肾上腺意外瘤指南Adrenal-Incidentaloma-guidelinesPPT课件

.,1,AdrenalIncidentalomaguidelines,AACE/AAES,.,2,Outline,DefinitionPrevalenceAnatomyandPhysiologyReviewDiagnosticWorkupsConclusions,.,3,Definition,“Masslesiongreaterthan1cmindiameterdiscovered“accidentally”duringaradiographicexaminationperformedforindicationsotherthananevaluationforadrenaldisease.”,Managementoftheclinicallyinapparentadrenalmass(incidentaloma).NIHState-of-the-ScienceConferenceStatementFeb4-6,2002.,.,4,Prevalence,Autopsies:87,065cases:6%withadrenaladenomasAbdominalCT(61,054CTscansreviewed):4%withadrenaladenomasNowapproachesthe8.7%incidencereportedinautopsyseries,.,5,IncidenceIncreaseswithAge,EndocrineandMetabolismClinicsofNorthAmerica.2000;29(1):159-185,.,6,ThreeMainQuestions,Istheadrenalmasshormonallyactive?Isthemassbenignormalignant?Doesthepatienthaveahistoryofapreviousmalignantlesion?Isitmetastatic?,.,7,Anatomy,/sealion/view_photo.php?set_albumName=album265repeatfunctionalstudiesannuallyfor5years.Ifmassgrowsmorethan1cmorbecomeshormonallyactive,thenadrenalectomyisrecommended.,.,15,HyperfunctioningHormonalEvaluation,SubclinicalCushingsSyndromePheochromocytomaPrimaryAldosteronismSexhormone-secretingadrenocorticaltumors,.,16,SubclinicalCushingsSyndrome,HypercortisolismwithoutclinicalmanifestationsofCushingssyndromeMostfrequenthormonalabnormalityinadrenalincidentalomas,.,17,SubclinicalCushingsSyndrome,CentralobesityFacialroundingBuffalohumpEasybruisingPurplestriaeProximalmuscleweaknessEmotional/cognitivechanges,.,18,SubclinicalCushingsSyndrome,Increaseriskfor:HypertensionDyslipidemiaImpairedglucosetoleranceType2DMAtherosclerosisOsteoporosis?,TauchmanovaL,et.al.PatientswithsubclinicalCushingssyndromeduetoadrenaladenomahaveincreasecardiovascularrisk.JCEM2000;85:1440.,.,19,SubclinicalCushingsSyndrome,BiochemicalabnormalitiesElevatedurinefreecortisolLoworsuppressedACTHBlunteddiurnalvariationNocortisolsuppressionafter1mgovernightdexamethasonesuppressiontest-BESTSCREENINGTEST!,1.ManteroF,etal.HormoneRes47:284289,19972.MontwillJ,etal.TheO/NDSTistheprocedureofchoiceforscreeningforCushingssyndrome.Steroids1994;59:2296,.,20,DexamethasoneSuppressionTest,1mgdexamethasoneat11PMMeasurecortisolat8AMthenextmorningNormal:cortisol30andPAC20ng/dL90%specandsensitivityforPAIfscreeningtestispositive-needtoconfirmwithsalinesuppressiontest,adrenalvenoussamplingandimaging,.,36,midnightsalivarycortisol,ora2-daylow-dosedexamethasonesuppressiontest,midnightsalivarycortisol,ora2-daylow-dosedexamethasonesuppressiontest,.,37,.,38,HyperfunctioningHormonalEvaluation,SubclinicalCushingsSyndromePheochromocytomaPrimaryAldosteronismSexhormone-secretingadrenocorticaltumors,.,39,Sexhormone-secretingAdrenocorticalTumors,RareTypicallyoccurinthepresenceofclinicalmanifestations(hirsutismorvirilization),.,40,Hirsutism,.,41,Sexhormone-secretingAdrenocorticalTumors,RareTypicallyoccurinthepresenceofclinicalmanifestations(hirsutismorvirilization)Routinescreeningforexcessandrogensandestrogensisnotwarranted,.,42,HormonalWorkupSummary,3hormonaltestsnecessaryforworkupofadrenalincidentaloma:1mgovernightdexamethasonesuppresiontestPlasmaorurinaryfractionatedmetaneprinesPlasmaaldosteroneconcentrationandplasmaaldosteroneconcentration/plasmareninactivityratio(PAC/PRA).,.,43,Treatment,AllpatientswithdocumentedpheochromocytomaandprimaryaldosteronismshouldundergosurgeryNoprospective,randomizedtrialsforSubclinicalCushingsSyndromebutconcensusistoproceedwithsurgeryifthepatientisyoung,.,44,ThreeMainQuestions,Istheadrenalmasshormonallyactive?Isthemassbenignormalignant?Doesthepatienthaveahistoryofapreviousmalignantlesion?Isitmetastatic?,.,45,PrimaryAdrenalCarcinoma,Veryrare:5casesper1millionpopulationSmallsizecorrespondstobetterprognosis5yearsurvivalOverall:16%Localizeddisease(stageIandII):42%Metastases:5.3%,.,46,Imaging,complexsolidandcystic,calcifiedmass,.,47,PatientwithKnownMalignancy,10-40%ofpatientswithknownmalignancyhaveadrenalmetastasesatautopsyMostcommonprimaryBreastLungKidneyMelanomaLymphoma,.,48,AssessmentofMalignantPotential,SizeImagingPhenotype(features),.,49,Size,ProbabilityofmalignancyincreaseswithsizeInastudyinvolving887patientswithadrenalincidentalomas,90%ofpatientswithadrenalcarcinomashastumor4cm(NationalItalianStudyGroup,1997)adrenalcarcinomas2%(6cm),.,50,Size,MayoClinicStudy342PatientswithadrenalincidentalomaretrospectivelyevaluatedTumordiameteraveraged2.5cmMostmalignanttumorsmeasured5cmIncidentallydiscoveredadrenaltumors:aninstitutionalperspective.HerreraMF;GrantCS;vanHeerdenJA;SheedyPF;IlstrupDM.Surgery1991Dec;110(6):1014-21,.,51,Size,ConsensusStatementMass6cmshouldberemovedMass4cmcanbemonitoredMassbetween4-6cm:Criteriaotherthansizeshouldbeusedtodictatesurgeryvs.monitoring,Managementoftheclinicallyinapparentadrenalmass(incidentaloma).NIHState-of-the-ScienceConferenceStatementFeb4-6,2002.,.,52,AssessmentofMalignantPotential,SizeImagingPhenotype,.,53,ImagePhenotype-CTScan,Hounsfieldunit(HU)-semiquantitativemethodformeasuringx-rayattenuationWater=0HUAdiposetissue=-20to-150HUKidney=20to50HUBone=1000HULipidrichmassarebenignHU10onunenhancedCT=benignadenoma100%,.,54,ImagePhenotype-CTScan,Retrospectiveanalysisof151patientswithadrenalmassesHU10oracombinationoftumorsize4cmandHU60%at10min=nocancerWashout60%at10min=highriskformalignantlesion,.,56,Imaging-metastases,.,57,MRI,EquallyeffectiveasCTAdenomasareisointensewiththeliveronT2weightedimagesCarcinomasarehyperintensecomparedtotheliveronT2weightedimages,.,58,FNA,CytologyfromFNAcannotdistinguishbenignadrenalmassvs.malignantItcandistinguishadrenaltissuefrommetastasesFNAisusefulonlyindistinguishingadrenaltumorfrommetastasisandinfectionNeedtoruleoutpheochromocytomabeforeFNA,.,59,FollowUp,