dr daniel wong department of surgery kwong wah hospital
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Dr Daniel WongDepartment of SurgeryKwong Wah Hospital
Adrenal Incidentaloma- DefinitionAdrenal mass >1cm Detected during investigation for extra-
adrenal pathologyExclude workup of
Known malignancy patientsHypertensive and hypokalaemic
patients
Adrenal Incidentaloma- Definition
Prevalence 1.4-8.7%Found in up to 5% CT
scan
Angeli Horm Res 1997Barzon et al Eur J Endocrinol 2003
Adrenal Incidentaloma- AetiologyAdrenal cortical tumours
Adenoma, nodular hyperplasia, carcinoma
Adrenal medullary tumoursPheochromocytoma
Rare tumours Lipoma, myelolipoma
Metastatic lesionOthers- cyst, abscess, haematoma
Adrenal Incidentaloma- AetiologyRisk of malignancy & functional tumours
overestimated
Condition Prevalence
Adrenal cancer 1.9%
Metastasis 0.7%
Phaeochromocytoma 3.1%
Conn’s syndrome 0.6%
Subclinical Cushing’s Syndrome
6.4%
Cawood et al Eur J Endocrinol 2009
Adrenal Incidentaloma- Natural History
Most are non functional adenoma Size of lesion crucial
>25% malignant if >6cm2% malignant if <4cm
20% develop subsequent hormone production
25% may increase in size
NIH State of the Science guidelines 2002
Management GuidelinesNational Institute of Health State of the
Science guidelines 2002Young NEJM 2007 guidelinesSingh et al ACP best practice guidelines
J Clin Pathol 2008
Adrenal Incidentaloma WorkupWhether it is functional
Blood pressure, potassium (not reliable)Aldosterone/renin ratio1mg overnight dexamethasone
suppression test24 hour urine metanephrine,
catecholaminesPlasma DHEAS level (optional)
NIH State of the Science Guidelines 2002
Adrenal Incidentaloma WorkupWhether it is malignant: CT scan findings
>6cm high chance of malignancyIdeal lower cut off controversial4cm cutoff- 90% sensitivity for cancer
76% of lesion excised were benignSmooth, sharp border, calcifications
Angeli Hormone Res 1998NIH State of the Science
Guidelines 2002Yong NEJM 2007
Adrenal Incidentaloma Workup
Whether it is malignant: CT scan findingsAdenoma has higher fat contentDensity (Hounsfield Unit): <10 likely
adenomaEnhancement washout >50% at 15
minutes likely adenoma
NIH State of the Science Guidelines 2002
Adapted from Dunnick AJR 2002
Adrenal Metastasis
Adrenal Carcinoma
Linos Hormone 2003
9x8x8cm benign adenoma
2.8x2.8x2.3cm pheochromocytoma
Adrenal Incidentaloma Workup
CT guided biopsyOnly recommended if known primary
canceri.e. not true incidentaloma
Need to exclude phaeochromocytoma first!
Random use give low diagnostic yield
Yield of CT Guided Biopsy
Mazzaglia Arch Surg 2009
Adrenal Incidentaloma WorkupMRI
No proven benefit over CT scanRole of PET scan
Only if known history of carcinoma100% sensitivity in detecting metastasis
Frilling et al Surgery 2004
Management- SurgeryIf hormonal active or suspicious CT scanLaparoscopic approach recommendedCrucial to consider the indication of
surgerySurgical Unit
Nonfunctioning adenomas
Secreting adenomas
Others Total
Endocrine 18 (29.0) 41 (66.1) 3 (4.8) 62
General 95 (50.5) 54 (28.7) 39 (20.7) 188
Conzo Can J Surg 2009
Management- Follow upCT scan at regular intervals
6/12/24 monthsAnnual hormonal workupDischarge if static for 4 years
NIH State of the Science Guidelines 2002
Subclinical Cushing’s SyndromeSubclinical Cushing’s Syndrome (SCS)
Mild secretion of cortisol without clinically evident signs of hormone excess
No universally accepted definition
Rossi J Clin Endocrinol Metab 2000
Subclinical Cushing’s Syndrome 5-20 % AI patients
Large percentage with hyperlipidaemia, hypertension, diabetes
Risk of cardiovascular diseasesLower bone density, increased fracture
riskSurgery improves diabetic, BP control,
lipid profile and obesityComlekci et al Endocrine 2009
Chiodini J Clin Endocrinol Metab 2009
Toniato Ann Surg 2009
ConclusionsAI - common radiological findingMost are benign and indolentSize good predictor of malignant riskRegular follow up neededExpanding indications for surgery in
laparoscopic era