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Adrenal Incidentaloma: Evidence Based Approach

Adrenal Incidentaloma: Evidence Based Approach

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Adrenal Incidentaloma: Evidence Based Approach

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  1. Adrenal Incidentaloma:Evidence Based Approach Dr Daniel Wong Department of Surgery Kwong Wah Hospital

  2. Adrenal Incidentaloma- Definition • Adrenal mass >1cm • Detected during investigation for extra-adrenal pathology • Exclude workup of • Known malignancy patients • Hypertensive and hypokalaemic patients

  3. 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

  4. Adrenal Incidentaloma- Aetiology • Adrenal cortical tumours • Adenoma, nodular hyperplasia, carcinoma • Adrenal medullary tumours • Pheochromocytoma • Rare tumours • Lipoma, myelolipoma • Metastatic lesion • Others- cyst, abscess, haematoma

  5. Adrenal Incidentaloma- Aetiology • Risk of malignancy & functional tumours overestimated Cawood et al Eur J Endocrinol 2009

  6. 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

  7. 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

  8. 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

  9. 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

  10. 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

  11. Adrenal Metastasis Adrenal Carcinoma Adapted from Dunnick AJR 2002

  12. 2.8x2.8x2.3cm pheochromocytoma 9x8x8cm benign adenoma Linos Hormone 2003

  13. 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

  14. Yield of CT Guided Biopsy Mazzaglia Arch Surg 2009

  15. 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

  16. Management- Surgery • If hormonal active or suspicious CT scan • Laparoscopic approach recommended • Crucial to consider the indication of surgery Conzo Can J Surg 2009

  17. 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

  18. 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

  19. 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

  20. 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