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Adrenal incidentaloma

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Adrenal incidentaloma by Supphachoke Khemla MD. Supphawatana phaphun MD. 20 March 2552 Cross Sectional Anatomy Normal size (Lt or Rt adrenal) : 3 cm 6 mm ... – PowerPoint PPT presentation

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Title: Adrenal incidentaloma


1
Adrenal incidentaloma
  • by
  • Supphachoke Khemla MD.
  • Supphawatana phaphun MD.
  • 20 March 2552

2
Cross Sectional Anatomy
  • Normal size (Lt or Rt adrenal) 3 cm 6 mm
  • Retroperitoneum organ
  • Gerotas fascia connect the gland to upper pole
    of the kidney

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Introduction
  • Mass lesion greater than 1 cm.
  • Serendipitiously discovered by radiologic
    examinations
  • Such as - Computed tomography (CT)
  • - Magnetic resonance imaging
    (MRI)
  • Two questions
  • - Is it malignancy ?
  • - Is it functioning ?

7
Prevalence
  • Autopsy Total 739 cases
  • (adrenal masses between 2 mm 4 cm)
  • - 9 normotensive
  • - 12 hypertension
  • The Mayo clinic
  • - 61,054 abdominal CT scans
  • - 1985 1990
  • - adrenal masses 2,066 cases (3.4)

8
Prevalence
  • The Mayo clinic
  • 2,066 cases
  • - 50 metastasis cancer
  • - 25 other known lesions
  • - 7.5 symptomatic tumors
  • - 16.5 incidental (include nodules lt 1cm)
  • - Overall incidental adrenal tumor
  • (gt 1cm) 0.4

9
Prevalence
  • Recent study high resolution scanner
  • - report prevalence from CT abdomen 4.4
  • Demonstration enlarged unusually shaped
  • 1. one adrenal mass
  • 2. bilateral adrenal masses

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Bilateral masses
  • Studies 887 and 202 cases (with adrenal
    incidentaloma)
  • - bilateral 10-15
  • - causes
  • - metastasis
    - pheochromocytoma
  • - congenital adrenal hyperplasia
    - amyloidosis
  • - cortical adenoma
    - infiltrative disease of adrenal gl.
  • - lymphoma
    - Infections TB, fungus
  • - hemorrhage
    - ACTH-dependent Cushings
  • - ACTH-independent bilateral
    macronodular adrenal hyperplasia

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Bilateral masses
  • One adrenal mass non-functioning cortical
    adenoma
  • Contralateral adrenal mass hormone secreting
  • All patients with bilateral adrenal masses
    should be screened for adrenocortical hyper/hypo
    function

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Evaluate for malignancy
  • Primary adrenal carcinoma quite rare
  • Others - metastasis
  • (particularly lung cancers)
  • Evaluate size and imaging characteristics
    (imaging phenotype)

20
Size
  • The maximum diameter is predictive of malignancy
  • Important if the smaller is at the time of
    diagnosis, the better overall prognosis
  • Adenocortical carcinomas
  • - significantly asso. with mass size
  • - 90 gt 4 cm

21
Size
  • The National Italian Study Groups
  • - 4 cm cutoff
  • - sensitivity 93
  • - specificity 76

22
Imaging phenotype
  • MRI or CT
  • 3-5 mm. cuts predict histological type of
    adrenal tumor
  • Characteristics of the mass
  • example lipid-rich nature of cortical
    adenomas
  • (benign tumor)

23
CT scan
  • Density (black is less dense)
  • Spectrum Air -black, Bone-white
  • Hounfield scale is a semiquantitative method of
    measuring x-ray attenuation
  • Typical precontrast Hounsfield unit (HU) valves
  • adipose tissue -20 to 150 HU
  • kidney 20 to 150 HU
  • if adrenal mass lt 10 HU on unenhanced CT
  • (ie, has density of fat)? likelihood
    benign
  • adenoma 100

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CT scan
  • contrast-enhanced CT
  • - adenoma rapid contrast medium washout
  • - non-adenoma delayed contrast medium
    washout
  • 10 mins after administration pf contrast
  • - adenoma absolute contrast media washout
    gt 50 ( 100 sensitivity specificity)
  • if compared with carcinomas, metastasis or
    pheochromocytoma

26
CT scan
  • Imaging phenotype does not predict hormone
    function, it can predict underlying pathology,
    and surgical resection

27
MRI
  • Although CT primary adrenal imaging
  • MRI has advantages in certain clinical situations
  • Several difference MRI
  • 1. - conventional spin-echo MRI
  • - was the first
  • - T1 and T2
  • - distinguish benign adenomas from
  • malignancy and pheochromocytoma

28
MRI
  • 2- gadolinium-DPTA-enhanced MRI
  • - adenoma mild enhancement and
    rapid
  • washout of contrast
  • - malignancy rapid and marked
  • enhancement and a slower washout
  • pattern

29
MRI
  • 3 - Chemical shift imaging (CSI)
  • - lipid sensitive imaging
  • - principle hydrogen protons in water,
  • lipid molecules
  • - chemical shift technique
  • 1. in-phase water lipid are aligned
  • signal intensity
    high
  • 2. out of phase opposite from each
    other
  • signal intensity
    low

30
MRI
  • Interpretation
  • - benign adrenal cortical adenoma lose
    signal on out-of-phase images, but appear
    relatively bright on in-phase images

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Others
  • PET (Positron emission tomography)
  • - fluoro-2-deoxy-D-glucose (FDG)
  • - high sensitivity for detect malignancy
  • - however 16 benign cortical lesions may
  • have FDG-PET uptake
  • - Metomidate (MTO) PET
  • lack of MTO specific to non-adrenal
  • cortical origin (metastasis
  • pheochromocytoma

33
Others
  • PET (Positron emission tomography)
  • - FDG-PET and MTO-PET are not recommend
  • (cost and insufficiency data to support
    their
  • routine use)

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Imaging characteristics
36
Benign adenoma
  • Benign cortical adenoma
  • Round homogenous density
  • ? lt 4 cm, unilateral
  • low unenhanced CT attenuate values (lt10HU)
  • Rapid contrast washout (10 min)
  • Absolute contrast washout gt50
  • Isointensity with liver on both T-1 T-2 (MRI)
  • Chemical shift lipid on MRI

37
Pheochromocytoma
  • Increase attenuate on nonenhanced CT (gt20HU)
  • Increase mass vascularity
  • Delayed contrast washout
  • (lt10 cm)
  • Absolute contrast washout lt50
  • High signal intensity on T-2 MRI
  • Cystic and hemorrhage
  • Variable size

38
Pheochromocytoma
39
Adrenocortical carcinoma
  • Irregular shape
  • Inhomogenous density (central necrosis)
  • ?gt 4 cm, unilateral, calcify
  • High unenhanced CT (gt20HU)
  • Delayed contrast washout (10 min)
  • Absolute contrast washout lt 50
  • Hypointensity compared with liver T-1 and high to
    intermidiateintensity T-2 MRI
  • High standard uptake value (SUV) on FDG-PET-CT
    study
  • Evidence of local invasion or metas.

40
Metastasis
  • Irregular, inhomogenous
  • Bilateral
  • High enhanced CT (gt20 HU)
  • Enhancement with contrast
  • Delayed contrast washout (10 min)
  • Absolute contrast washout lt 50
  • Isointensity or slightly less intense than liver
    T-1 , high to intermediate intensity T-2 MRI
    (represent water increase)

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Others
  • Adrenal cysts
  • Adrenal hemorrhage
  • myelolipoma

43
Fine-needle aspiration biopsy
  • Cannot distinguish a benign adrenal mass from the
    rare adrenal carcinoma
  • Thus FNA biopsy
  • - indicated a suspicion of cancer outside
    the adrenal gland
  • - staging evaluation for a known cancer
  • - not useful routine evaluation

44
IS IT FUNCTIONAL?
  • 6 - 20 of adrenal incidentalomas have hormonal
    abnormality.
  • Hormonal hypersecretion is most likely in mass
    are at least 3 cm in diameter.
  • Occurs mostly within the first 3 years after
    diagnosis.

45
  • 85 percent of the masses were non fuctioning.
  • 9 percent secreted sufficient cortisol to produce
    subclinical Cushing's syndrome .
  • 4 percent were pheochromocytomas (less than half
    caused hypertension) .
  • 2 percent were aldosteronomas .

46
  • A careful personal and family history, review of
    systems, PE.
  • At minimum for the following condition.
  • Pheochromocytoma
  • Cushing syndrome (including subclinical disease)
  • Primary aldosteronism (only if hypertensive)

47
Pheochromocytoma
  • 3-10 of adrenal incidentalomas prove to be
    pheochromocytomas.
  • Screening for pheochromocytoma is mandatory in
    all case.
  • Because high rate morbidity and mortality.
  • It is symptomatic up to 15 of case.

48
  • Screening test is measurement of plasma free
    metanephrines or 24 hr urine metanephrine .
  • Plasma free metanephrines is 99 sensitive.
  • Not very specific 85-89

49
Cushing syndrome
  • 5-20 of pt with adrenal incidentaloma are report
    to have subclinical Cushing syndrome.
  • Subclinical Cushing's syndrome
  • mild hypercortisolism without clinical
    manifestations of Cushing's syndrome .
  • most frequent hormonal abnormality detected in
    patients with adrenal incidentalomas .

50
  • In 2002 ,a National institutes of Health
    consensus panel recommened a 1 mg over night
    dexamethasone supression test.
  • Lack of supression interfering condition.
  • Decrease dexamethason absorbtion.
  • Drug barbiturate, phenyltoin, carbamazepine,
    rifampicin.
  • Increase concentration of corticosteroid-binding
    globulin
  • Pseudo Cushhig state

51
  • Hormonal evaluation in subclinical Cushing's
    syndrome showed the following
  • Low baseline secretion of corticotropine (ACTH)
    in 79 percent
  • Lack of suppressibility of cortisol secretion
    after 1 mg dexamethasone in 73 percent
  • Supranormal 24-hour urinary cortisol excretion in
    75 percent

52
  • Disturbed cortisol circadian rhythm in 43 percent
  • Blunted plasma ACTH responses to
    corticotropin-releasing hormone in 55 percent

53
  • If the post-overnight DST
  • Then baseline serum ACTH, two-day high-dose DST
    is indicated to confirm the excess hormone
    secretion.

54
Primary Hyperaldosteronism
  • 1.6-3.8 of adrenal incidentalomas.
  • Pt with hypertension should be evaluated for
    primary aldosteronism.
  • Hypokalemia suggest aldosteronism.
  • Normal K not exclude.
  • The best screening test is the ratio of the
    plasma aldosterone to the plasma renin activity.

55
Management of adrenal incidentaloma
56
Clinical and CT apperance
True cyst
adrenolipoma
Metastasis carcinoma
FNAB
investigation
Metastasia CA
resect
Aspirate?
Treatment
or
F/U
Resect if appropriate
Repeat CT at 1 yr
57
Diagnosis unclear
BP serumK Catecholamine Overnigth 1 gm DST Urine
17 OHCS 17KS
Non fuctioning
functioning
FNA lt 6 CM
gt 6CM
Adenal tissue
resect
resect
Repeat CT at 2,8,18 mo
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  • subclinical Cushing's syndrome and unilateral
    adrenalectomy?
  • absence of a prospective randomized study
  • candidates for adrenalectomy.
  • who have attributable to excess glucocorticoid
    secretion (eg, recent onset of hypertension,
    diabetes, obesity, and low bone mass)
  • lack of suppression to both an overnight DST) and
    a two-day high-dose DST.

60
Bilateral adrenal masses 
  • The management of bilateral adrenal masses is
    different from that for unilateral masses.

61
SUMMARY
  • All patients should be evaluated for subclinical
    hormonal hyperfunction and cancer.
  • History and physical examination are important in
    the initial assessment.

62
  • Benign cortical adenoma.
  • A homogeneous adrenal mass lt4 cm in diameter,
  • with a smooth border,
  • and an attenuation value lt10 HU on unenhanced CT,
  • and rapid contrast medium washout (eg, gt50
    percent at 10 minutes)

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  • The imaging suggest adrenal carcinoma or
    metastases include
  • irregular shape.
  • inhomogeneous density.
  • high unenhanced CT attenuation values (gt20 HU),
    delayed contrast medium washout (eg, lt50 percent
    at 10 minutes),
  • diameter gt4 cm, and tumor calcification. Other
    characteristics are described above.

64
  • Pheochromocytoma should be excluded by measuring
    24-hour urinary fractionated metanephrines and
    catecholamines.
  • Subclinical Cushing's syndrome should be ruled
    out by the 1-mg overnight dexamethasone.
  • primary aldosteronism. should be screen in
    patient is hypertensive by a plasma
    aldosterone-to-plasma renin activity ratio and
    plasma potassium concentration

65
  • Recommend surgery pheochromocytoma,
    aldosteronoma.
  • Suggest surgery for patients with subclinical
    Cushing's syndrome who are younger and who have
    disorders potentially attributable to autonomous
    glucocorticoid secretion.

66
  • Suggest surgery for patients with adrenal masses
    greater than 4 cm in diameter .
  • If there is evidence of metastasis and after
    excluding pheochromocytoma with biochemical
    testing, suggest performing a diagnostic
    CT-guided FNA biopsy .

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THANK YOU
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