肾上腺意外瘤指南Adrenal Incidentaloma guidelines

AdrenalIncidentalomaguidelines,AACE/AAES,Outline,DefinitionPrevalenceAnatomyandPhysiologyReviewDiagnosticWorkupsConclusions,Definition,“Masslesiongreaterthan1cmindiameterdiscovered“accidentally”duringaradiographicexaminationperformedforindicationsotherthananevaluationforadrenaldisease.”,Managementoftheclinicallyinapparentadrenalmass(incidentaloma).NIHState-of-the-ScienceConferenceStatementFeb4-6,2002.,Prevalence,Autopsies:87,065cases:6%withadrenaladenomasAbdominalCT(61,054CTscansreviewed):4%withadrenaladenomasNowapproachesthe8.7%incidencereportedinautopsyseries,IncidenceIncreaseswithAge,EndocrineandMetabolismClinicsofNorthAmerica.2000;29(1):159-185,ThreeMainQuestions,Istheadrenalmasshormonallyactive?Isthemassbenignormalignant?Doesthepatienthaveahistoryofapreviousmalignantlesion?Isitmetastatic?,Anatomy,/sealion/view_photo.php?set_albumName=album265repeatfunctionalstudiesannuallyfor5years.Ifmassgrowsmorethan1cmorbecomeshormonallyactive,thenadrenalectomyisrecommended.,HyperfunctioningHormonalEvaluation,SubclinicalCushingsSyndromePheochromocytomaPrimaryAldosteronismSexhormone-secretingadrenocorticaltumors,SubclinicalCushingsSyndrome,HypercortisolismwithoutclinicalmanifestationsofCushingssyndromeMostfrequenthormonalabnormalityinadrenalincidentalomas,SubclinicalCushingsSyndrome,CentralobesityFacialroundingBuffalohumpEasybruisingPurplestriaeProximalmuscleweaknessEmotional/cognitivechanges,SubclinicalCushingsSyndrome,Increaseriskfor:HypertensionDyslipidemiaImpairedglucosetoleranceType2DMAtherosclerosisOsteoporosis?,TauchmanovaL,et.al.PatientswithsubclinicalCushingssyndromeduetoadrenaladenomahaveincreasecardiovascularrisk.JCEM2000;85:1440.,SubclinicalCushingsSyndrome,BiochemicalabnormalitiesElevatedurinefreecortisolLoworsuppressedACTHBlunteddiurnalvariationNocortisolsuppressionafter1mgovernightdexamethasonesuppressiontest-BESTSCREENINGTEST!,1.ManteroF,etal.HormoneRes47:284289,19972.MontwillJ,etal.TheO/NDSTistheprocedureofchoiceforscreeningforCushingssyndrome.Steroids1994;59:2296,DexamethasoneSuppressionTest,1mgdexamethasoneat11PMMeasurecortisolat8AMthenextmorningNormal:cortisol30andPAC20ng/dL90%specandsensitivityforPAIfscreeningtestispositive-needtoconfirmwithsalinesuppressiontest,adrenalvenoussamplingandimaging,midnightsalivarycortisol,ora2-daylow-dosedexamethasonesuppressiontest,midnightsalivarycortisol,ora2-daylow-dosedexamethasonesuppressiontest,HyperfunctioningHormonalEvaluation,SubclinicalCushingsSyndromePheochromocytomaPrimaryAldosteronismSexhormone-secretingadrenocorticaltumors,Sexhormone-secretingAdrenocorticalTumors,RareTypicallyoccurinthepresenceofclinicalmanifestations(hirsutismorvirilization),Hirsutism,Sexhormone-secretingAdrenocorticalTumors,RareTypicallyoccurinthepresenceofclinicalmanifestations(hirsutismorvirilization)Routinescreeningforexcessandrogensandestrogensisnotwarranted,HormonalWorkupSummary,3hormonaltestsnecessaryforworkupofadrenalincidentaloma:1mgovernightdexamethasonesuppresiontestPlasmaorurinaryfractionatedmetaneprinesPlasmaaldosteroneconcentrationandplasmaaldosteroneconcentration/plasmareninactivityratio(PAC/PRA).,Treatment,AllpatientswithdocumentedpheochromocytomaandprimaryaldosteronismshouldundergosurgeryNoprospective,randomizedtrialsforSubclinicalCushingsSyndromebutconcensusistoproceedwithsurgeryifthepatientisyoung,ThreeMainQuestions,Istheadrenalmasshormonallyactive?Isthemassbenignormalignant?Doesthepatienthaveahistoryofapreviousmalignantlesion?Isitmetastatic?,PrimaryAdrenalCarcinoma,Veryrare:5casesper1millionpopulationSmallsizecorrespondstobetterprognosis5yearsurvivalOverall:16%Localizeddisease(stageIandII):42%Metastases:5.3%,Imaging,complexsolidandcystic,calcifiedmass,PatientwithKnownMalignancy,10-40%ofpatientswithknownmalignancyhaveadrenalmetastasesatautopsyMostcommonprimaryBreastLungKidneyMelanomaLymphoma,AssessmentofMalignantPotential,SizeImagingPhenotype(features),Size,ProbabilityofmalignancyincreaseswithsizeInastudyinvolving887patientswithadrenalincidentalomas,90%ofpatientswithadrenalcarcinomashastumor4cm(NationalItalianStudyGroup,1997)adrenalcarcinomas2%(6cm),Size,MayoClinicStudy342PatientswithadrenalincidentalomaretrospectivelyevaluatedTumordiameteraveraged2.5cmMostmalignanttumorsmeasured5cmIncidentallydiscoveredadrenaltumors:aninstitutionalperspective.HerreraMF;GrantCS;vanHeerdenJA;SheedyPF;IlstrupDM.Surgery1991Dec;110(6):1014-21,Size,ConsensusStatementMass6cmshouldberemovedMass4cmcanbemonitoredMassbetween4-6cm:Criteriaotherthansizeshouldbeusedtodictatesurgeryvs.monitoring,Managementoftheclinicallyinapparentadrenalmass(incidentaloma).NIHState-of-the-ScienceConferenceStatementFeb4-6,2002.,AssessmentofMalignantPotential,SizeImagingPhenotype,ImagePhenotype-CTScan,Hounsfieldunit(HU)-semiquantitativemethodformeasuringx-rayattenuationWater=0HUAdiposetissue=-20to-150HUKidney=20to50HUBone=1000HULipidrichmassarebenignHU10onunenhancedCT=benignadenoma100%,ImagePhenotype-CTScan,Retrospectiveanalysisof151patientswithadrenalmassesHU10oracombinationoftumorsize4cmandHU60%at10min=nocancerWashout60%at10min=highriskformalignantlesion,Imaging-metastases,MRI,EquallyeffectiveasCTAdenomasareisointensewiththeliveronT2weightedimagesCarcinomasarehyperintensecomparedtotheliveronT2weightedimages,FNA,CytologyfromFNAcannotdistinguishbenignadrenalmassvs.malignantItcandistinguishadrenaltissuefrommetastasesFNAisusefulonlyindistinguishingadrenaltumorfrommetastasisandinfectionNeedtoruleoutpheochromocytomabeforeFNA,FollowUp