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Adrenal Incidentaloma: Evidence Based Approach. Dr Daniel Wong Department of Surgery Kwong Wah Hospital. Adrenal Incidentaloma- Definition. Adrenal mass >1cm Detected during investigation for extra-adrenal pathology Exclude workup of Known malignancy patients

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adrenal incidentaloma evidence based approach

Adrenal Incidentaloma:Evidence Based Approach

Dr Daniel Wong

Department of Surgery

Kwong Wah Hospital

adrenal incidentaloma definition
Adrenal Incidentaloma- Definition
  • Adrenal mass >1cm
  • Detected during investigation for extra-adrenal pathology
    • Exclude workup of
      • Known malignancy patients
      • Hypertensive and hypokalaemic patients
adrenal incidentaloma definition3
Adrenal Incidentaloma- Definition
  • Prevalence 1.4-8.7%
  • Found in up to 5% CT scan

Angeli Horm Res 1997

Barzon et al Eur J Endocrinol 2003

adrenal incidentaloma aetiology
Adrenal Incidentaloma- Aetiology
  • Adrenal cortical tumours
    • Adenoma, nodular hyperplasia, carcinoma
  • Adrenal medullary tumours
    • Pheochromocytoma
  • Rare tumours
    • Lipoma, myelolipoma
  • Metastatic lesion
  • Others- cyst, abscess, haematoma
adrenal incidentaloma aetiology5
Adrenal Incidentaloma- Aetiology
  • Risk of malignancy & functional tumours overestimated

Cawood et al Eur J Endocrinol 2009

adrenal incidentaloma natural history
Adrenal Incidentaloma- Natural History
  • Most are non functional adenoma
  • Size of lesion crucial
    • >25% malignant if >6cm
    • 2% malignant if <4cm
  • 20% develop subsequent hormone production
  • 25% may increase in size

NIH State of the Science guidelines 2002

management guidelines
Management Guidelines
  • National Institute of Health State of the Science guidelines 2002
  • Young NEJM 2007 guidelines
  • Singh et al ACP best practice guidelines
    • J Clin Pathol 2008
adrenal incidentaloma workup
Adrenal Incidentaloma Workup
  • Whether it is functional
    • Blood pressure, potassium (not reliable)
    • Aldosterone/renin ratio
    • 1mg overnight dexamethasone suppression test
    • 24 hour urine metanephrine, catecholamines
    • Plasma DHEAS level (optional)

NIH State of the Science Guidelines 2002

adrenal incidentaloma workup9
Adrenal Incidentaloma Workup
  • Whether it is malignant: CT scan findings
    • >6cm high chance of malignancy
    • Ideal lower cut off controversial
    • 4cm cutoff- 90% sensitivity for cancer
      • 76% of lesion excised were benign
    • Smooth, sharp border, calcifications

Angeli Hormone Res 1998

NIH State of the Science Guidelines 2002

Yong NEJM 2007

adrenal incidentaloma workup10
Adrenal Incidentaloma Workup
  • Whether it is malignant: CT scan findings
    • Adenoma has higher fat content
    • Density (Hounsfield Unit): <10 likely adenoma
    • Enhancement washout >50% at 15 minutes likely adenoma

NIH State of the Science Guidelines 2002

slide11

Adrenal Metastasis

Adrenal Carcinoma

Adapted from Dunnick AJR 2002

slide12

2.8x2.8x2.3cm pheochromocytoma

9x8x8cm benign adenoma

Linos Hormone 2003

adrenal incidentaloma workup13
Adrenal Incidentaloma Workup
  • CT guided biopsy
    • Only recommended if known primary cancer
      • i.e. not true incidentaloma
    • Need to exclude phaeochromocytoma first!
    • Random use give low diagnostic yield
yield of ct guided biopsy
Yield of CT Guided Biopsy

Mazzaglia Arch Surg 2009

adrenal incidentaloma workup15
Adrenal Incidentaloma Workup
  • MRI
    • No proven benefit over CT scan
  • Role of PET scan
    • Only if known history of carcinoma
    • 100% sensitivity in detecting metastasis

Frilling et al Surgery 2004

management surgery
Management- Surgery
  • If hormonal active or suspicious CT scan
  • Laparoscopic approach recommended
  • Crucial to consider the indication of surgery

Conzo Can J Surg 2009

management follow up
Management- Follow up
  • CT scan at regular intervals
    • 6/12/24 months
  • Annual hormonal workup
  • Discharge if static for 4 years

NIH State of the Science Guidelines 2002

subclinical cushing s syndrome
Subclinical Cushing’s Syndrome
  • Subclinical Cushing’s Syndrome (SCS)
    • Mild secretion of cortisol without clinically evident signs of hormone excess
    • No universally accepted definition

Rossi J Clin Endocrinol Metab 2000

subclinical cushing s syndrome19
Subclinical Cushing’s Syndrome
  • 5-20 % AI patients
    • Large percentage with hyperlipidaemia, hypertension, diabetes
    • Risk of cardiovascular diseases
    • Lower bone density, increased fracture risk
  • Surgery improves diabetic, BP control, lipid profile and obesity

Comlekci et al Endocrine 2009

Chiodini J Clin Endocrinol Metab 2009

Toniato Ann Surg 2009

conclusions
Conclusions
  • AI - common radiological finding
  • Most are benign and indolent
  • Size good predictor of malignant risk
  • Regular follow up needed
  • Expanding indications for surgery in laparoscopic era