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Sconfienza E, Tetti M, Forestiero V, Veglio F, Mulatero P, Monticone S. Prevalence of Functioning Adrenal Incidentalomas: A Systematic Review and Meta-analysis. J Clin Endocrinol Metab 2023; 108:1813-1823. [PMID: 36718682 DOI: 10.1210/clinem/dgad044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 12/28/2022] [Accepted: 01/24/2023] [Indexed: 02/01/2023]
Abstract
CONTEXT Adrenal hyperfunction is associated with an increased risk of cardiometabolic complications in subjects with adrenal incidentaloma (AI). Reliable prevalence estimates of functioning AIs are important to direct resources allocations. OBJECTIVE To assess the prevalence of autonomous/possible autonomous cortisol secretion (ACS), primary aldosteronism (PA), pheochromocytoma (PHEO), and Cushing syndrome (CS) in patients with AI. METHODS We performed a comprehensive search of multiple databases (PubMed, Ovid MEDLINE, Web of Science) for potentially relevant studies without language restriction, up to February 2022. Of the 1661 publications evaluated at title and abstract levels, 161 were examined as full text and 36 were included. Study level clinical data were extracted by 3 independent reviewers. RESULTS The overall prevalence of functioning AIs was 27.5% (95% CI 23.0, 32.5). ACS/possible ACS, with a prevalence of 11.7% (95% CI 8.6, 15.7), was the most frequent hormonal alteration, while PA occurred in 4.4% of the patients (95% CI 3.1, 6.2). Subgroup analysis showed that PA was more prevalent in patients from Asia than in patients from Europe/America; in contrast, ACS/possible ACS had a lower prevalence in Asian countries. At meta-regression analysis, the prevalence of ACS/possible ACS was influenced by the proportion of female patients, while the prevalence of PA was positively associated with the proportion of patients with hypertension and the publication year. Finally, PHEO and CS prevalence were 3.8% (95% CI 2.8, 5.0) and 3.1% (95% CI 2.3, 4.3) respectively. CONCLUSION This meta-analysis provides extensive data on the prevalence of functioning AIs and the factors affecting heterogeneity in prevalence estimates.
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Affiliation(s)
- Elisa Sconfienza
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Via Genova 3, 10126 Torino, Italy
| | - Martina Tetti
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Via Genova 3, 10126 Torino, Italy
| | - Vittorio Forestiero
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Via Genova 3, 10126 Torino, Italy
| | - Franco Veglio
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Via Genova 3, 10126 Torino, Italy
| | - Paolo Mulatero
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Via Genova 3, 10126 Torino, Italy
| | - Silvia Monticone
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Via Genova 3, 10126 Torino, Italy
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Grigoryan S, Nhan W, Zhang L, Urban C, Zhao L, Turcu AF. Rates of Pheochromocytoma/Paraganglioma Screening in At-Risk Populations. J Clin Endocrinol Metab 2023; 108:e343-e349. [PMID: 36469797 PMCID: PMC10188311 DOI: 10.1210/clinem/dgac701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 11/11/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
CONTEXT Pheochromocytomas and paragangliomas (PPGL) are rare causes of secondary hypertension, but when unrecognized, they can lead to serious complications. Data regarding PPGL screening are lacking. OBJECTIVE This study aimed to assess the rates and patterns of PPGL screening among eligible patients. METHODS We conducted a retrospective review of adults with hypertension seen in outpatient clinics of a large academic center between January 1, 2017, and June 30, 2020. We included patients with treatment-resistant hypertension, hypertension at age < 35 years, and/or adrenal mass(es). RESULTS Of 203 535 patients with hypertension identified, 71 088 (35%) met ≥ 1 inclusion criteria, and 2013 (2.83%) were screened for PPGL. Patients screened were younger (56.2 ± 17.4 vs 64.0 ± 17.1 years), more often women (54.1% vs 44.2%), and never-smokers (54.6% vs 47.5%, P < 0.001 for all). The rate of screening was highest in patients with hypertension and adrenal mass(es) (51.7%, vs 3.9% in patients with early-onset hypertension, and 2.4% in those with treatment-resistant hypertension). Multivariable logistic regression showed higher odds ratio (OR) of PPGL screening in women (OR [95% CI]: 1.48 [1.34-1.63]); Black vs White patients (1.35 [1.19-1.53]); patients with adrenal mass(es) (55.1 [44.53-68.15]), stroke (1.34 [1.16-1.54]), dyslipidemia (1.41 [1.26-1.58]), chronic kidney disease (1.40 [1.26-1.56]), and obstructive sleep apnea (1.96 [1.76-2.19]). CONCLUSION PPGL screening is pursued in roughly half of patients with adrenal nodules and hypertension, but rarely in patients with treatment-resistant or early-onset hypertension. Similar to screening for other forms of secondary hypertension, PPGL screening occurs more often after serious complications develop.
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Affiliation(s)
- Seda Grigoryan
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI 48109, USA
| | - Winnie Nhan
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI 48109, USA
| | - Lei Zhang
- School of Public Health, University of Michigan, Ann Arbor, MI 48109, USA
| | - Caitlin Urban
- Michigan State University College of Human Medicine, Grand Rapids, MI 49503, USA
| | - Lili Zhao
- School of Public Health, University of Michigan, Ann Arbor, MI 48109, USA
| | - Adina F Turcu
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI 48109, USA
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Teixeira AP, Haddad Jr. W, Barreto LO, Secaf A, Mermejo LM, Lucchesi FR, Tucci Jr. S, Elias Junior J, Molina CAF, Muglia VF. Histogram analysis in the differentiation between adrenal adenomas and pheochromocytomas: the value of a single measurement. Radiol Bras 2023; 56:59-66. [PMID: 37168042 PMCID: PMC10165976 DOI: 10.1590/0100-3984.2022.0067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 09/12/2022] [Indexed: 05/13/2023] Open
Abstract
Objective To assess the diagnostic accuracy of histogram analysis on unenhanced computed tomography (CT) for differentiating between adrenal adenomas and pheochromocytomas (PCCs). Materials and Methods We retrospectively identified patients with proven PCCs who had undergone CT examinations between January 2009 and July 2019 at one of two institutions. For each PCC, we selected one or two adenomas diagnosed within two weeks of the date of diagnosis of the PCC. For each lesion, two readers scored the size, determined the mean attenuation, and generated a voxel histogram. The 10th percentile (P10) was obtained from the conventional histogram analysis, as well as being calculated with the following formula: P10 = mean attenuation - (1.282 × standard deviation). The mean attenuation threshold, histogram analysis (observed) P10, and calculated P10 (calcP10) were compared in terms of their diagnostic accuracy. Results We included 52 adenomas and 29 PCCs. The sensitivity, specificity, and accuracy of the mean attenuation threshold were 75.0%, 100.0%, and 82.5%, respectively, for reader 1, whereas they were 71.5%, 100.0%, and 81.5%, respectively, for reader 2. The sensitivity, specificity, and accuracy of the observed P10 and calcP10 were equal for both readers: 90.4%, 96.5%, and 92.6%, respectively, for reader 1; and 92.3%, 93.1%, and 92.6%, respectively, for reader 2. The increase in sensitivity was significant for both readers (p = 0.009 and p = 0.005, respectively). Conclusion For differentiating between adenomas and PCCs, the histogram analysis (observed P10 and calcP10) appears to outperform the mean attenuation threshold as a diagnostic criterion.
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Affiliation(s)
- Ana P. Teixeira
- Faculdade de Medicina de Ribeirão Preto da Universidade de São
Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | - William Haddad Jr.
- Faculdade de Medicina de Ribeirão Preto da Universidade de São
Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | - Luan Oliveira Barreto
- Faculdade de Medicina de Ribeirão Preto da Universidade de São
Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | | | - Livia M. Mermejo
- Faculdade de Medicina de Ribeirão Preto da Universidade de São
Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | | | - Silvio Tucci Jr.
- Faculdade de Medicina de Ribeirão Preto da Universidade de São
Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | - Jorge Elias Junior
- Faculdade de Medicina de Ribeirão Preto da Universidade de São
Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | - Carlos A. F. Molina
- Faculdade de Medicina de Ribeirão Preto da Universidade de São
Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | - Valdair F. Muglia
- Faculdade de Medicina de Ribeirão Preto da Universidade de São
Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
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Araujo-Castro M, García Centeno R, Robles Lázaro C, Parra Ramírez P, Gracia Gimeno P, Rojas-Marcos PM, Fernández-Ladreda MT, Percovich Hualpa JC, Sampedro Núñez M, López-García MC, Lamas C, Álvarez Escolá C, Calatayud Gutiérrez M, Blanco Carrera C, de Miguel Novoa P, Valdés Gallego N, Hanzu F, Marazuela M, Mora Porta M, Mínguez Ojeda C, García Gómez Muriel I, Escobar-Morreale HF, Valderrabano P. Predictive model of pheochromocytoma based on the imaging features of the adrenal tumours. Sci Rep 2022; 12:2671. [PMID: 35177692 PMCID: PMC8854552 DOI: 10.1038/s41598-022-06655-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 02/03/2022] [Indexed: 12/18/2022] Open
Abstract
The purpose of our study was to develop a predictive model to rule out pheochromocytoma among adrenal tumours, based on unenhanced computed tomography (CT) and/or magnetic resonance imaging (MRI) features. We performed a retrospective multicentre study of 1131 patients presenting with adrenal lesions including 163 subjects with histological confirmation of pheochromocytoma (PHEO), and 968 patients showing no clinical suspicion of pheochromocytoma in whom plasma and/or urinary metanephrines and/or catecholamines were within reference ranges (non-PHEO). We found that tumour size was significantly larger in PHEO than non-PHEO lesions (44.3 ± 33.2 versus 20.6 ± 9.2 mm respectively; P < 0.001). Mean unenhanced CT attenuation was higher in PHEO (52.4 ± 43.1 versus 4.7 ± 17.9HU; P < 0.001). High lipid content in CT was more frequent among non-PHEO (83.6% versus 3.8% respectively; P < 0.001); and this feature alone had 83.6% sensitivity and 96.2% specificity to rule out pheochromocytoma with an area under the receiver operating characteristics curve (AUC-ROC) of 0.899. The combination of high lipid content and tumour size improved the diagnostic accuracy (AUC-ROC 0.961, sensitivity 88.1% and specificity 92.3%). The probability of having a pheochromocytoma was 0.1% for adrenal lesions smaller than 20 mm showing high lipid content in CT. Ninety percent of non-PHEO presented loss of signal in the “out of phase” MRI sequence compared to 39.0% of PHEO (P < 0.001), but the specificity of this feature for the diagnosis of non-PHEO lesions low. In conclusion, our study suggests that sparing biochemical screening for pheochromocytoma might be reasonable in patients with adrenal lesions smaller than 20 mm showing high lipid content in the CT scan, if there are no typical signs and symptoms of pheochromocytoma.
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Affiliation(s)
- Marta Araujo-Castro
- Department of Endocrinology & Nutrition, Hospital Universitario Ramón y Cajal, Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Universidad de Alcalá, Madrid, Spain.
| | - Rogelio García Centeno
- Department of Endocrinology & Nutrition, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Cristina Robles Lázaro
- Department of Endocrinology & Nutrition, Hospital Universitario Virgen de La Concha, Zamora, Spain
| | - Paola Parra Ramírez
- Department of Endocrinology & Nutrition, Hospital Universitario La Paz, Madrid, Spain
| | - Paola Gracia Gimeno
- Department of Endocrinology & Nutrition, Hospital Universitario Rollo Villanova, Zaragoza, Spain
| | | | | | | | - Miguel Sampedro Núñez
- Department of Endocrinology & Nutrition, Hospital Universitario La Princesa, Madrid, Spain
| | - María-Carmen López-García
- Department of Endocrinology & Nutrition, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | - Cristina Lamas
- Department of Endocrinology & Nutrition, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | | | | | | | - Paz de Miguel Novoa
- Department of Endocrinology & Nutrition, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - Nuria Valdés Gallego
- Department of Endocrinology & Nutrition, Hospital Universitario de Cabueñes, Asturias, Spain
| | - Felicia Hanzu
- Department of Endocrinology & Nutrition, Hospital Clinic, Barcelona, Spain
| | - Mónica Marazuela
- Department of Endocrinology & Nutrition, Hospital Universitario La Princesa, Madrid, Spain
| | - Mireia Mora Porta
- Department of Endocrinology & Nutrition, Hospital Clinic, Barcelona, Spain
| | | | | | - Héctor F Escobar-Morreale
- Department of Endocrinology & Nutrition, Hospital Universitario Ramón y Cajal, Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Universidad de Alcalá, Madrid, Spain
| | - Pablo Valderrabano
- Department of Endocrinology & Nutrition, Hospital Universitario Ramón y Cajal, Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Universidad de Alcalá, Madrid, Spain.
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Beltsevich DG, Troshina EA, Melnichenko GA, Platonova NM, Ladygina DO, Chevais A. Draft of the clinical practice guidelines “Adrenal incidentaloma”. ENDOCRINE SURGERY 2021. [DOI: 10.14341/serg12712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The wider application and technical improvement of abdominal imaging procedures in recent years has led to an increasingly frequent detection of adrenal gland masses — adrenal incidentaloma, which have become a common clinical problem and need to be investigated for evidence of hormonal hypersecretion and/or malignancy. Clinical guidelines are the main working tool of a practicing physician. Laconic, structured information about a specific nosology, methods of its diagnosis and treatment, based on the principles of evidence-based medicine, make it possible to give answers to questions in a short time, to achieve maximum efficiency and personalization of treatment. These clinical guidelines include data on the prevalence, etiology, radiological features and assessment of hormonal status of adrenal incidentalomas. In addition, this clinical practice guideline provides information on indications for surgery, postoperative rehabilitation and follow-up.
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6
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Hallin Thompson L, Makay Ö, Brunaud L, Raffaelli M, Bergenfelz A. Adrenalectomy for incidental and symptomatic phaeochromocytoma: retrospective multicentre study based on the Eurocrine® database. Br J Surg 2021; 108:1199-1206. [PMID: 34270711 PMCID: PMC10364866 DOI: 10.1093/bjs/znab199] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 05/05/2021] [Indexed: 11/13/2022]
Abstract
BACKGROUND Phaeochromocytoma is sometimes not diagnosed before surgery and may present as an adrenal incidentaloma. The aim of this study was to investigate differences in clinical presentation and perioperative outcome in patients with subclinical and symptomatic phaeochromocytoma, and in patients operated with and without preoperative α-blockade. METHODS This was a retrospective observational study of patients with a histopathological diagnosis of phaeochromocytoma registered in Eurocrine®, the European registry for endocrine tumours, between 1 January 2015 and 31 March 2020. Patient characteristics, clinical presentation, tumour detection, and perioperative variables were analysed. RESULTS Some 551 patients were included. Of these, 486 patients (88.2 per cent) had a preoperative diagnosis of phaeochromocytoma. Tumours were detected as incidentalomas in 239 patients (43.4 per cent) and 265 (48.1 per cent) had a preoperative diagnosis of hypertension. Preoperative α-blockade was more frequently used in patients with a known phaeochromocytoma (350, 90.9 per cent) than in patients with other indications for adrenalectomy (16, 31 per cent). Complications did not differ between patients who had surgery because of catecholamine excess compared with those who had other indications for surgery (19 (3.9 per cent) versus 2 (3 per cent); P = 0.785), nor did the conversion rate from minimally invasive to open surgery differ between the groups. There were no obvious differences in complications, according to the Clavien-Dindo classification, based on preoperative α-blockade or not. CONCLUSION Subclinical phaeochromocytoma detected incidentally is common. A significantproportion of patients with phaeochromocytoma did not have α-blockade before surgery, without an apparent effect on complications.
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Affiliation(s)
- L Hallin Thompson
- Department of Surgery, Skåne University Hospital, Lund, Sweden.,Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Ö Makay
- Department of General Surgery, Division of Endocrine Surgery, Ege University Hospital, Izmir, Turkey
| | - L Brunaud
- Department of Gastrointestinal, Metabolic and Surgical Oncology, Université de Lorraine, CHU Nancy, Hospital Brabois Adultes, Vandoevre les Nancy, France
| | - M Raffaelli
- Division of Endocrine and Metabolic Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Dipatimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - A Bergenfelz
- Department of Surgery, Skåne University Hospital, Lund, Sweden.,Department of Clinical Sciences, Lund University, Lund, Sweden
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Yozamp N, Vaidya A. Assessment of mild autonomous cortisol secretion among incidentally discovered adrenal masses. Best Pract Res Clin Endocrinol Metab 2021; 35:101491. [PMID: 33593680 DOI: 10.1016/j.beem.2021.101491] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Incidentally discovered adrenal masses are common and mostly benign and non-functioning adenomas. However, evolving evidence suggests that a notable proportion of these adrenal adenomas may demonstrate mild autonomous cortisol secretion (MACS), which has been associated with an increased risk for hypertension, hyperglycemia, obesity, dyslipidemia, vertebral fractures, adverse cardiovascular events, and mortality. Therefore, it is advised that all patients with an incidentally discovered adrenal mass be tested for MACS. When there is convincing evidence for MACS, surgical adrenalectomy has been associated with an improvement in certain metabolic parameters and a reduction in vertebral fractures; however, conclusive evidence demonstrating decreased cardiovascular outcomes or mortality are not yet available. Future studies with adequate randomization and follow-up to assess adverse clinical endpoints are needed to determine the optimal management and follow-up of patients with MACS.
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Affiliation(s)
- Nicholas Yozamp
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Abstract
PURPOSE OF REVIEW To discuss selected endocrine causes of hypertension and to provide practical clinical recommendations regarding the evaluation and treatment of these disorders. RECENT FINDINGS More than 15 endocrine disorders with varying rates of prevalence can cause hypertension. For example, primary aldosteronism may exist in up to 20% of patients with resistant hypertension. Recognition of these important secondary causes of hypertension is essential to provide contemporary targeted therapies in order to improve long-term disease outcomes. Clinicians must have a broad understanding of the prevalence, clinical presentation, and current diagnostic modalities for endocrine causes of hypertension to facilitate prompt referral, identification, and optimal management of these disorders. Endocrine causes of hypertension are multifactorial and, in some cases, widely prevalent. It is important for clinicians considering secondary causes of hypertension to be knowledgeable about the underlying pathophysiology of these disorders and to understand when additional evaluation and treatment may be needed.
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Practical guide on the initial evaluation, follow-up, and treatment of adrenal incidentalomas Adrenal Diseases Group of the Spanish Society of Endocrinology and Nutrition. ACTA ACUST UNITED AC 2020; 67:408-419. [PMID: 32349941 DOI: 10.1016/j.endinu.2020.03.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 03/03/2020] [Indexed: 12/16/2022]
Abstract
Initial evaluation of adrenal incidentalomas should be aimed at ruling out malignancy and functionality. For this, a detailed clinical history should be taken, and an adequate radiographic assessment and a complete blood chemistry and hormone study should be performed. The most controversial condition, because of the lack of consensus in its definition, is autonomous cortisol secretion. Our recommendation is that, except when cortisol levels <1.8μg/dL in the dexamethasone suppression test rule out diagnosis and levels ≥5μg/dL establish the presence of autonomous cortisol secretion, diagnosis should be based on a combined definition of dexamethasone suppression test ≥3μg/dL and at least one of the following: elevated urinary free cortisol, ACTH level <10 pg/mL, or elevated nocturnal cortisol (in serum and/or saliva). During follow-up, dexamethasone suppression test should be repeated, usually every year, on an individual basis depending on the results of prior tests and the presence of comorbidities potentially related to hypercortisolism. The initial radiographic test of choice for characterization of adrenal incidentalomas is a computed tomography scan without contrast, but there is no unanimous agreement on subsequent monitoring. Our general recommendation is a repeat imaging test 6-12 months after diagnosis (based on the radiographic characteristics of the lesion). If the lesion remains stable and there are no indeterminate characteristics, no additional radiographic studies would be needed. We think that patients with autonomous cortisol secretion with comorbidities potentially related to hypercortisolism, particularly if they are young and there is a poor control, may benefit from unilateral adrenalectomy. The indication for unilateral adrenalectomy is clear in patients with overt hormonal syndromes or suspected malignancy. In conclusion, adrenal incidentalomas require a comprehensive evaluation that takes into account the possible clinical signs and comorbidities related to hormonal syndromes or malignancy; a complete hormone profile (taking into account the conditions that may lead to falsely positive and negative results); and an adequate radiographic study. Monitoring and/or treatment will be decided based on the results of the initial evaluation.
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10
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Gruber LM, Strajina V, Bancos I, Murad MH, Dy BM, Young WF, Farley DR, Lyden ML, Thompson GB, McKenzie TJ. Not all adrenal incidentalomas require biochemical testing to exclude pheochromocytoma: Mayo clinic experience and a meta-analysis. Gland Surg 2020; 9:362-371. [PMID: 32420260 DOI: 10.21037/gs.2020.03.04] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background Excluding a pheochromocytoma is important when a patient presents with an incidentally discovered adrenal mass. However, biochemical testing for pheochromocytoma can be cumbersome, time consuming, or falsely positive. Our objective was to determine if unenhanced computed tomography (CT) imaging alone can be used to rule out pheochromocytoma. Methods We performed a retrospective study of all patients with a pathologically confirmed pheochromocytoma and unenhanced CT imaging who were treated at the Mayo Clinic between 1998 and 2016. Additionally, we performed a systematic review and meta-analysis of original studies published after 2005 with patients who had adrenal masses, more than 10 patients with pheochromocytomas, and reported attenuation on unenhanced CT imaging in Hounsfield units (HU). Results In the Mayo cohort, we identified 186 patients and 199 pheochromocytomas with unenhanced CT imaging. The mean unenhanced CT attenuation was 35±9 HU (range, 15-62), and only 15 tumors had attenuation ≤20 HU. The systematic review identified 26 studies (1,217 tumors), and 23 studies provided a mean unenhanced CT attenuation. The overall mean unenhanced CT attenuation across the studies was 35.6 HU (95% CI, 22.0-49.1 HU). A cutoff of >10 HU had a 100% sensitivity (95% CI, 1.00-1.00) for pheochromocytoma with low heterogeneity between the 21 qualified studies (I2=0%). Sensitivity for pheochromocytoma was 100% and 99% for an unenhanced CT attenuation cutoff of >15 and >20 HU. Conclusions Biochemical testing may not be required to exclude pheochromocytoma if an incidental adrenal mass has low attenuation (<10 HU) on unenhanced CT images.
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Affiliation(s)
- Lucinda M Gruber
- Division of Endocrinology, Metabolism, Nutrition & Diabetes, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Veljko Strajina
- Department of Surgery, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Irina Bancos
- Division of Endocrinology, Metabolism, Nutrition & Diabetes, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - M Hassan Murad
- Evidence Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Benzon M Dy
- Department of Surgery, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - William F Young
- Division of Endocrinology, Metabolism, Nutrition & Diabetes, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - David R Farley
- Department of Surgery, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Melanie L Lyden
- Department of Surgery, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Geoffrey B Thompson
- Department of Surgery, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Travis J McKenzie
- Department of Surgery, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
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11
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Jeon S, Cho AR, Ri HS, Lee HJ, Hong JM, Lee D, Park EJ, Kim J, Kang C. The effect of combined Epidural-general Anesthesia on Hemodynamic Instability during Pheochromocytoma and Paraganglioma Surgery: A multicenter retrospective cohort study. Int J Med Sci 2020; 17:1956-1963. [PMID: 32788874 PMCID: PMC7415391 DOI: 10.7150/ijms.47299] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 07/10/2020] [Indexed: 11/05/2022] Open
Abstract
Objectives: The purpose of this study was to compare the effects of combined epidural-general anesthesia with those of general anesthesia alone on hemodynamic instability (intraoperative hypotension and hypertensive crisis) during pheochromocytoma and sympathetic paraganglioma surgery. Methods: A total of 119 patients' medical records were reviewed who were diagnosed as having pheochromocytoma and sympathetic paraganglioma on the basis of histological findings. Intraoperative hypotension was defined as a mean blood pressure < 60 mmHg or a decrease > 30% in baseline systolic blood pressure after adrenal vein ligation. Hypertensive crisis was defined as a systolic blood pressure > 200 mmHg or an increase > 30% in baseline systolic blood pressure during the operation. The predictor variables for intraoperative hypotension and hypertensive crisis were analyzed with logistic regression models. Data were presented as adjusted odds ratio with 95% confidence interval. Results: The independent predictors of intraoperative hypotension were an increased attenuation number on unenhanced computed tomography (1.112 [1.009-1.226], p = 0.033), a high baseline mean blood pressure (1.063 [1.012-1.117], p = 0.015), and the combined epidural-general anesthesia (5.439 [1.410-20.977], p = 0.014). In contrast, an increased attenuation number on unenhanced computed tomography was the only independent predictor of hypertensive crisis (1.087 [1.021-1.158], p = 0.009). Conclusions: The combined epidural-general anesthesia was not effective in attenuating hypertensive responses, but could have exacerbated intraoperative hypotension. These findings should be taken into account before selecting the anesthetic technique in pheochromocytoma and sympathetic paraganglioma surgery.
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Affiliation(s)
- Soeun Jeon
- Department of Anesthesia and Pain Medicine, Pusan National University, School of Medicine, Yangsan, Republic of Korea.,Department of Anesthesia and Pain Medicine, Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Ah-Reum Cho
- Department of Anesthesia and Pain Medicine, Pusan National University, School of Medicine, Yangsan, Republic of Korea.,Department of Anesthesia and Pain Medicine, Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Hyun-Su Ri
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Hyeon-Jeong Lee
- Department of Anesthesia and Pain Medicine, Pusan National University, School of Medicine, Yangsan, Republic of Korea.,Department of Anesthesia and Pain Medicine, Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Jeong-Min Hong
- Department of Anesthesia and Pain Medicine, Pusan National University, School of Medicine, Yangsan, Republic of Korea.,Department of Anesthesia and Pain Medicine, Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Dowon Lee
- Department of Anesthesia and Pain Medicine, Pusan National University, School of Medicine, Yangsan, Republic of Korea.,Department of Anesthesia and Pain Medicine, Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Eun Ji Park
- Department of Anesthesia and Pain Medicine, Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Jinsil Kim
- Department of Anesthesia and Pain Medicine, Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Christine Kang
- Department of Anesthesia and Pain Medicine, Pusan National University, School of Medicine, Yangsan, Republic of Korea.,Department of Anesthesia and Pain Medicine, Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
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12
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Buitenwerf E, Berends AMA, van Asselt ADI, Korteweg T, Greuter MJW, Veeger NJM, Links TP, Dullaart RPF, Kerstens MN. Diagnostic Accuracy of Computed Tomography to Exclude Pheochromocytoma: A Systematic Review, Meta-analysis, and Cost Analysis. Mayo Clin Proc 2019; 94:2040-2052. [PMID: 31515105 DOI: 10.1016/j.mayocp.2019.03.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 02/26/2019] [Accepted: 03/07/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To assess the diagnostic accuracy of unenhanced computed tomography (CT) attenuation values to exclude a pheochromocytoma in the diagnostic work-up of patients with an adrenal incidentaloma and to model the associated difference in diagnostic costs. METHODS The MEDLINE and Embase databases were searched from indexing to September 27, 2018, and studies reporting the proportion of pheochromocytomas on either side of the 10-Hounsfield unit (HU) threshold on unenhanced CT were included. The pooled proportion of pheochromocytomas with an attenuation value greater than 10 HU was determined, as were the modeled financial costs of the current and alternative diagnostic approaches. RESULTS Of 2957 studies identified, 31 were included (N=1167 pheochromocytomas). Overall risk of bias was low. Heterogeneity was not observed between studies (Q=11.5, P=.99, I2=0%). The pooled proportion of patients with attenuation values greater than 10 HU was 0.990 (95% CI, 0.984-0.995). The modeled financial costs using the new diagnostic approach were €55 (∼$63) lower per patient. CONCLUSION Pheochromocytomas can be reliably ruled out in the case of an adrenal lesion with an unenhanced CT attenuation value of 10 HU or less. Therefore, determination of metanephrine levels can be restricted to adrenal tumors with an unenhanced CT attenuation value greater than 10 HU. Implementing this novel diagnostic strategy is cost-saving.
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Affiliation(s)
- Edward Buitenwerf
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, the Netherlands.
| | - Annika M A Berends
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Antoinette D I van Asselt
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Tijmen Korteweg
- Department of Radiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Marcel J W Greuter
- Department of Radiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Nic J M Veeger
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Thera P Links
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Robin P F Dullaart
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Michiel N Kerstens
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, the Netherlands
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13
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Elhassan YS, Alahdab F, Prete A, Delivanis DA, Khanna A, Prokop L, Murad MH, O'Reilly MW, Arlt W, Bancos I. Natural History of Adrenal Incidentalomas With and Without Mild Autonomous Cortisol Excess: A Systematic Review and Meta-analysis. Ann Intern Med 2019; 171:107-116. [PMID: 31234202 DOI: 10.7326/m18-3630] [Citation(s) in RCA: 109] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Adrenal incidentalomas are mostly benign nonfunctioning adrenal tumors (NFATs) or adenomas causing mild autonomous cortisol excess (MACE), but their natural history is unclear. PURPOSE To summarize the follow-up data of adults with NFAT or MACE to determine the proportions of tumor growth, malignant transformation, and incident changes in hormone function; the prevalence of incident cardiometabolic comorbid conditions; and mortality. DATA SOURCES MEDLINE, Embase, Cochrane, and Scopus (January 1990 to February 2019) and bibliographies of identified articles, without language restriction. STUDY SELECTION Studies that included 20 or more conservatively managed patients with NFAT or MACE and reported outcomes at baseline and after at least 12 months of follow-up. DATA EXTRACTION Pairs of reviewers extracted outcomes and assessed methodological quality. DATA SYNTHESIS Thirty-two studies reported outcomes of 4121 patients with NFAT or MACE, 61.5% of whom were women; the mean age was 60.2 years, and mean follow-up was 50.2 months. Mean tumor growth was 2 mm over 52.8 months. Clinically significant tumor enlargement (≥10 mm) occurred in 2.5% of patients, and none developed adrenal cancer. Clinically overt hormone excess was unlikely to develop (<0.1%) in patients with NFAT or MACE. Only 4.3% of patients with NFAT developed MACE, and preexisting MACE was unlikely to resolve (<0.1%). Hypertension, obesity, dyslipidemia, and type 2 diabetes were highly prevalent (60.0%, 42.0%, 33.7%, and 18.1% of patients, respectively) and were more likely to develop and worsen in MACE than NFAT. New cardiovascular events were more prevalent in MACE (15.5%) than NFAT (6.4%). Mortality was 11.2% and was similar between NFAT and MACE. LIMITATION Evidence was scarce, and definitions of MACE and comorbid conditions were heterogeneous. CONCLUSION During follow-up, NFAT and MACE do not show clinically relevant changes in size or hormonal function, but they may carry an increased risk for cardiometabolic comorbid conditions. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Yasir S Elhassan
- University of Birmingham Institute of Metabolism and Systems Research and Birmingham Health Partners Centre for Endocrinology, Diabetes and Metabolism, Birmingham, United Kingdom (Y.S.E., A.P., M.W.O., W.A.)
| | - Fares Alahdab
- Evidence-based Practice Center, Mayo Clinic, Rochester, Minnesota (F.A., D.A.D., A.K., M.H.M., I.B.)
| | - Alessandro Prete
- University of Birmingham Institute of Metabolism and Systems Research and Birmingham Health Partners Centre for Endocrinology, Diabetes and Metabolism, Birmingham, United Kingdom (Y.S.E., A.P., M.W.O., W.A.)
| | - Danae A Delivanis
- Evidence-based Practice Center, Mayo Clinic, Rochester, Minnesota (F.A., D.A.D., A.K., M.H.M., I.B.)
| | - Aakanksha Khanna
- Evidence-based Practice Center, Mayo Clinic, Rochester, Minnesota (F.A., D.A.D., A.K., M.H.M., I.B.)
| | - Larry Prokop
- Mayo Clinic, Rochester, Minnesota; Mayo Clinic Libraries, Mayo Clinic, Rochester, Minnesota (L.P.)
| | - Mohammad H Murad
- Evidence-based Practice Center, Mayo Clinic, Rochester, Minnesota (F.A., D.A.D., A.K., M.H.M., I.B.)
| | - Michael W O'Reilly
- University of Birmingham Institute of Metabolism and Systems Research and Birmingham Health Partners Centre for Endocrinology, Diabetes and Metabolism, Birmingham, United Kingdom (Y.S.E., A.P., M.W.O., W.A.)
| | - Wiebke Arlt
- University of Birmingham Institute of Metabolism and Systems Research and Birmingham Health Partners Centre for Endocrinology, Diabetes and Metabolism, Birmingham, United Kingdom (Y.S.E., A.P., M.W.O., W.A.)
| | - Irina Bancos
- Evidence-based Practice Center, Mayo Clinic, Rochester, Minnesota (F.A., D.A.D., A.K., M.H.M., I.B.)
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14
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Kostiainen I, Hakaste L, Kejo P, Parviainen H, Laine T, Löyttyniemi E, Pennanen M, Arola J, Haglund C, Heiskanen I, Schalin-Jäntti C. Adrenocortical carcinoma: presentation and outcome of a contemporary patient series. Endocrine 2019; 65:166-174. [PMID: 30980285 PMCID: PMC6606857 DOI: 10.1007/s12020-019-01918-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 03/28/2019] [Indexed: 12/08/2022]
Abstract
BACKGROUND Adrenocortical carcinoma (ACC) is a rare endocrine carcinoma with poor 5-year survival rates of < 40%. According to the literature, ACC is rarely an incidental imaging finding. However, presentation, treatment and outcome may differ in modern series. DESIGN AND METHODS We studied all patients (n = 47, four children) from a single centre during years 2002-2018. We re-evaluated radiologic and histopathological findings and assessed treatments and outcome. We searched for possible TP53 gene defects and assessed nationwide incidence of ACC. RESULTS In adults, incidental radiologic finding led to diagnosis in 79% at median age of 61 years. ENSAT stage I, II, III and IV was 19%, 40%, 19% and 21%, respectively. Nonenhanced CT demonstrated > 20 Hounsfield Units (HU) for all tumours (median 34 (21-45)), median size 92 mm (20-196), Ki67 17% (1-40%), Weiss score 7 (4-9) and Helsinki score 24 (4-48). ACC was more often found in the left than the right adrenal (p < 0.05). One child had Beckwith-Wiedemann and one a TP53 mutation. In adults, the primary tumour was resected in 88 and 79% received adjuvant mitotane therapy. Median hospital stay was significantly shorter in the laparoscopic vs. open surgery group (4 (3-7) vs. 8 (5-38) days, respectively; p < 0.001). In 3/4 patients, prolonged remission of > 5 to > 10 years was achieved after repeated surgery of metastases. Overall 5-year survival was 67%, and 96% vs. 26% for ENSAT stage I-II vs. III-IV (p < 0.0001). ENSAT stage and Ki67 predicted survival, type of surgery did not. Mitotane associated with better survival. CONCLUSIONS Contemporary ACC predominantly presents as an incidental imaging finding, characterised by HU > 20 on nonenhanced CT but variable tumour size (20-196 mm). Malignancy cannot be ruled out by small tumour size only. The 5-year survival of 96% in ENSAT stage I-III compares favourably to previous studies.
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Affiliation(s)
- Iiro Kostiainen
- Endocrinology, Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Liisa Hakaste
- Endocrinology, Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Pekka Kejo
- Department of Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Helka Parviainen
- HUS Medical Imaging Centre, Radiology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Tiina Laine
- Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Eliisa Löyttyniemi
- Department of Biostatistics, University of Turku and Turku University Hospital, Turku, Finland
| | - Mirkka Pennanen
- Department of Pathology, University of Helsinki and HUSLAB, Helsinki, Finland
| | - Johanna Arola
- Department of Pathology, University of Helsinki and HUSLAB, Helsinki, Finland
| | - Caj Haglund
- Department of Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ilkka Heiskanen
- Department of Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Camilla Schalin-Jäntti
- Endocrinology, Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
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15
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Canu L, Van Hemert JAW, Kerstens MN, Hartman RP, Khanna A, Kraljevic I, Kastelan D, Badiu C, Ambroziak U, Tabarin A, Haissaguerre M, Buitenwerf E, Visser A, Mannelli M, Arlt W, Chortis V, Bourdeau I, Gagnon N, Buchy M, Borson-Chazot F, Deutschbein T, Fassnacht M, Hubalewska-Dydejczyk A, Motyka M, Rzepka E, Casey RT, Challis BG, Quinkler M, Vroonen L, Spyroglou A, Beuschlein F, Lamas C, Young WF, Bancos I, Timmers HJLM. CT Characteristics of Pheochromocytoma: Relevance for the Evaluation of Adrenal Incidentaloma. J Clin Endocrinol Metab 2019; 104:312-318. [PMID: 30383267 DOI: 10.1210/jc.2018-01532] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 10/26/2018] [Indexed: 02/11/2023]
Abstract
Background Up to 7% of all adrenal incidentalomas (AIs) are pheochromocytomas (PCCs). In the evaluation of AI, it is generally recommended that PCC be excluded by measurement of plasma-free or 24-hour urinary fractionated metanephrines. However, recent studies suggest that biochemical exclusion of PCC not be performed for lesions with CT characteristics of an adrenocortical adenoma (ACA). Aim To determine the proportion of PCCs with ACA-like attenuation or contrast washout on CT. Methods For this multicenter retrospective study, two central investigators independently analyzed the CT reports of 533 patients with 548 histologically confirmed PCCs. Data on tumor size, unenhanced Hounsfield units (HU), absolute percentage washout (APW), and relative percentage washout (RPW) were collected in addition to clinical parameters. Results Among the 376 PCCs for which unenhanced attenuation data were available, 374 had an attenuation of >10 HU (99.5%). In the two exceptions (0.5%), unenhanced attenuation was exactly 10 HU, which lies just within the range of ≤10 HU that would suggest a diagnosis of ACA. Of 76 PCCs with unenhanced HU > 10 and available washout data, 22 (28.9%) had a high APW and/or RPW, suggestive of ACA. Conclusion Based on the lack of PCCs with an unenhanced attenuation of <10 HU and the low proportion (0.5%) of PCCs with an attenuation of 10 HU, it seems reasonable to abstain from biochemical testing for PCC in AIs with an unenhanced attenuation of ≤10 HU. The assessment of contrast washout, however, is unreliable for ruling out PCC.
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Affiliation(s)
- Letizia Canu
- Department of Internal Medicine, Division of Endocrinology, Radboud University Medical Center, Nijmegen, Netherlands
- Department of Experimental and Clinical Biomedical Sciences University of Florence, Florence, Italy
| | - Janna A W Van Hemert
- Department of Internal Medicine, Division of Endocrinology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Michiel N Kerstens
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | | | - Aakanksha Khanna
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota
| | - Ivana Kraljevic
- Department of Endocrinology, University Hospital Center Zagreb, Zagreb, Croatia
| | - Darko Kastelan
- Department of Endocrinology, University Hospital Center Zagreb, Zagreb, Croatia
| | - Corin Badiu
- National Institute of Endocrinology C. I. Parhon, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Urszula Ambroziak
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland
| | - Antoine Tabarin
- Service d'Endocrinologie Hôpital Haut-Lévêque, CHU de Bordeaux, Pessac, France
| | | | - Edward Buitenwerf
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Anneke Visser
- Department of Applied Health Research, University of Groningen, University Medical Center Groningen, GZ Groningen, Netherlands
| | - Massimo Mannelli
- Department of Experimental and Clinical Biomedical Sciences University of Florence, Florence, Italy
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
| | - Vasileios Chortis
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
| | - Isabelle Bourdeau
- Division of Endocrinology, Center Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Nadia Gagnon
- Division of Endocrinology, Center Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Marie Buchy
- Fédération d'Endocrinologie, Groupement Hospitalier Est, Hospices Civils de Lyon, Bron, France
| | - Francoise Borson-Chazot
- Fédération d'Endocrinologie, Groupement Hospitalier Est, Hospices Civils de Lyon, Bron, France
| | - Timo Deutschbein
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Wuerzburg, Wuerzburg, Germany
| | - Martin Fassnacht
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Wuerzburg, Wuerzburg, Germany
- Comprehensive Cancer Center Mainfranken, University of Wuerzburg, Wuerzburg, Germany
| | | | - Marcin Motyka
- Department of Endocrinology, Jagiellonian University, Collegium Medicum, Krakow, Poland
| | - Ewelina Rzepka
- Department of Endocrinology, Jagiellonian University, Collegium Medicum, Krakow, Poland
| | - Ruth T Casey
- Addenbrooke's Hospital, Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge and NIHR Biomedical Research Center, Cambridge, United Kingdom
| | - Benjamin G Challis
- Addenbrooke's Hospital, Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge and NIHR Biomedical Research Center, Cambridge, United Kingdom
| | | | - Laurent Vroonen
- Department of Endocrinology, Center Hospitalier Universitaire de Liège, Liège, Belgium
| | - Ariadni Spyroglou
- Medizinische Klinik und Poliklinik IV Ludwig-Maximilians-Universität München, Munich, Germany
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, UniversitätsSpital Zürich, Zurich, Switzerland
| | - Felix Beuschlein
- Medizinische Klinik und Poliklinik IV Ludwig-Maximilians-Universität München, Munich, Germany
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, UniversitätsSpital Zürich, Zurich, Switzerland
| | - Cristina Lamas
- Endocrinology Department, Hospital General Universitario de Albacete, Albacete, Spain
| | - William F Young
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota
| | - Henri J L M Timmers
- Department of Internal Medicine, Division of Endocrinology, Radboud University Medical Center, Nijmegen, Netherlands
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16
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Morelli V, Palmieri S. Adrenal incidentaloma: differential diagnosis and management strategies. MINERVA ENDOCRINOL 2018; 44:4-18. [PMID: 29808642 DOI: 10.23736/s0391-1977.18.02868-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Adrenal incidentaloma is a frequent clinical finding. Once an adrenal mass is detected, is mandatory to determine whether the lesion is malignant or benign and whether it is hormonally active or non-functioning, to estabilish an adequate treatement or follow-up. The European Society of Endocrinology and ENSAT Guideline recently provided the best recommendation based on the available literature. However, due to the retrospective design of the majority of the studies, the small number of patients included and the inadequate follow-up, some issues are still unresolved. In particular, there is a general consensus about the need of adrenalectomy in the presence of unilateral adrenal mass and clinically relevant hormone excess or radiological findings suspected for malignancy. On the other side, how to manage adrenal masses with indeterminate characteristics or subtle cortisol secretion, and how long the radiological and functional follow-up of benign adrenal mass should last in non-operated patients, are still open questions. Therefore, high-quality research for establish the adequate management of these patients and randomized clinical trials are needed to avoid unnecessary investigations and invasive procedures and ensure a clinically effective work-up.
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Affiliation(s)
- Valentina Morelli
- Unit of Endocrinology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy -
| | - Serena Palmieri
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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17
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Buitenwerf E, Korteweg T, Visser A, Haag CMSC, Feelders RA, Timmers HJLM, Canu L, Haak HR, Bisschop PHLT, Eekhoff EMW, Corssmit EPM, Krak NC, Rasenberg E, van den Bergh J, Stoker J, Greuter MJW, Dullaart RPF, Links TP, Kerstens MN. Unenhanced CT imaging is highly sensitive to exclude pheochromocytoma: a multicenter study. Eur J Endocrinol 2018; 178:431-437. [PMID: 29467230 DOI: 10.1530/eje-18-0006] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 02/20/2018] [Indexed: 11/08/2022]
Abstract
BACKGROUND A substantial proportion of all pheochromocytomas is currently detected during the evaluation of an adrenal incidentaloma. Recently, it has been suggested that biochemical testing to rule out pheochromocytoma is unnecessary in case of an adrenal incidentaloma with an unenhanced attenuation value ≤10 Hounsfield Units (HU) at computed tomography (CT). OBJECTIVES We aimed to determine the sensitivity of the 10 HU threshold value to exclude a pheochromocytoma. METHODS Retrospective multicenter study with systematic reassessment of preoperative unenhanced CT scans performed in patients in whom a histopathologically proven pheochromocytoma had been diagnosed. Unenhanced attenuation values were determined independently by two experienced radiologists. Sensitivity of the 10 HU threshold was calculated, and interobserver consistency was assessed using the intraclass correlation coefficient (ICC). RESULTS 214 patients were identified harboring a total number of 222 pheochromocytomas. Maximum tumor diameter was 51 (39-74) mm. The mean attenuation value within the region of interest was 36 ± 10 HU. Only one pheochromocytoma demonstrated an attenuation value ≤10 HU, resulting in a sensitivity of 99.6% (95% CI: 97.5-99.9). ICC was 0.81 (95% CI: 0.75-0.86) with a standard error of measurement of 7.3 HU between observers. CONCLUSION The likelihood of a pheochromocytoma with an unenhanced attenuation value ≤10 HU on CT is very low. The interobserver consistency in attenuation measurement is excellent. Our study supports the recommendation that in patients with an adrenal incidentaloma biochemical testing for ruling out pheochromocytoma is only indicated in adrenal tumors with an unenhanced attenuation value >10 HU.
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Affiliation(s)
- Edward Buitenwerf
- Departments of EndocrinologyUniversity of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Tijmen Korteweg
- Departments of RadiologyUniversity of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Anneke Visser
- Departments of EndocrinologyUniversity of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Charlotte M S C Haag
- Departments of RadiologyUniversity of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Richard A Feelders
- Department of EndocrinologyErasmus Medical Center, Rotterdam, The Netherlands
| | - Henri J L M Timmers
- Section of EndocrinologyDepartment of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Letizia Canu
- Section of EndocrinologyDepartment of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Experimental and Clinical Biomedical SciencesUniversity of Florence, Florence, Italy
| | - Harm R Haak
- Department of Internal MedicineMáxima Medical Center, Eindhoven, The Netherlands
- Division of General Internal MedicineDepartment of Internal Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
- Maastricht UniversityCAPHRI School for Public Health and Primary Care, Ageing and Long-Term Care, Maastricht, The Netherlands
| | - Peter H L T Bisschop
- Department of Endocrinology and MetabolismAcademic Medical Center, Amsterdam, The Netherlands
| | - Elisabeth M W Eekhoff
- Endocrinology SectionDepartment of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Eleonora P M Corssmit
- Department of EndocrinologyLeiden University Medical Center, Leiden, The Netherlands
| | - Nanda C Krak
- Department of RadiologyErasmus Medical Center, Rotterdam, The Netherlands
| | - Elise Rasenberg
- Department of RadiologyMáxima Medical Center, Eindhoven, The Netherlands
| | | | - Jaap Stoker
- Department of Radiology and Nuclear MedicineAcademic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Marcel J W Greuter
- Departments of RadiologyUniversity of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Robin P F Dullaart
- Departments of EndocrinologyUniversity of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Thera P Links
- Departments of EndocrinologyUniversity of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Michiel N Kerstens
- Departments of EndocrinologyUniversity of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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18
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Anand G, Beuschlein F, Schmid C. [Not Available]. PRAXIS 2017; 106:1033-1038. [PMID: 28927363 DOI: 10.1024/1661-8157/a002783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Zusammenfassung. Nebenniereninzidentalome sind Raumforderungen der Nebenniere, welche in einer Bildgebung der Bauchregion unerwartet gefunden werden, ohne dass vorher eine zielführende Klinik und die Labordiagnostik einer Nebennierenerkrankung vorliegen und zur Bildgebung Anlass gegeben hätten. Das Inzidentalom ist keine eigenständige Diagnose. Es sollte grundsätzlich (bereits bei der Erstdiagnose) die Dignität der Raumforderung (benigne versus maligne) festgelegt und eine allfällig relevante Hormonproduktion ausgeschlossen oder nachgewiesen werden. Bei hormoninaktiven Tumoren sowie bei morphologisch eindeutig benignen Tumoren (Dichte <10 Hounsfield-Einheiten, Grösse <4 cm) kann auf eine weitere Nachsorge verzichtet werden, falls auch im Verlauf keine klinischen Verdachtsmomente hinzukommen. Bei unklaren und komplexen Fällen sollte die geeignete Nachsorge in einem interdisziplinären Tumorboard besprochen werden. Wenn die Indikation für eine Operation gestellt wird (z.B. hormonaktive Tumoren, maligne Raumforderung <6 cm ohne Hinweise auf Lokalinvasion), kann diese in einem spezialisierten Zentrum meist laparoskopisch (inkl. retroperitoneoskopisch) erfolgen.
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Affiliation(s)
- Gurpreet Anand
- 1 Klinik für Endokrinologie, Diabetologie und klinische Ernährung, Universitätsspital Zürich
| | - Felix Beuschlein
- 1 Klinik für Endokrinologie, Diabetologie und klinische Ernährung, Universitätsspital Zürich
- 2 Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Deutschland
| | - Christoph Schmid
- 1 Klinik für Endokrinologie, Diabetologie und klinische Ernährung, Universitätsspital Zürich
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Fassnacht M, Arlt W, Bancos I, Dralle H, Newell-Price J, Sahdev A, Tabarin A, Terzolo M, Tsagarakis S, Dekkers OM. Management of adrenal incidentalomas: European Society of Endocrinology Clinical Practice Guideline in collaboration with the European Network for the Study of Adrenal Tumors. Eur J Endocrinol 2016; 175:G1-G34. [PMID: 27390021 DOI: 10.1530/eje-16-0467] [Citation(s) in RCA: 896] [Impact Index Per Article: 112.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 06/02/2016] [Indexed: 12/13/2022]
Abstract
: By definition, an adrenal incidentaloma is an asymptomatic adrenal mass detected on imaging not performed for suspected adrenal disease. In most cases, adrenal incidentalomas are nonfunctioning adrenocortical adenomas, but may also represent conditions requiring therapeutic intervention (e.g. adrenocortical carcinoma, pheochromocytoma, hormone-producing adenoma or metastasis). The purpose of this guideline is to provide clinicians with best possible evidence-based recommendations for clinical management of patients with adrenal incidentalomas based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. We predefined four main clinical questions crucial for the management of adrenal incidentaloma patients, addressing these four with systematic literature searches: (A) How to assess risk of malignancy?; (B) How to define and manage low-level autonomous cortisol secretion, formerly called 'subclinical' Cushing's syndrome?; (C) Who should have surgical treatment and how should it be performed?; (D) What follow-up is indicated if the adrenal incidentaloma is not surgically removed? SELECTED RECOMMENDATIONS: (i) At the time of initial detection of an adrenal mass establishing whether the mass is benign or malignant is an important aim to avoid cumbersome and expensive follow-up imaging in those with benign disease. (ii) To exclude cortisol excess, a 1mg overnight dexamethasone suppression test should be performed (applying a cut-off value of serum cortisol ≤50nmol/L (1.8µg/dL)). (iii) For patients without clinical signs of overt Cushing's syndrome but serum cortisol levels post 1mg dexamethasone >138nmol/L (>5µg/dL), we propose the term 'autonomous cortisol secretion'. (iv) All patients with '(possible) autonomous cortisol' secretion should be screened for hypertension and type 2 diabetes mellitus, to ensure these are appropriately treated. (v) Surgical treatment should be considered in an individualized approach in patients with 'autonomous cortisol secretion' who also have comorbidities that are potentially related to cortisol excess. (vi) In principle, the appropriateness of surgical intervention should be guided by the likelihood of malignancy, the presence and degree of hormone excess, age, general health and patient preference. (vii) Surgery is not usually indicated in patients with an asymptomatic, nonfunctioning unilateral adrenal mass and obvious benign features on imaging studies. We provide guidance on which surgical approach should be considered for adrenal masses with radiological findings suspicious of malignancy. Furthermore, we offer recommendations for the follow-up of patients with adrenal incidentaloma who do not undergo adrenal surgery, for those with bilateral incidentalomas, for patients with extra-adrenal malignancy and adrenal masses and for young and elderly patients with adrenal incidentalomas.
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Affiliation(s)
- Martin Fassnacht
- Department of Internal Medicine IDivision of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany Comprehensive Cancer Center MainfrankenUniversity of Würzburg, Würzburg, Germany
| | - Wiebke Arlt
- Institute of Metabolism & Systems ResearchUniversity of Birmingham, Birmingham, UK Centre for EndocrinologyDiabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Irina Bancos
- Institute of Metabolism & Systems ResearchUniversity of Birmingham, Birmingham, UK Centre for EndocrinologyDiabetes and Metabolism, Birmingham Health Partners, Birmingham, UK Division of EndocrinologyMetabolism, Nutrition and Diabetes, Mayo Clinic, Rochester, Minnesota, USA
| | - Henning Dralle
- Department of GeneralVisceral, and Vascular Surgery, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - John Newell-Price
- Department of Oncology and MetabolismMedical School, University of Sheffield, Sheffield, UK Endocrine UnitRoyal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Anju Sahdev
- Department of ImagingSt Bartholomew's Hospital, Barts Health, London, UK
| | - Antoine Tabarin
- Department of Endocrinology and INSERM U862University and CHU of Bordeaux, Pessac, France
| | - Massimo Terzolo
- Internal Medicine 1Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Stylianos Tsagarakis
- Department of EndocrinologyDiabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Olaf M Dekkers
- Departments of Clinical Epidemiology and Internal MedicineLeiden University Medical Centre, Leiden, The Netherlands Department of Clinical EpidemiologyAarhus University, Aarhus, Denmark
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20
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Gunawardane PTK, Grossman A. Phaeochromocytoma and Paraganglioma. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 956:239-259. [PMID: 27888488 DOI: 10.1007/5584_2016_76] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Phaeochromocytomas and paragangliomas are relatively uncommon tumours which may be manifest in many ways, specifically as sustained or paroxysmal hypertension, episodes of palpitations, sweating, headache and anxiety, or increasingly as an incidental finding. Recent studies have shown that an increasing number are due to germline mutations. This review concentrates on the diagnosis, biochemistry and treatment of these fascinating tumours.
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Affiliation(s)
- P T Kavinga Gunawardane
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK.,Ministry of Health, Colombo, Sri Lanka
| | - Ashley Grossman
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK.
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21
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Baltzer P, Clauser P, Klatte T, Walz J. Work-up of the Incidental Adrenal Mass. Eur Urol Focus 2015; 1:217-222. [PMID: 28723390 DOI: 10.1016/j.euf.2015.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 12/07/2015] [Indexed: 12/26/2022]
Abstract
CONTEXT Incidental adrenal masses (or adrenal incidentalomas [AI]) are a common finding during imaging and are present in up to 5% of the computed tomography (CT) scans performed on the general population. The best way to manage these lesions is still under discussion. OBJECTIVE To evaluate recent literature and available guidelines regarding the work-up of AIs. EVIDENCE ACQUISITION We used a medical search engine to identify studies published in the past 5 yr regarding AIs. We also evaluated current guidelines and the most relevant papers published before 2010. EVIDENCE SYNTHESIS Unenhanced and contrast-enhanced CT, with laboratory tests to exclude functional lesions, are the most sensitive and specific methods currently available for the characterisation of adrenal masses. Magnetic resonance imaging, positron emission tomography-CT and fine-needle aspiration biopsy can be used as adjunct diagnostic tools in indeterminate lesions but are rarely indicated. In a relatively high number of indeterminate nodules, follow-up or surgery is suggested, although most of these lesions turn out to be benign. CONCLUSIONS Various imaging modalities, with CT being most important, are available to diagnose malignant and functional lesions in AIs. An improved identification of benign lesions is warranted to reduce the number of unnecessary surgeries and follow-up examinations in patients with benign lesions. PATIENT SUMMARY We performed a review of the literature on and guidelines for the management of incidental adrenal masses. It is possible to detect the presence of lesions that require surgery in the majority of cases. Follow-up is required for lesions that are not treated surgically.
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Affiliation(s)
- Pascal Baltzer
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna General Hospital, Vienna, Austria.
| | - Paola Clauser
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Tobias Klatte
- Department of Urology, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Jochen Walz
- Institut Paoli-Calmettes, Service de chirurgie urologique, Marseille, France
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22
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Schalin-Jäntti C, Raade M, Hämäläinen E, Sane T. A 5-Year Prospective Follow-Up Study of Lipid-Rich Adrenal Incidentalomas: No Tumor Growth or Development of Hormonal Hypersecretion. Endocrinol Metab (Seoul) 2015; 30:481-7. [PMID: 26354488 PMCID: PMC4722402 DOI: 10.3803/enm.2015.30.4.481] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 02/24/2015] [Accepted: 08/14/2015] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Current guidelines for follow-up of adrenal incidentalomas are extensive and hampered by lack of follow-up studies. We tested the hypothesis that small lipid-rich adrenal incidentalomas, initially characterized by tumor size <40 mm and <10 Hounsfield units (HUs) on unenhanced computed tomography (CT) may not demonstrate excessive growth/hormonal hypersecretion on follow-up. METHODS Sixty-nine incidentalomas in 56 patients were restudied with unenhanced CT and screening for hypercortisolism (dexamethasone suppression test [DST], plasma adrenocorticotropic hormone) and pheochromocytoma (24-hour urinary metanephrines and normetanephrines) 5 years later. Primary hyperaldosteronism was excluded at base-line. RESULTS Tumor (n=69) size was similar before and after 5 years follow-up (19±6 mm vs. 20±7 mm). Mean tumor growth was 1±2 mm. Largest increase in tumor size was 8 mm, this tumor was surgically removed and histopathology confirmed cortical adenoma. DST was normal in 54 patients and two patients (3.6%) were still characterized by subclinical hypercortisolism. Initial tumor size was >20 mm for the patient with largest tumor growth and those with subclinical hypercortisolism. All patients had normal 24-hour urinary metanephrines and normetanephrines. Low attenuation (<10 HU) was demonstrated in 97% of 67 masses re-evaluated with unenhanced CT. CONCLUSION None of the patients developed clinically relevant tumor growth or new subclinical hypercortisolism. Biochemical screening for pheochromocytoma in incidentalomas demonstrating <10 HU on unenhanced CT is not needed. For such incidentalomas <40 mm, it seems sufficient to perform control CT and screen for hypercortisolism after 5 years.
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Affiliation(s)
- Camilla Schalin-Jäntti
- Department of Endocrinology, Abdominal Center, Helsinki University Central Hospital, University of Helsinki, Helsinki, Finland.
| | - Merja Raade
- Department of Radiology, HUS Medical Imaging Center, Helsinki University Central Hospital, University of Helsinki, Helsinki, Finland
| | - Esa Hämäläinen
- HUSLAB, Department of Clinical Chemistry, University of Helsinki, Helsinki, Finland
| | - Timo Sane
- Department of Endocrinology, Abdominal Center, Helsinki University Central Hospital, University of Helsinki, Helsinki, Finland
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Kastelan D, Kraljevic I, Dusek T, Knezevic N, Solak M, Gardijan B, Kralik M, Poljicanin T, Skoric-Polovina T, Kastelan Z. The clinical course of patients with adrenal incidentaloma: is it time to reconsider the current recommendations? Eur J Endocrinol 2015; 173:275-82. [PMID: 26024670 DOI: 10.1530/eje-15-0199] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 05/29/2015] [Indexed: 01/15/2023]
Abstract
OBJECTIVE The current guidelines for the management of adrenal incidentaloma advise hormonal and radiological follow-up of patients for 2-5 years after the initial diagnosis. However, the vast majority of adrenal incidentaloma are non-functional benign cortical adenomas that require no treatment, so the routine application of the current strategies often results in a number of unnecessary biochemical and radiological investigations. The aim of this study was to analyse the clinical course of patients with adrenal incidentaloma and to provide a critical review of the current management strategy of the disease. DESIGN AND METHODS This was a retrospective study performed in the Croatian Referral Center for adrenal gland disorders. The study included 319 consecutive patients with adrenal incidentaloma, 174 of which were followed for at least 24 months. RESULTS The vast majority of patients were diagnosed with benign adrenal masses, whereas in about 5% of them adrenal tumor corresponded to adrenal carcinoma or metastasis. Tumor density was found to be superior to tumor size in distinguishing benign adrenal masses from malignant tumors and pheochromocytomas. During the follow-up, no patient demonstrated a clinically significant increase in tumor size. In addition, no changes, either in metanephrines and normetanephrines or in the activity of renin-aldosterone axis, were observed during the follow-up. Six patients developed subclinical Cushing's syndrome (SCS) whereas eight patients with SCS showed biochemical remission during follow-up. CONCLUSION The study suggests that the risk of an adrenal mass initially diagnosed as benign and non-functional becoming malignant or hormonally active is extremely low. Therefore, the clinical management of those patients should be tailored on an individual basis in order to avoid unnecessary procedures.
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Affiliation(s)
- Darko Kastelan
- Department of EndocrinologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaSchool of MedicineUniversity of Zagreb, Salata 3, 10000 Zagreb, CroatiaDepartment of UrologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaDepartment of Internal MedicineUniversity Hospital Merkur, Zajceva 19, 10000 Zagreb, CroatiaDepartment of RadiologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaCroatian Institute of Public HealthRockefellerova 7, 10000 Zagreb, Croatia Department of EndocrinologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaSchool of MedicineUniversity of Zagreb, Salata 3, 10000 Zagreb, CroatiaDepartment of UrologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaDepartment of Internal MedicineUniversity Hospital Merkur, Zajceva 19, 10000 Zagreb, CroatiaDepartment of RadiologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaCroatian Institute of Public HealthRockefellerova 7, 10000 Zagreb, Croatia
| | - Ivana Kraljevic
- Department of EndocrinologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaSchool of MedicineUniversity of Zagreb, Salata 3, 10000 Zagreb, CroatiaDepartment of UrologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaDepartment of Internal MedicineUniversity Hospital Merkur, Zajceva 19, 10000 Zagreb, CroatiaDepartment of RadiologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaCroatian Institute of Public HealthRockefellerova 7, 10000 Zagreb, Croatia
| | - Tina Dusek
- Department of EndocrinologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaSchool of MedicineUniversity of Zagreb, Salata 3, 10000 Zagreb, CroatiaDepartment of UrologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaDepartment of Internal MedicineUniversity Hospital Merkur, Zajceva 19, 10000 Zagreb, CroatiaDepartment of RadiologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaCroatian Institute of Public HealthRockefellerova 7, 10000 Zagreb, Croatia Department of EndocrinologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaSchool of MedicineUniversity of Zagreb, Salata 3, 10000 Zagreb, CroatiaDepartment of UrologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaDepartment of Internal MedicineUniversity Hospital Merkur, Zajceva 19, 10000 Zagreb, CroatiaDepartment of RadiologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaCroatian Institute of Public HealthRockefellerova 7, 10000 Zagreb, Croatia
| | - Nikola Knezevic
- Department of EndocrinologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaSchool of MedicineUniversity of Zagreb, Salata 3, 10000 Zagreb, CroatiaDepartment of UrologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaDepartment of Internal MedicineUniversity Hospital Merkur, Zajceva 19, 10000 Zagreb, CroatiaDepartment of RadiologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaCroatian Institute of Public HealthRockefellerova 7, 10000 Zagreb, Croatia
| | - Mirsala Solak
- Department of EndocrinologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaSchool of MedicineUniversity of Zagreb, Salata 3, 10000 Zagreb, CroatiaDepartment of UrologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaDepartment of Internal MedicineUniversity Hospital Merkur, Zajceva 19, 10000 Zagreb, CroatiaDepartment of RadiologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaCroatian Institute of Public HealthRockefellerova 7, 10000 Zagreb, Croatia
| | - Bojana Gardijan
- Department of EndocrinologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaSchool of MedicineUniversity of Zagreb, Salata 3, 10000 Zagreb, CroatiaDepartment of UrologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaDepartment of Internal MedicineUniversity Hospital Merkur, Zajceva 19, 10000 Zagreb, CroatiaDepartment of RadiologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaCroatian Institute of Public HealthRockefellerova 7, 10000 Zagreb, Croatia
| | - Marko Kralik
- Department of EndocrinologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaSchool of MedicineUniversity of Zagreb, Salata 3, 10000 Zagreb, CroatiaDepartment of UrologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaDepartment of Internal MedicineUniversity Hospital Merkur, Zajceva 19, 10000 Zagreb, CroatiaDepartment of RadiologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaCroatian Institute of Public HealthRockefellerova 7, 10000 Zagreb, Croatia
| | - Tamara Poljicanin
- Department of EndocrinologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaSchool of MedicineUniversity of Zagreb, Salata 3, 10000 Zagreb, CroatiaDepartment of UrologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaDepartment of Internal MedicineUniversity Hospital Merkur, Zajceva 19, 10000 Zagreb, CroatiaDepartment of RadiologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaCroatian Institute of Public HealthRockefellerova 7, 10000 Zagreb, Croatia
| | - Tanja Skoric-Polovina
- Department of EndocrinologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaSchool of MedicineUniversity of Zagreb, Salata 3, 10000 Zagreb, CroatiaDepartment of UrologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaDepartment of Internal MedicineUniversity Hospital Merkur, Zajceva 19, 10000 Zagreb, CroatiaDepartment of RadiologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaCroatian Institute of Public HealthRockefellerova 7, 10000 Zagreb, Croatia
| | - Zeljko Kastelan
- Department of EndocrinologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaSchool of MedicineUniversity of Zagreb, Salata 3, 10000 Zagreb, CroatiaDepartment of UrologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaDepartment of Internal MedicineUniversity Hospital Merkur, Zajceva 19, 10000 Zagreb, CroatiaDepartment of RadiologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaCroatian Institute of Public HealthRockefellerova 7, 10000 Zagreb, Croatia Department of EndocrinologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaSchool of MedicineUniversity of Zagreb, Salata 3, 10000 Zagreb, CroatiaDepartment of UrologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaDepartment of Internal MedicineUniversity Hospital Merkur, Zajceva 19, 10000 Zagreb, CroatiaDepartment of RadiologyUniversity Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, CroatiaCroatian Institute of Public HealthRockefellerova 7, 10000 Zagreb, Croatia
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Ioachimescu AG, Remer EM, Hamrahian AH. Adrenal incidentalomas: a disease of modern technology offering opportunities for improved patient care. Endocrinol Metab Clin North Am 2015; 44:335-54. [PMID: 26038204 DOI: 10.1016/j.ecl.2015.02.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Adrenal incidentalomas (AIs) are found in approximately 4% of patients undergoing abdominal imaging, with peak prevalence in the sixth and seventh decades of life. Detection of AI warrants clinical, biochemical, and radiological evaluation to establish its secretory status and risk of malignancy. Careful review of the lipid content, size, and imaging phenotype of an adrenal mass is needed to evaluate the risk for malignancy. Identification of an AI may be an opportunity to identify an underlying secretory tumor that may have been otherwise unrecognized. A practical approach to investigation and follow-up of AIs is presented in this article.
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Affiliation(s)
- Adriana G Ioachimescu
- Emory University School of Medicine, 1365 B Clifton Road, Northeast, B6209, Atlanta, GA 30322, USA
| | - Erick M Remer
- Imaging Institute, Cleveland Clinic, 9500 Euclid Avenue, A21, Cleveland, OH 44195, USA
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25
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Kannan S, Purysko A, Faiman C, Remer EM, Shah L, Bena J, Siperstein A, Berber E, Fergany A, Bravo E, Hamrahian AH. Biochemical and radiological relationships in patients with pheochromocytoma: lessons from a case control study. Clin Endocrinol (Oxf) 2014; 80:790-6. [PMID: 24494743 DOI: 10.1111/cen.12420] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 12/05/2013] [Accepted: 01/27/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND An elevation of fractionated plasma or urinary metanephrine (MN) or nor-metanephrine (NMN), collectively called metanephrines (MN and NMN), >4-fold above the upper limit of normal (ULN) is usually considered to be diagnostic for pheochromocytoma (PHEO). There are a greater number of false positive results when the elevations are more modest. AIM To identify biochemical and radiological features in PHEOs with modest elevations (<4-fold above ULN) of metanephrines. METHODOLOGY We retrospectively reviewed the charts of 112 patients with PHEO (10% extra-adrenal) and 208 patients with a non-PHEO adrenal mass operated from 1997-2011, who had metanephrines measured pre-operatively. We divided PHEO into group 1 (n = 90) with metanephrines ≥4-fold ULN and group 2 (n = 22) with metanephrines <4-fold ULN. The non-PHEO group was designated as group 3. RESULTS The median (range) tumour size in group 1 and group 2 was 4·8 cm (1·7-22) and 3·0 cm (1·7-5) respectively (P < 0·001). All patients with PHEO in group 2 had a tumour <5 cm in size. The MN fraction was elevated in about 65% of groups 1 and 2; only 2 (1%) patients in group 3 had an elevated urinary MN fraction, and none were associated with an elevated plasma MN fraction. All PHEOs had a pre-contrast attenuation ≥17 Hounsfield Units (HU). CONCLUSIONS Modest elevations (<4-fold ULN) of the NMN fraction in an adrenal mass >5 cm are almost always falsely positive. Elevations in plasma and urinary MN fraction are less likely to be false positive. The CT pre-contrast attenuation of PHEOs is >10 HU.
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Affiliation(s)
- Subramanian Kannan
- Department of Endocrinology and Metabolism, Cleveland Clinic Foundation, Cleveland, OH, USA
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Abstract
Pheochromocytomas or functioning paragangliomas can present in a dramatic manner with headache, palpitations and sometimes shock, but many occur with few symptoms despite at times markedly elevated catecholamine levels. Hypertension is not invariable, and may be paroxysmal. Increased diligence in the diagnosis of presymptomatic pheochromocytoma/paraganglioma is warranted from autopsy studies, suggesting that many of these tumors may be fatal at first presentation. Fortunately, an increasing number of pheochromocytomas/paragangliomas are now diagnosed before the advent of symptoms, either as an incidental finding on abdominal imaging or by targeted surveillance in subjects with known genetic susceptibility. The challenges and pitfalls associated with diagnosis of these silent pheochromocytoma/paragangliomas are reviewed in this article.
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Affiliation(s)
- Roderick Clifton-Bligh
- a University of Sydney, Sydney, NSW, Australia and Royal North Shore Hospital, St Leonards, NSW 2065, Australia.
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27
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[Subclinical adrenal diseases: silent pheochromocytoma and subclinical Addison's disease]. ANNALES D'ENDOCRINOLOGIE 2012; 73 Suppl 1:S45-54. [PMID: 23089381 DOI: 10.1016/s0003-4266(12)70014-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The silent pheochromocytoma, a hidden form of pheochromocytoma, exposes the patient to an increased risk of mortality if the diagnosis is not established on time. Biological diagnosis of pheochromocytoma can be difficult. Catecholamine secretion is dependent on tumor size and a large number of physiological, pharmacological, lifestyle modifications and sampling conditions influence the measurement of urinary and plasma metanephrines. The prevalence of pheochromocytoma is 2% among adrenal incidentaloma smaller than 3 cm (2/3 of tumors). Recent studies suggest the almost zero risk of pheochromocytoma among these tumors if they are hypodense (<10 housefield units) on adrenal tomography. Addison's disease is a pathology affecting about 1 in 8000. Immunopathology is still unknown, but some elements advocated the hypothesis of a predominant cell-mediated immunity in particular Interferon-gamma production by CD4 T lymphocytes in the presence of an epitope from the 21-hydroxylase, as well as IgG1 subtype produced by activated B lymphocytes, autoantibodies do appear to be a simple marker of the disease. Subclinical Addison's disease is defined by the presence of anti-21-hydroxylase autoantibodies, without clinical symptoms. It evolves faster to the clinical phase in young subjects, male, having high levels of autoantibodies and with an initially impaired adrenal function. Dosage of ACTH, plasma renin active, and basal cortisol and after Synacthen allow to discriminate the subjects with low or high risk of evolution and establish an appropriate monitoring.
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