and do not exhibit hormonal,hypersecretion,over 4 years, further following up may not be warranted.,Algorithm,Thank you for your attention,Questions?,