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Tilala YM, Panda S, Tripathi A, Sharma S, Paul AS, Choudhuri S, Swain S. Assessment of the diagnostic efficacy of radiological and functional evaluation of primary adrenal mass and its' surgical outcomes. Urologia 2024:3915603241259881. [PMID: 39051607 DOI: 10.1177/03915603241259881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
INTRODUCTION Objective of this study was to assess the diagnostic efficacy of the most commonly used radiological evaluation in form of contrast enhanced computed tomography of abdomen with adrenal protocol, basic functional evaluation and surgical outcomes of primary adrenal masses. MATERIAL AND METHODS We have retrospectively analysed the institutional records of 108, patients admitted from August 2017 to September 2023, who had underwent surgical intervention for their adrenal mass after thorough evaluation and stabilization. RESULTS Flank pain was the most common symptoms in 44 (40.74%) patients. Non-functional adrenal adenoma was found in 36 (33.33%) patients. Pheochromocytoma was the most the common functional adrenal mass found in 24 (22.22%) patients. CECT abdomen had suggested features of malignancy in 16(14.81%) patients. In final histopathological report 26(24.07%) patients had pheochromocytoma and 12 (11.11%) patients had adrenocortical carcinoma. CECT abdomen had sensitivity of 75%, specificity of 95.6%. Plasma free metanephrines and normetanephrine analysis had shown sensitivity of 90%, specificity of 92.86%, aldosterone to renin ratio had sensitivity of 92%, specificity of 100%. Sensitivity and specificity of the low-dose dexamethasone suppression test and plasma dehydroepiandrosterone was 100% in our study. Eighty patients (74.07%) were operated with laparoscopic adrenalectomy, 20 (18.52%) patients with open adrenalectomy. Eight patients (7.41%) were converted from laparoscopic to open. Laparoscopic approach had significantly lesser mean operating time, lesser blood loss, lesser hospitalization and lesser post-operative complications. CONCLUSION Radiological analysis and functional analysis has shown good sensitivity and high specificity. Laparoscopic approach has advantage of lesser operative time, lesser hospitalization and lesser post-operative complications.
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Affiliation(s)
- Yash Manharlal Tilala
- Department of Urology and Renal Transplant, S.C.B. Medical College & Hospital, Cuttack, Odisha, India
| | - Sabyasachi Panda
- Department of Urology and Renal Transplant, S.C.B. Medical College & Hospital, Cuttack, Odisha, India
| | - Abhilekh Tripathi
- Department of Urology and Renal Transplant, S.C.B. Medical College & Hospital, Cuttack, Odisha, India
| | - Sachin Sharma
- Department of Urology and Renal Transplant, S.C.B. Medical College & Hospital, Cuttack, Odisha, India
| | - Amiya Shankar Paul
- Department of Urology and Renal Transplant, S.C.B. Medical College & Hospital, Cuttack, Odisha, India
| | - Sanjay Choudhuri
- Department of Urology and Renal Transplant, S.C.B. Medical College & Hospital, Cuttack, Odisha, India
| | - Samir Swain
- Department of Urology and Renal Transplant, S.C.B. Medical College & Hospital, Cuttack, Odisha, India
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Adnan A, Raju S, Kumar R, Basu S. An Appraisal and Update of Fluorodeoxyglucose and Non-Fluorodeoxyglucose-PET Tracers in Thyroid and Non-Thyroid Endocrine Neoplasms. PET Clin 2022; 17:343-367. [PMID: 35717097 DOI: 10.1016/j.cpet.2022.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Endocrine neoplasms and malignancies are a diverse group of tumors with varied clinical, histopathologic, and functional features. These tumors vary from sporadic to hereditary, isolated entities to multiple neoplastic syndromes, functioning and non functioning tumors, unifocal locally invasive, and advanced to multifocal tumors with disseminated distant metastases. The presence of various specific biomarkers and specific receptor targets serves as valuable tools for diagnosis, prognosis, and management. PET-CT with FDG and a multitude of novel and specific radiotracers towards specific therapeutic targets mandates personalization of their use, so as to ensure maximum clinical benefit in the management of these neoplasms.
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Affiliation(s)
- Aadil Adnan
- Radiation Medicine Centre (B.A.R.C), Tata Memorial Centre Annexe, Parel, Mumbai, India; Homi Bhabha National Institute, Mumbai, India
| | - Shobhana Raju
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Kumar
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sandip Basu
- Radiation Medicine Centre (B.A.R.C), Tata Memorial Centre Annexe, Parel, Mumbai, India; Homi Bhabha National Institute, Mumbai, India.
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Hanna FWF, Issa BG, Lea SC, George C, Golash A, Firn M, Ogunmekan S, Maddock E, Sim J, Xydopoulos G, Fordham R, Fryer AA. Adrenal lesions found incidentally: how to improve clinical and cost-effectiveness. BMJ Open Qual 2020; 9:bmjoq-2018-000572. [PMID: 32054639 PMCID: PMC7047483 DOI: 10.1136/bmjoq-2018-000572] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 10/21/2019] [Accepted: 10/22/2019] [Indexed: 11/13/2022] Open
Abstract
Introduction Adrenal incidentalomas are lesions that are incidentally identified while scanning for other conditions. While most are benign and hormonally non-functional, around 20% are malignant and/or hormonally active, requiring prompt intervention. Malignant lesions can be aggressive and life-threatening, while hormonally active tumours cause various endocrine disorders, with significant morbidity and mortality. Despite this, management of patients with adrenal incidentalomas is variable, with no robust evidence base. This project aimed to establish more effective and timely management of these patients. Methods We developed a web-based, electronic Adrenal Incidentaloma Management System (eAIMS), which incorporated the evidence-based and National Health Service–aligned 2016 European guidelines. The system captures key clinical, biochemical and radiological information necessary for adrenal incidentaloma patient management and generates a pre-populated outcome letter, saving clinical and administrative time while ensuring timely management plans with enhanced safety. Furthermore, we developed a prioritisation strategy, with members of the multidisciplinary team, which prioritised high-risk individuals for detailed discussion and management. Patient focus groups informed process-mapping and multidisciplinary team process re-design and patient information leaflet development. The project was partnered by University Hospital of South Manchester to maximise generalisability. Results Implementation of eAIMS, along with improvements in the prioritisation strategy, resulted in a 49% reduction in staff hands-on time, as well as a 78% reduction in the time from adrenal incidentaloma identification to multidisciplinary team decision. A health economic analysis identified a 28% reduction in costs. Conclusions The system’s in-built data validation and the automatic generation of the multidisciplinary team outcome letter improved patient safety through a reduction in transcription errors. We are currently developing the next stage of the programme to proactively identify all new adrenal incidentaloma cases.
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Affiliation(s)
- Fahmy W F Hanna
- Department of Diabetes and Endocrinology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK .,Centre for Health and Development, Staffordshire University, Stoke-on-Trent, UK
| | - Basil G Issa
- Department of Diabetes and Endocrinology, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - Simon C Lea
- Research and Innovation Directorate, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Cherian George
- Imaging, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, Staffordshire, UK
| | - Anurag Golash
- Department of Urology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Mike Firn
- Springfield Consultancy, South West London and Saint George's Mental Health NHS Trust, London, UK
| | | | - Elloise Maddock
- Department of Information and Communications Technology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Julius Sim
- School of Primary, Community and Social Care, Keele University, Keele, UK
| | | | - Richard Fordham
- Department of Health Economics, University of East Anglia, Norwich, UK
| | - Anthony A Fryer
- Department of Clinical Biochemistry, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
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Nabi T, Rafiq N, Dar S, Rasool S. Presentation and outcome of patients with an adrenal mass: A retrospective observational study. CLINICAL CANCER INVESTIGATION JOURNAL 2020. [DOI: 10.4103/ccij.ccij_70_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Terzolo M, Reimondo G. Insights on the Natural History of Adrenal Incidentalomas. Ann Intern Med 2019; 171:135-136. [PMID: 31234201 DOI: 10.7326/m19-1482] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Massimo Terzolo
- San Luigi Gonzaga Hospital, University of Turin, Turin, Italy (M.T., G.R.)
| | - Giuseppe Reimondo
- San Luigi Gonzaga Hospital, University of Turin, Turin, Italy (M.T., G.R.)
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Nuzzo V, Attardo T, Augello G, Brancato D, Canale C, Camerlingo S, Coretti F, Franco A, Giacometti F, Gambacorta M, Loreno M, Maffettone A, Provenzano V, Zuccoli A. A clinical audit: diagnostic and epidemiological evaluation of the adrenal incidentaloma. MINERVA ENDOCRINOL 2018; 45:18-28. [PMID: 29442478 DOI: 10.23736/s0391-1977.18.02780-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Audit is a clinical instrument of government characterized by a whole process of evaluation inter pares to improve medical behaviors in the clinical practice. Different endocrinopathies are underestimated in the clinical and diagnostics practice but they can be a real problem in patients admitted in the departments of Internal Medicine. The adrenal incidentaloma is an accidental discovery with an incidence equal to 4% in radiologic studies but it's rarely considereted in the internal disorders. In the departments of Internal Medicine are hospitalized each year approximately 1450,000 patients and 58,000 about them show a surrenalic lesion identified with CT or MRI as Adrenal Incidentaloma. METHODS Through a search in the radiological archives, were reviewed all abdominal CT performed in the year 2012 in 8 departments of Internal Medicine of 8 Italian public hospitals. They also examined all medical records of these patients to value clinical management of the adrenal masses and the real incidence of the adrenal incidentaloma. RESULTS Distribution of pathological results show an important incidence about adrenal incidentaloma in Italian patients although this pathology is represented as a rare disease and its clinical and economic burden are significant. Many questions remain unanswered as the association between duration and severity of the disease, morbidity and how the dimensions affecting it. These results need to be supported by important studies with long follow-up to realize an easy diagnosis. CONCLUSIONS The results of this audit confirm the real incidence of this pathology in the internistic patients and the final target is to implement changes about therapeutic diagnostic pathway of the hospital patients in the internal medicine departments.
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Affiliation(s)
- Vincenzo Nuzzo
- Unit of Endocrinology and Human Nutrition, Ospedale del Mare, Naples, Italy -
| | | | | | | | - Clelia Canale
- Bianchi Melacrino Morelli Hospital, Reggio Calabria, Italy
| | | | - Federica Coretti
- Unit of Endocrinology and Human Nutrition, Ospedale del Mare, Naples, Italy
| | | | | | | | | | | | | | - Alfonso Zuccoli
- Unit of Endocrinology and Human Nutrition, Ospedale del Mare, Naples, Italy
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Li L, Yang G, Zhao L, Dou J, Gu W, Lv Z, Lu J, Mu Y. Baseline Demographic and Clinical Characteristics of Patients with Adrenal Incidentaloma from a Single Center in China: A Survey. Int J Endocrinol 2017; 2017:3093290. [PMID: 28848603 PMCID: PMC5564109 DOI: 10.1155/2017/3093290] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 06/14/2017] [Accepted: 06/19/2017] [Indexed: 11/18/2022] Open
Abstract
AIM To investigate the clinical and endocrinological characteristics of patients with adrenal incidentaloma (AI). MATERIALS AND METHODS This retrospective study enrolled 1941 AI patients hospitalized at the Department of Endocrinology, Chinese PLA General Hospital, Beijing, China, between January 1997 and December 2016. The patient gender, age at visits, imaging features, functional status, and histological results were analyzed. RESULTS Of the 1941 patients, 984 (50.70%) were men. The median age was 52 years (interquartile range: 44-69 years). 140 cases had bilateral AI. Endocrine evaluation showed that 1411 (72.69%) patients had nonfunctional tumor, 152 (7.83%) had subclinical Cushing syndrome (SCS), and 82 (4.33%) had primary hyperaldosteronism. A total of 925 patients underwent operation for removal of 496 cortical adenomas (53.62%), 15 adrenal cortical carcinomas (1.62%), and 172 pheochromocytomas (18.59%). The bilateral group had a higher proportion of SCS (18.57% versus 7.10%, P < 0.001, P = 0.006). A mass size of 46 mm was of great value in distinguishing malignant tumors from the benign tumors, with sensitivity of 88.2% and specificity of 95.5%. CONCLUSIONS We reported the baseline demographic and clinical characteristics of patients with AI in a large series from a single center in China.
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Affiliation(s)
- Lele Li
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
- Chinese PLA Key Laboratory of Endocrinology and Metabolism, Beijing 100853, China
| | - Guoqing Yang
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
- Chinese PLA Key Laboratory of Endocrinology and Metabolism, Beijing 100853, China
| | - Ling Zhao
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
- Chinese PLA Key Laboratory of Endocrinology and Metabolism, Beijing 100853, China
| | - Jingtao Dou
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
- Chinese PLA Key Laboratory of Endocrinology and Metabolism, Beijing 100853, China
- *Jingtao Dou:
| | - Weijun Gu
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
- Chinese PLA Key Laboratory of Endocrinology and Metabolism, Beijing 100853, China
| | - Zhaohui Lv
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
- Chinese PLA Key Laboratory of Endocrinology and Metabolism, Beijing 100853, China
| | - Juming Lu
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
- Chinese PLA Key Laboratory of Endocrinology and Metabolism, Beijing 100853, China
| | - Yiming Mu
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
- Chinese PLA Key Laboratory of Endocrinology and Metabolism, Beijing 100853, China
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Determining the Cost of Incidental Findings for Patients Undergoing Preoperative Planning for Abdominally Based Perforator Free Flap Breast Reconstruction with Computed Tomographic Angiography. Plast Reconstr Surg 2016; 138:804e-810e. [DOI: 10.1097/prs.0000000000002621] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abaroa-Salvatierra A, Shaikh B, Deshmukh M, Alweis R, Patel A. Calcitriol-mediated hypercalcemia in a patient with bilateral adrenal non-Hodgkin's B-cell lymphoma case report. J Community Hosp Intern Med Perspect 2016; 6:30381. [PMID: 27124160 PMCID: PMC4857720 DOI: 10.3402/jchimp.v6.30381] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 02/04/2016] [Accepted: 02/08/2016] [Indexed: 01/23/2023] Open
Abstract
Calcitriol-mediated hypercalcemia is a frequent manifestation of hematological malignancies. However, there are a few reports of cases presenting with increased angiotensin-converting enzyme (ACE) level, which suggests a possible mechanism similar to that of granulomatous diseases. We present a patient with hypercalcemia, normal parathyroid hormone, and parathyroid hormone-related protein levels but high calcitriol and ACE levels that, after further investigation, was diagnosed with bilateral adrenal non-Hodgkin's B-cell lymphoma. Primary adrenal lymphoma represents only 1% of all non-Hodgkin's lymphomas and is usually asymptomatic but should be considered by clinicians among the malignancies that cause calcitriol-mediated hypercalcemia.
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Affiliation(s)
| | - Bilal Shaikh
- Department of Internal Medicine, Reading Health System, West Reading, PA, USA
| | - Mrunalini Deshmukh
- Department of Endocrinology and Diabetes Center, Reading Health System, West Reading, PA, USA
| | - Richard Alweis
- Department of Internal Medicine, Reading Health System, West Reading, PA, USA
| | - Arti Patel
- Department of Endocrinology and Diabetes Center, Reading Health System, West Reading, PA, USA
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Sabet FA, Majdzadeh R, Mostafazadeh Davani B, Heidari K, Soltani A. Likelihood ratio of computed tomography characteristics for diagnosis of malignancy in adrenal incidentaloma: systematic review and meta-analysis. J Diabetes Metab Disord 2016; 15:12. [PMID: 27104171 PMCID: PMC4839087 DOI: 10.1186/s40200-016-0224-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 02/24/2016] [Indexed: 11/24/2022]
Abstract
Purpose To propose an evidence based diagnostic algorithm using mass characteristics to determine malignancy in patients with adrenal incidentaloma by CTscan. Methods A systematic review in Medline, Scopus, relevant reference books and desk searching was performed up to January 2016 with relevant reference checking. The summery estimates of sensitivity, specificity, positive and negative likelihood ratio of different characteristics were calculated in two groups of the articles investigating the cases without previous malignancy and the articles investigating the oncologic cases. Results Thirty six articles were included in this study. In the first group with no history of malignancy a positive and negative LR of 3.1 and 0.13 in 4 cm threshold and positive and negative LR of 2.85 and 0 in 10HU density were found. In the second group with history of malignancy positive and negative LR of 2.3 and 0.27 in 3 cm threshold and positive and negative LR of 3.6 and 0.08 in 20HU density were resulted. Conclusion The results retrieved in this study considering the limitations show that adrenal incidentaloma with a size less than 4 cm or a mass larger than 4 cm with density less than 10HU in the first group can be managed with imaging follow up. For masses larger than 4 cm with density more than 10HU another diagnostic procedure should be performed. In the second group an adrenal mass larger than 3 cm or less than 3 cm with density more than 20HU should go under operation. But masses smaller than 3 cm with less than 20HU density can be followed by imaging.
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Affiliation(s)
- Fatemeh Alsadat Sabet
- School of Medicine and Public Health, Evidence based Practice Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Majdzadeh
- Center for Knowledge Translation and Exchange, Tehran University of Medical Sciences, School of Public Health, Tehran, Iran
| | - Babak Mostafazadeh Davani
- Evidence based Practice Research Center, Endocrinology and Metabolism Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Kazem Heidari
- School of public health, Tehran University of Medical Sciences, Tehran, Iran
| | - Akbar Soltani
- Evidence based Practice Research Center, Endocrinology and Metabolism Research Center, Tehran University of Medical Sciences, Tehran, Iran
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A Retroperitoneal Leiomyosarcoma Presenting as an Adrenal Incidentaloma in a Subject on Warfarin. Case Rep Endocrinol 2015; 2015:830814. [PMID: 26064705 PMCID: PMC4429207 DOI: 10.1155/2015/830814] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Revised: 04/15/2015] [Accepted: 04/16/2015] [Indexed: 12/19/2022] Open
Abstract
Adrenal incidentalomas (AIs) are mostly benign and nonsecretory. Management algorithms lack sensitivity when assessing malignant potential, although functional status is easier to assess. We present a subject whose AI was a retroperitoneal leiomyosarcoma (RL). Case Presentation. A woman on warfarin with SLE and the antiphospholipid syndrome, presented with left loin pain. She was normotensive and clinically normal. Ultrasound scans demonstrated left kidney scarring, but CT scans revealed an AI. MRI scans later confirmed the AI without significant fat and no interval growth. Cortisol after 1 mg dexamethasone, urinary free cortisol and catecholamines, plasma aldosterone renin ratio, and 17-hydroxyprogesterone were within the reference range. Initially, adrenal haemorrhage was diagnosed because of warfarin therapy and the acute presentation. However, she underwent adrenalectomy because of interval growth of the AI. Histology confirmed an RL. The patient received adjuvant radiotherapy. Discussion. Our subject presented with an NSAI. However, we highlight the following: (a) the diagnosis of adrenal haemorrhage in this anticoagulated woman was revised because of interval growth; (b) the tumour, an RL, was relatively small at diagnosis; (c) this subject has survived well over 60 months despite an RL perhaps because of her acute presentation and early diagnosis of a small localised tumour.
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12
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Adrenal Lesions. Surg Oncol 2015. [DOI: 10.1007/978-1-4939-1423-4_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Reimondo G, Allasino B, Coletta M, Pia A, Peraga G, Zaggia B, Massaglia C, Paccotti P, Terzolo M. Evaluation of Midnight Salivary Cortisol as a Predictor Factor for Common Carotid Arteries Intima Media Thickness in Patients with Clinically Inapparent Adrenal Adenomas. Int J Endocrinol 2015; 2015:674734. [PMID: 26074962 PMCID: PMC4446512 DOI: 10.1155/2015/674734] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 04/22/2015] [Accepted: 04/28/2015] [Indexed: 12/19/2022] Open
Abstract
Purpose. The aim of the present study was to investigate the atherosclerotic vascular damage in a consecutive series of patients with AI and to correlate it with MSC. Methods. We studied 32 patients with AI matched with control subjects for age, sex, and cardiovascular risk factors. Either patients or control subjects underwent MSC measurement as outpatients and carotid arteries ultrasound (US) imaging studies. Results. The patients with AI had higher mean carotid artery IMT values and higher MSC levels than control subjects. In a multivariate analysis performed in AI age was the best predictor for IMT. We have stratified patients and control subjects by age (<60 yrs and ≥60 yrs). The patients showed significantly higher MSC levels than controls in both groups, whereas significantly higher IMT values were observed only in older subjects. Conclusions. Patients with AI have signs of accelerated atherosclerosis. Patients older than 60 years seem more susceptible to the possible detrimental effect of subclinical hypercortisolism on cardiovascular system. The MSC levels are not a strong predictor of the accelerated atherosclerosis, but they seem to indicate the subtle but not autonomous cortisol excess that may potentially raise the cardiovascular risk.
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Affiliation(s)
- Giuseppe Reimondo
- Internal Medicine I, Department of Clinical and Biological Sciences, University of Turin, San Luigi Hospital, 10043 Orbassano, Italy
- *Giuseppe Reimondo:
| | - Barbara Allasino
- Internal Medicine I, Department of Clinical and Biological Sciences, University of Turin, San Luigi Hospital, 10043 Orbassano, Italy
| | - Marcella Coletta
- Internal Medicine I, Department of Clinical and Biological Sciences, University of Turin, San Luigi Hospital, 10043 Orbassano, Italy
| | - Anna Pia
- Internal Medicine I, Department of Clinical and Biological Sciences, University of Turin, San Luigi Hospital, 10043 Orbassano, Italy
| | - Giulia Peraga
- Internal Medicine I, Department of Clinical and Biological Sciences, University of Turin, San Luigi Hospital, 10043 Orbassano, Italy
| | - Barbara Zaggia
- Internal Medicine I, Department of Clinical and Biological Sciences, University of Turin, San Luigi Hospital, 10043 Orbassano, Italy
| | - Chiara Massaglia
- Internal Medicine I, Department of Clinical and Biological Sciences, University of Turin, San Luigi Hospital, 10043 Orbassano, Italy
| | - Piero Paccotti
- Internal Medicine I, Department of Clinical and Biological Sciences, University of Turin, San Luigi Hospital, 10043 Orbassano, Italy
| | - Massimo Terzolo
- Internal Medicine I, Department of Clinical and Biological Sciences, University of Turin, San Luigi Hospital, 10043 Orbassano, Italy
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Abstract
Endocrine tumors are hormonally active benign or malignant neoplasms arising within endocrine organs or from specialized cells of the amine precursor uptake and decarboxylation system. The detection rate of these tumors is increasing as a result of sensitive biochemical tests and high-resolution diagnostic imaging. Medical imaging has become a key component in the diagnosis and staging of endocrine malignancies; however, despite the impressive advances in computed tomography (CT) and MRI, detection of small primary tumors and metastases continues to be a challenge. Functional imaging techniques use radiopharmaceuticals targeted at unique tumor cellular processes in order to provide sensitive and highly specific whole-body imaging. Functional imaging allows prediction of the efficacy of radionuclide or receptor-based therapies and surveillance after therapy. Advances in imaging have not been limited to radiopharmaceuticals. Hybrid scanner technology in the form of PET/CT and single photon emission computed tomography (SPECT)/CT, designed to combine functional images with anatomic maps, has further improved the diagnostic accuracy. High-resolution hybrid imaging when deployed with novel PET and SPECT radiopharmaceuticals has the potential to dramatically change, individualize, and optimize imaging plans based on the histological grade, degree of differentiation, and genetic profile of each patient's endocrine neoplasm.
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Adrenal mass in pregnancy: Diagnostic approach and dilemmas. APOLLO MEDICINE 2013. [DOI: 10.1016/j.apme.2013.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Abstract
Adrenal incidentaloma is a common clinical problem and its prevalence, in radiological studies, comes close to that of autoptic data as a result of imaging technological advances. The diagnostic challenge is to distinguish the majority of benign lesions from other masses, either malignant or hormone secreting, which require further therapy. The imaging evaluation (unenhanced CT and MRI) can differentiate malignant to benign lesions because the benign lesions have high lipid content. All patients should be tested for hypercortisolism and pheochromocytoma whereas aldosteronism should be tested in hypertensive patients only. The optimal diagnostic management for adrenal incidentaloma is still controversial, and the endocrinologist must devise a cost-effective approach taking into account the extensive endocrine work-up and imaging investigations that may be necessary. A tailored strategy may be based on the selection of patients at increased risk who require a careful and extensive follow-up among the vast majority of patients who require a simplified follow-up.
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Affiliation(s)
- Giorgio Arnaldi
- Division of Endocrinology, Polytechnic University of Marche, 60020 Ancona, Italy
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Abstract
Subclinical Cushing's syndrome is an ill-defined endocrine disorder that may be observed in patients bearing an incidentally found adrenal adenoma. The concept of subclinical Cushing's syndrome stands on the presence of ACTH-independent cortisol secretion by an adrenal adenoma, that is not fully restrained by pituitary feed-back. A hypercortisolemic state of usually minimal intensity may ensue and eventually cause harm to the patients in terms of metabolic and vascular diseases, and bone fractures. However, the natural history of subclinical Cushing's syndrome remains largely unknown. The present review illustrates the currently used methods to ascertain the presence of subclinical Cushing's syndrome and the surrounding controversy. The management of subclinical Cushing's syndrome, that remains a highly debated issue, is also addressed and discussed. Most of the recommendations made in this chapter reflects the view and the clinical experience of the Authors and are not based on solid evidence.
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Affiliation(s)
- M Terzolo
- Internal Medicine I, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy.
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Androulakis II, Kaltsas GA, Markou A, Tseniklidi E, Kafritsa P, Pappa T, Papanastasiou L, Piaditis GP. The functional status of incidentally discovered bilateral adrenal lesions. Clin Endocrinol (Oxf) 2011; 75:44-9. [PMID: 21521282 DOI: 10.1111/j.1365-2265.2011.04013.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To investigate autonomous cortisol and aldosterone secretion and insulin resistance (IR) indices, in patients with incidentally discovered bilateral adrenal lesions (BA). PATIENTS Thirty-six patients with BA, 113 patients with unilateral adrenal incidentalomas (UA) and 89 healthy subjects (C) with normal adrenal imaging. MEASUREMENTS All participants underwent adrenal imaging, baseline biochemical and hormonal measurements and the following investigations on consecutive days: (i) A 2-h oral glucose tolerance test (OGTT) (75 g) with glucose and insulin measurements every 30 min. (ii) An adrenocorticotrophin (ACTH) stimulation test with intravenous (i.v.) bolus administration of 250 μg of ACTH (1-24) and measurement of serum cortisol and aldosterone before and after 30 and 60 min. (iii) A low-dose dexamethasone suppression test (LDDST) (0·5 mg of dexamethasone every 6-h for 2 days) with cortisol measurement 6 h after the last dexamethasone dose and (iv) A NaCl (0·9%) postdexamethasone saline infusion test (PD-SIT) (2 l of NaCl 0·9% iv in 4 h) following the LDDST, with aldosterone measurement at the end of the test. RESULTS Cortisol and aldosterone cut-offs based on the mean + 2 SD values obtained from the C group following the LDDST and PD-SITs were calculated (34·11 nm and 74·83 pm, respectively). Based on the above cut-offs, autonomous cortisol and aldosterone secretion was found in 42·5 and 15·9% of patients with UA, and in 41·7 and 19·4% of patients with BA, respectively. In addition, 17·7% of patients with UA and 19·4% of patients with BA had concomitant autonomous cortisol and aldosterone secretion. Cortisol and aldosterone levels following the LDDST and PD-SIT were significantly higher in the BA compared to the UA group, respectively. Furthermore, patients with BA had more pronounced glucose levels and insulin resistance (IR) indices compared to patients with UA. CONCLUSIONS Patients with BA have more pronounced autonomous cortisol and aldosterone secretion and glucose metabolism alterations than patients with UA. Further studies are needed to evaluate the potential long-term consequences of these findings.
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Affiliation(s)
- Ioannis I Androulakis
- Department of Endocrinology and Diabetes, General Hospital of Athens "G. Genimatas"Department of Pathophysiology, Endocrine Unit, Medical School, University of Athens, Athens, Greece
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Wong KK, Arabi M, Bou-Assaly W, Marzola MC, Rubello D, Gross MD. Evaluation of incidentally discovered adrenal masses with PET and PET/CT. Eur J Radiol 2011; 81:441-50. [PMID: 21295930 DOI: 10.1016/j.ejrad.2010.12.060] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2010] [Accepted: 12/23/2010] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE Incidentally discovered adrenal masses are commonly seen with high resolution diagnostic imaging performed for indications other than adrenal disease. Although the majority of these masses are benign and non-secretory, their unexpected discovery prompts further biochemical and often repeated imaging evaluations, sufficient to identify hormonally active adrenal masses and/or primary or metastatic neoplasms to the adrenal(s). In the present paper we investigate the role of PET and PET/CT for the detection of adrenal incidentalomas in comparison with CT and MRI. MATERIALS AND METHODS a systematic revision of the papers published in PubMed/Medline until September 2010 was done. RESULTS The diagnostic imaging approach to incidentally discovered adrenal masses includes computed tomography (CT), magnetic resonance imaging (MRI) and more recently positron emission tomography (PET) with radiopharmaceuticals designed to exploit mechanisms of cellular metabolism, adrenal substrate precursor uptake, or receptor binding. CONCLUSION The functional maps created by PET imaging agents and the anatomic information provided by near-simultaneously acquired, co-registered CT facilitates localization and diagnosis of adrenal dysfunction, distinguishes unilateral from bilateral disease, and aids in characterizing malignant primary and metastatic adrenal disease.
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Affiliation(s)
- Ka Kit Wong
- Department of Nuclear Medicine, Veterans Affairs Hospital, and University of Michigan Health System, Department of Radiology, Division of Nuclear Medicine, Ann Arbor, MI 48105, USA.
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Abstract
In the last decades discoveries of adrenal masses incidentally during the course of diagnostic procedures for unrelated disorders (incidentalomas) have become progressively more frequent. The clinician in this position must answer two main questions: Is the mass benign or malignant?, and To what extent is the adrenal secretion altered? To come to a clinical decision, several diagnostic tools need to be engaged, starting with an accurate and correct radiological evaluation and a hormonal assessment of the adrenal function. When necessary, other diagnostic procedures such as functional imaging and fine-needle biopsy (FNB) can be considered in selected cases. Surgical removal is recommended for clinically relevant hypersecretory masses, as well as for masses suspected to be malignant. Most frequently, adrenal incidentalomas (AIs) are represented by benign cortical adenomas, a subset of which causes a mild hypercortisolism, known as subclinical Cushing's syndrome (SCS). The criteria to define this syndrome, as well as its treatment, are still debated and controversial. AIs that are not surgically removed should be re-examined in time to exclude a supervening increase in size or function. Follow-up criteria have not been established. Laparoscopic surgery is the recommended procedure to remove benign masses. The surgical procedure for adrenal malignancies is still debated.
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Affiliation(s)
- Massimo Mannelli
- Department of Clinical Pathophysiology, Endocrinology Unit, University of Florence, Florence, Italy.
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Peppa M, Boutati E, Koliaki C, Papaefstathiou N, Garoflos E, Economopoulos T, Hadjidakis D, Raptis SA. Insulin resistance and metabolic syndrome in patients with nonfunctioning adrenal incidentalomas: a cause-effect relationship? Metabolism 2010; 59:1435-41. [PMID: 20153874 DOI: 10.1016/j.metabol.2010.01.007] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2009] [Revised: 11/24/2009] [Accepted: 01/12/2010] [Indexed: 01/15/2023]
Abstract
The objective of the study was to assess insulin resistance (IR) and metabolic syndrome (MS) in patients with nonfunctioning adrenal incidentalomas (NFAIs). Among a total cohort of 46 patients with adrenal incidentalomas, we studied 29 patients with NFAIs (mean age, 54 ± 9 years; body mass index, 29 ± 3 kg/m(2)) and 37 age-, sex-, and body mass index-matched healthy controls. Besides the endocrine workup, IR was evaluated using fasting glucose and insulin concentrations, homeostasis model assessment of IR, and quantitative insulin sensitivity check index. In a subgroup of patients undergoing an oral glucose tolerance test, Matsuda index and total area under the curve for glucose and insulin were also evaluated. Total cholesterol, high-density lipoprotein, low-density lipoprotein, triglycerides, and other biochemical parameters were measured with standard techniques. Body composition was determined with dual-energy x-ray absorptiometry. Patients with NFAIs exhibited higher fasting glucose, insulin, and homeostasis model assessment of IR values; decreased quantitative insulin sensitivity check index and Matsuda index; and an increased-although not statistically significant-area under the curve for glucose and insulin compared with controls (P < .05). In addition, they exhibited higher systolic and diastolic blood pressure, triglycerides, and γ-glutamyltransferase and lower high-density lipoprotein cholesterol levels compared with controls (P < .05). Patients with NFAIs were all obese with a central type of fat accumulation and increased appendicular lean mass. Indices of IR showed a positive correlation with indices of MS (P < .05), but no correlation with markers of hormonal activity. Nonfunctioning adrenal incidentalomas are characterized by IR, hypertension, dyslipidemia, and fatty liver disease, all of them being components of MS. Thus, patients with NFAIs should be screened for MS during their initial workup to identify those at cardiometabolic risk and implement the appropriate interventions.
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Affiliation(s)
- Melpomeni Peppa
- Endocrine Unit, 2nd Department of Internal Medicine-Propaedeutic, Research Institute and Diabetes Center, Athens University Medical School, Attikon University Hospital, Athens 12462, Greece.
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Lumbreras B, Donat L, Hernández-Aguado I. Incidental findings in imaging diagnostic tests: a systematic review. Br J Radiol 2010; 83:276-89. [PMID: 20335439 DOI: 10.1259/bjr/98067945] [Citation(s) in RCA: 242] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The objective of this review is to summarise the available evidence on the frequency and management of incidental findings in imaging diagnostic tests. Original articles were identified by a systematic search of the MEDLINE, EMBASE and Cochrane Library Plus databases using appropriate medical headings. Extracted variables were study design; sample size; type of imaging test; initial diagnosis; frequency and location of incidental findings; whether clinical follow-up was performed; and whether a definitive diagnosis was made. Study characteristics were assessed by one reviewer and checked by a second reviewer. Any disagreement was solved by consensus. The relationship between the frequency of incidental findings and the study characteristics was assessed using a one-way ANOVA test, as was the frequency of follow-up of incidental findings and the frequency of confirmation. 251 potentially relevant abstracts were identified and 44 articles were finally included in the review. Overall, the mean frequency of incidental findings was 23.6% (95% confidence interval (CI) 15.8-31.3%). The frequency of incidental findings was higher in studies involving CT technology (mean 31.1%, 95% CI 20.1-41.9%), in patients with an unspecific initial diagnosis (mean 30.5, 95% CI 0-81.6) and when the location of the incidental findings was unspecified (mean 33.9%, 95% CI 18.1-49.7). The mean frequency of clinical follow-up was 64.5% (95% CI 52.9-76.1%) and mean frequency of clinical confirmation was 45.6% (95% CI 32.1-59.2%). Although the optimal strategy for the management of these abnormalities is still unclear, it is essential to be aware of the low clinical confirmation in findings of moderate and major importance.
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Affiliation(s)
- B Lumbreras
- Departament of Public Health, University Miguel Hernandez, Alicante, Spain.
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Guerrieri M, Campagnacci R, Patrizi A, Romiti C, Arnaldi G, Boscaro M. Primary adrenal hypercortisolism: minimally invasive surgical treatment or medical therapy? A retrospective study with long-term follow-up evaluation. Surg Endosc 2010; 24:2542-6. [PMID: 20336323 DOI: 10.1007/s00464-010-1000-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2009] [Accepted: 01/29/2010] [Indexed: 11/28/2022]
Abstract
BACKGROUND Because the most suitable management of subclinical Cushing syndrome (SCS, which involves hypersecretion of cortisol without clinically evident disease) still is undefined, the current study aimed to compare retrospectively the outcome for a cohort of patients treated by medical therapy or laparoscopic adrenalectomy (LA). METHODS Over a 12-year period, 47 patients with SCS have been treated by means of LA (19 patients, group A) or medical therapy (28 patients, group B). Group A consisted of 15 women and 4 men with a mean age of 54.8 years. Eight patients had a left adrenal mass, whereas nine had a right adrenal mass, and one patient had bilateral lesion. Group B was composed of 18 women and 10 men with a mean age of 57.8 years. Of these patients, 14 had a left adrenal lesion, 12 had a right adrenal lesion, and 1 had bilateral lesion. The patients were followed up for a mean 4 years (range, 1-11 years) by both an endocrinologist and a surgeon. RESULTS In group A, hypertension improved for 66.3% of the patients; body mass index (BMI) decreased for 47.4%; and hyperlipidemia based on high-density lypoproteins (HDL) cholesterol, total cholesterol ratio, and triglyceridemic concentration improved for 63.2% of the patients. No changes in bone parameters were seen after surgery in SCS patients with osteoporosis. Some patients in group B, during their long-term medical therapy, experienced worsening hypertension (14.2%), hyperlipidemia (17.8%), and diabetes mellitus (8%). CONCLUSIONS This retrospective study focused on a cohort of patients with SCS. Their medium long-term follow-up evaluation showed that LA is better than medical therapy for treating this condition, especially by reducing the cardiovascular risk (hypertension-hyperlipidemia).
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Affiliation(s)
- Mario Guerrieri
- Clinica di Chirurgia Generale e Metodologia Chirurgica, Università Politecnica delle Marche-Ospedali Riuniti, via Conca 1, 60121, Ancona, Italy
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Abdelmannan D, Aron DC. Incidentally discovered pituitary masses: pituitary incidentalomas. Expert Rev Endocrinol Metab 2010; 5:253-264. [PMID: 30764049 DOI: 10.1586/eem.09.68] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
With the widespread use of computed tomography and MRI, the incidental discovery of pituitary incidentalomas is increasing in frequency. The most common cause of a pituitary mass is a pituitary adenoma (90% of all pituitary masses); however, the differential diagnosis remains extensive. The challenge is to distinguish those that can or will cause morbidity/mortality from those that will not. Opinions on approaching management of these lesions vary. This article will review current data regarding the prevalence, natural history and potential morbidity associated with this entity and describe an epidemiological approach based on four questions: does an incidental mass put the patient at increased risk for an adverse outcome? Can individuals with treatable syndromes be accurately diagnosed? Is the treatment of these syndromes more effective in presymptomatic patients? And do the beneficial effects of presymptomatic detection and treatment of these patients justify the costs incurred? We recommend the following approach: recognizing that one size does not fit all and that the approach should be tailored to the needs of the particular case. If the mass was discovered on a computed tomography, an enhanced MRI is recommended. Detailed history and physical examination should be carried out to look for signs of functional or 'subclinically' functional tumor. Size and structure should be assessed, especially proximity to the optic chiasm. Laboratory evaluation with a serum prolactin for small tumors is cost effective, other lab testing is indicated if metabolic problems are present. Care should be taken to assess for hypopituitarism, clinically and biochemically, if the mass is large, that is, more than 1 cm, visual field testing is also recommended. Note that the vast majority of patients with pituitary incidentalomas that are microadenomas die with them, not from them.
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Affiliation(s)
- Dima Abdelmannan
- a Endocrinology Section 111(W), Louis Stokes Department of Veterans Affairs Medical Center, 10701 East Boulevard, Cleveland, OH 44106, USA and Division of Clinical and Molecular Endocrinology, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | - David C Aron
- b Division of Clinical and Molecular Endocrinology, Case Western Reserve University School of Medicine, Cleveland, OH, USA and Associate Chief of Staff/Education, Co-Director VA Health Services Research and Development Service Center for Implementation Practice and Research Support, Education Office 14 (W), Louis Stokes Department of Veterans Affairs Medical Center, 10701 East Boulevard, Cleveland, OH 44106, USA.
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Yener S, Genc S, Akinci B, Secil M, Demir T, Comlekci A, Ertilav S, Yesil S. Carotid intima media thickness is increased and associated with morning cortisol in subjects with non-functioning adrenal incidentaloma. Endocrine 2009; 35:365-70. [PMID: 19277910 DOI: 10.1007/s12020-009-9160-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2008] [Revised: 11/27/2008] [Accepted: 01/16/2009] [Indexed: 11/24/2022]
Abstract
Data regarding cardiovascular risk in subjects with non-functioning adrenal adenoma are limited. The objectives of this study are to investigate carotid intima media thickness (IMT) as an indicator of atherosclerosis in subjects with non-functioning adrenal incidentaloma (AI) and to evaluate the factors that could be associated with IMT. Forty-nine subjects without findings of hypercortisolism or other adrenal gland disorders, 34 body mass index (BMI)-unmatched controls (C) and 18 BMI-matched controls (BC) were enrolled. Participants underwent hormonal evaluation including morning cortisol, adrenocorticotrophic hormone (ACTH), post dexamethasone suppression test cortisol (DST), dehydroepiandrosterone sulfate (DHEAS), and urinary free cortisol. Anthropometric and metabolic parameters and carotid IMT were measured. AI group had increased BMI, blood pressure, waist circumference, post DST cortisol, uric acid, and homeostasis model assessment (HOMA) levels when compared with C. Blood pressure, uric acid and, post DST cortisol remained significantly elevated in AI versus BC. Average IMT was increased significantly in AI versus C (0.74 mm vs. 0.68 mm, P = 0.029) and insignificantly elevated in AI versus BC (0.74 mm vs. 0.67 mm, P = 0.086). In all participants, IMT was correlated with age, BMI, HOMA, waist circumference, morning cortisol, and uric acid. Morning cortisol was independently associated with HOMA levels in both AI group and all participants. Increased IMT in non-functioning AI was a consequence of insulin resistant state associated with subtle cortisol autonomy rather than a direct effect of cortisol. The correlation between morning cortisol and IMT may be associated with the effect of hypothalamus-pituitary-adrenal axis disturbances on vasculature.
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Affiliation(s)
- Serkan Yener
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Dokuz Eylul University, Inciralti, Izmir 35340, Turkey.
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Vassilatou E, Vryonidou A, Michalopoulou S, Manolis J, Caratzas J, Phenekos C, Tzavara I. Hormonal activity of adrenal incidentalomas: results from a long-term follow-up study. Clin Endocrinol (Oxf) 2009; 70:674-9. [PMID: 19067718 DOI: 10.1111/j.1365-2265.2008.03492.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To investigate the natural course of apparently benign adrenal incidentalomas with no overt hyperfunction at diagnosis, as their clinical significance and appropriate management are still controversial. DESIGN Prospective long-term follow-up study of patients with adrenal incidentalomas with periodic hormonal and morphological evaluation. PATIENTS AND METHODS A total of 77 patients with incidental adrenal masses, diameter 1.0-6.0 cm (median 2.5 cm), were submitted to a hormonal assessment of adrenal function at diagnosis. This was repeated, together with an adrenal CT scan, 12 months later and then every 12-24 months, for a period of 12-154 months (mean 62.7 +/- 31.9, median 60.0). RESULTS At diagnosis, 57 patients had normal adrenal function and 20 had subclinical Cushing's syndrome. During follow-up, adrenal function remained normal in 49 patients, subclinical Cushing's syndrome was confirmed in 12, whilst intermittent subclinical autonomous cortisol hypersecretion was found in 12 patients. Overt endocrine disease was diagnosed in 4 patients (Cushing's syndrome in 2 and phaeochromocytoma in 2). A change in mass size (> or = 0.5 cm) was observed in 26 patients (enlargement in 20--including patients who developed overt hyperfunction--with no signs of malignancy and reduction in size in 6). CONCLUSIONS Subclinical autonomous cortisol hypersecretion is the most frequent hormonal abnormality in patients with adrenal incidentalomas, and may be intermittent in a significant percentage of cases. Few patients develop overt endocrine disease. A growth tendency is observed in some adrenal incidentalomas without evidence of malignant transformation and occasionally can be related to development of overt hyperfunction. These findings indicate the need for periodic hormonal and morphological evaluation for several years.
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Affiliation(s)
- E Vassilatou
- Department of Endocrinology, Diabetes and Metabolism, Amalia Fleming General Hospital, Athens, Greece.
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Surgical versus conservative management for subclinical Cushing syndrome in adrenal incidentalomas: a prospective randomized study. Ann Surg 2009; 249:388-91. [PMID: 19247023 DOI: 10.1097/sla.0b013e31819a47d2] [Citation(s) in RCA: 156] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare the clinical outcome of patients with subclinical Cushing syndrome (SCS) due to an adrenal incidentaloma (the autonomous hypersecretion of a small amount of cortisol, which is not enough to cause clinically-evident disease) who underwent surgery or were managed conservatively. SUMMARY BACKGROUND DATA The most appropriate management of SCS patients is controversial, either adrenalectomy or close follow-up being recommended for their treatment. METHODS Over a 15-year period, 45 SCS patients were randomly selected to undergo surgery (n = 23) or conservative management (n = 22). All surgical procedures were laparoscopic adrenalectomies performed by the same surgeon. All patients were followed up (mean, 7.7 years; range, 2-17 years) clinically by 2 experienced endocrinologists 6 and 12 months after surgery and then yearly, or yearly after joining the trial, particularly monitoring diabetes mellitus (DM), arterial hypertension, hyperlipidemia, obesity, and osteoporosis. The study end point was the clinical outcome of SCS patients who underwent adrenalectomy versus those managed conservatively. RESULTS All 23 patients in the surgical arm had elective surgery. Another 3 patients randomly assigned to conservative management crossed over to the surgical group due to an increasing adrenal mass >3.5 cm. In the surgical group, DM normalized or improved in 62.5% of patients (5 of 8), hypertension in 67% (12 of 18), hyperlipidemia in 37.5% (3 of 8), and obesity in 50% (3 of 6). No changes in bone parameters were seen after surgery in SCS patients with osteoporosis. On the other hand, some worsening of DM, hypertension, and hyperlipidemia was noted in conservatively-managed patients. CONCLUSIONS Based on the results of this study, laparoscopic adrenalectomy performed by skilled surgeons appears more beneficial than conservative management for SCS patients complying with our selection criteria. This trial is registered with Australian Clinical Trials Registry number, ANZCTR12608000567325.
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Abstract
Clinically inapparent adrenal masses, or adrenal incidentalomas, are discovered inadvertently in the course of work-up or treatment of unrelated disorders. Cortical adenoma is the most frequent tumour detected incidentally, but adrenocortical cancer, phaeochromocytoma and metastasis are not rare. Two critical questions should be answered before trying to outline the management of adrenal incidentaloma: (1) which tumours may cause harm to the patient, and (2) can we recognize and effectively treat such tumours? Based on the available scientific evidence, two major recommendations should be made: (1) identify either primary (adrenocortical cancer) or secondary (adrenal metastasis) malignancy; (2) identify phaeochromocytoma. Radiological evaluation is the key to the differential diagnosis of benign and malignant tumours. Endocrine testing is necessary to exclude phaeochromocytoma in all patients with an adrenal incidentaloma because this tumour may remain undiagnosed after imaging studies. The management of clinically inapparent adrenal adenomas may vary depending whether or not they are functioning. It is reasonable to screen for primary aldosteronism all hypertensive patients and recommend adrenalectomy when an aldosterone-producing adenoma is confirmed. A subset of adenomas secretes cortisol autonomously and may lead to mild hypercortisolism, a condition defined as subclinical Cushing's syndrome. The criteria for defining subclinical Cushing's syndrome are controversial, and we currently do not have sufficient evidence to define a gold standard for screening. Also the management of this condition is largely empirical, and data are insufficient to indicate the superiority of a surgical or non-surgical approach to managing patients with subclinical Cushing's syndrome.
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Affiliation(s)
- Massimo Terzolo
- Medicina Interna I, Dipartimento di Scienze Cliniche e Biologiche, Università di Torino, ASO San Luigi, Orbassano, Italy.
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Hoang C. [Rare incidentalomas: diagnostic procedure]. Ann Pathol 2008; 28 Spec No 1:S45-8. [PMID: 18984297 DOI: 10.1016/j.annpat.2008.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Catherine Hoang
- Service d'anatomie et de cytologie pathologique, groupe hospitalier Pitié-Salpêtrière, AP-HP, 47-83, boulevard de l'Hôpital, 75651 Paris cedex 13, France.
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Terzolo M, Bovio S, Pia A, Osella G, Borretta G, Angeli A, Reimondo G. Subclinical Cushing's syndrome. ACTA ACUST UNITED AC 2007; 51:1272-9. [DOI: 10.1590/s0004-27302007000800013] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2007] [Accepted: 08/19/2007] [Indexed: 01/15/2023]
Abstract
Subclinical Cushing's syndrome (CS) is attracting increasing interest since the serendipitous discovery of an adrenal mass has become a rather frequent event owing to the routine use of sophisticated radiologic techniques. Cortical adenoma is the most frequent type of adrenal incidentaloma accounting for approximately 50% of cases in surgical series and even greater shares in medical series. Incidentally discovered adrenal adenomas may secrete cortisol in an autonomous manner that is not fully restrained by pituitary feedback, in 5 to 20% of cases depending on study protocols and diagnostic criteria. The criteria for qualifying subclinical cortisol excess are controversial and presently there is no consensus on a gold standard for the diagnosis of this condition. An increased frequency of hypertension, central obesity, impaired glucose tolerance, diabetes and hyperlipemia has been described in patients with subclinical CS; however, there is still no clear demonstration of the long-term complications of this condition whose management remains largely empirical. Either adrenalectomy or careful observation associated with treatment of the metabolic syndrome have been suggested as treatment options.
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Weismann D, Fassnacht M, Schubert B, Bonfig R, Tschammler A, Timm S, Hahner S, Wunder C, Allolio B. A dangerous liaison--pheochromocytoma in patients with malignant disease. Ann Surg Oncol 2006; 13:1696-701. [PMID: 17009139 DOI: 10.1245/s10434-006-9184-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2006] [Revised: 05/19/2006] [Accepted: 07/07/2006] [Indexed: 11/18/2022]
Abstract
BACKGROUND Adrenal masses in patients with known malignancy may be interpreted as metastasized disease, although a significant proportion of these tumors are of adrenal origin. Despite improved imaging techniques, it remains difficult to distinguish an adrenal metastasis from a pheochromocytoma or a lipid-poor adrenocortical adenoma. PATIENTS AND METHODS We report a case series of four patients with established or suspected malignant disease (melanoma, transitional cell carcinoma and prostate carcinoma, thyroid carcinoma, colorectal carcinoma) harboring an adrenal mass. None of these patients showed clinical symptoms indicative for a pheochromocytoma. RESULTS Surgery unrelated to the adrenal lesion (n = 3) or biopsy of the adrenal mass (n = 1) was performed without prior endocrine work-up. Pronounced hemodynamic instability including hypertensive crisis was observed during surgery in all patients. In contrast, in the same patients preoperative alpha-blockade with phenoxybenzamine and an increased awareness of the potential risks led to improved hemodynamic stability following adrenalectomy for pheochromocytoma. CONCLUSION Our series is a strong reminder of the risks associated with surgery in patients harboring an unsuspected pheochromocytoma and underscores the need to exclude a pheochromocytoma in all patients with an adrenal mass and without a definitive diagnosis of the mass, especially when they are scheduled for surgery or adrenal biopsy. Otherwise, life-threatening hypertensive crisis can be precipitated even in the previously asymptomatic patient.
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Affiliation(s)
- Dirk Weismann
- Endocrine and Diabetes Unit, Department of Medicine, University of Wuerzburg, Josef-Schneider-Str. 2, Wuerzburg, D-97080, Germany
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Terzolo M, Bovio S, Reimondo G, Pia A, Osella G, Borretta G, Angeli A. Subclinical Cushing's syndrome in adrenal incidentalomas. Endocrinol Metab Clin North Am 2005; 34:423-39, x. [PMID: 15850851 DOI: 10.1016/j.ecl.2005.01.008] [Citation(s) in RCA: 131] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
This article reviews the available evidence on subclinical Cushing's syndrome in patients who have adrenal incidentalomas. The authors' aim is to present up-to-date information on the most relevant issues of subclinical Cushing's syndrome by addressing the many uncertainties and controversies surrounding this ill-defined endocrine condition.
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Affiliation(s)
- Massimo Terzolo
- Division of Internal Medicine, University of Turin, Azienda Sanitaria Ospedaliera San Luigi, Regione Gonzole 10, 10043 Orbassano, Italy.
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Chen M, Hawks CL, Huang Q, Sun B, Hornsby PJ. Telomerase is not required for experimental tumorigenesis of human and bovine adrenocortical cells. Endocr Res 2004; 30:555-65. [PMID: 15666792 DOI: 10.1081/erc-200043682] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Telomerase has often been thought to be essential for tumorigenesis of human cells. Adrenocortical cancers, like other cancers, typically have telomerase activity. We reinvestigated the requirement for telomerase in the conversion of normal human and bovine adrenocortical cells to cancer cells. When primary adrenocortical cells were transduced with retroviruses encoding SV40 large T antigen and Ha-RasG12V and immediately transplanted into immunodeficient mice they produced invasive and metastatic tumors. Cells had negligible telomerase activity before transplantation and after recovery from tumors. However, these tumors were not immortal and cells entered crisis, limiting further growth of the tumor as well as invasion and metastasis. Infection of these tumor cells with a retrovirus encoding hTERT restored growth in culture and restored the malignant properties of the cells in immunodeficient animals. These experiments differ from previous studies in which telomerase was found to be essential for tumorigenicity: 1) we used tissue reconstruction techniques for introduction of cells into host animals and 2) we infected primary cells with retroviruses and immediately transplanted them without drug selection.
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Affiliation(s)
- Meizhen Chen
- Department of Physiology and Sam and Ann Barshop Center for Longevity and Aging Studies, University of Texas Health Science Center, San Antonio, Texas, USA
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Abstract
The most striking age-related change in the human adrenal cortex is the decline in secretion of dehydroepiandrosterone and its sulfate, steroids synthesized by the inner zone of the cortex, the zona reticularis. Because these steroids are of essentially unknown function, the importance of this age-related change is the subject of considerable debate. It is likely that the age-related change in these steroids results from loss of zona reticularis cells or impairment of their function. During aging, cumulative damage to the zona reticularis could occur through ischemia-related infarcts and other causes of cell death. Cellular senescence could contribute to a loss of the ability of the tissue to replace lost cells. In contrast, feedback mechanisms that regulate adrenocortical growth cause compensatory local tissue hyperplasias called nodules. The effect of imperfect repair of damage combined with compensatory overgrowth in the form of nodules leads to an increasingly abnormal tissue architecture.
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Affiliation(s)
- Peter J Hornsby
- Department of Physiology and Sam and Ann Barshop Center for Longevity and Aging Studies, University of Texas Health Science Center, San Antonio, TX 78245, USA.
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Mansmann G, Lau J, Balk E, Rothberg M, Miyachi Y, Bornstein SR. The clinically inapparent adrenal mass: update in diagnosis and management. Endocr Rev 2004; 25:309-40. [PMID: 15082524 DOI: 10.1210/er.2002-0031] [Citation(s) in RCA: 532] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Clinically inapparent adrenal masses are incidentally detected after imaging studies conducted for reasons other than the evaluation of the adrenal glands. They have frequently been referred to as adrenal incidentalomas. In preparation for a National Institutes of Health State-of-the-Science Conference on this topic, extensive literature research, including Medline, BIOSIS, and Embase between 1966 and July 2002, as well as references of published metaanalyses and selected review articles identified more than 5400 citations. Based on 699 articles that were retrieved for further examination, we provide a comprehensive update of the diagnostic and therapeutic approaches focusing on endocrine and radiological features as well as surgical options. In addition, we present recent developments in the discovery of tumor markers, endocrine testing for subclinical disease including autonomous glucocorticoid hypersecretion and silent pheochromocytoma, novel imaging techniques, and minimally invasive surgery. Based on the statements of the conference, the available literature, and ongoing studies, our aim is to provide practical recommendations for the management of this common entity and to highlight areas for future studies and research.
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Affiliation(s)
- Georg Mansmann
- Department of Endocrinology, Heinrich-Heine-University, Moorenstrasse 5, D-40225 Düsseldorf, Germany.
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Abstract
Clinically inapparent adrenal masses, or adrenal incidentalomas, are discovered inadvertently in the course of workup or treatment of unrelated disorders. Cortical adenoma is the most frequent type of adrenal incidentaloma accounting for approximately 50% of cases in surgical series and even greater shares in medical series. Incidentally discovered adrenal adenomas may secrete cortisol in an autonomous manner, that is not fully restrained by pituitary feed-back, in 5 to 20% of cases depending on study protocols and diagnostic criteria. A number of different alterations in the endocrine tests aimed to assess the function of the hypothalamic-pituitary-adrenal axis has been demonstrated in such patients. This heterogeneous condition has been termed as subclinical Cushing's syndrome, a definition that is more accurate than preclinical Cushing's syndrome since the evolution towards clinically overt hypercortisolism does occur rarely, if ever. The criteria for qualifying subclinical cortisol excess are controversial and we presently do not have sufficient evidence to define a gold standard for the diagnosis of subclinical Cushing's syndrome. An increased frequency of hypertension, central obesity, impaired glucose tolerance, diabetes and hyperlipoproteinemia has been described in patients with subclinical Cushing's syndrome; however, there is not evidence-based demonstration of its long-term complications and, consequently, the management of this condition is largely empirical. Either adrenalectomy or careful observation associated with treatment of metabolic syndrome has been suggested as treatment options because data are insufficient to indicate the superiority of a surgical or nonsurgical approach to manage patients with subclinical hyperfunctioning adrenal cortical adenomas.
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Affiliation(s)
- Massimo Terzolo
- Medicina Interna I, Dipartimento di Scienze Cliniche e Biologiche, Università di Torino, ASO San Luigi, Orbassano, Italy.
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Auchus RJ. Aldo is back: recent advances and unresolved controversies in hyperaldosteronism. Curr Opin Nephrol Hypertens 2003; 12:153-8. [PMID: 12589175 DOI: 10.1097/00041552-200303000-00005] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Hyperaldosteronism in its various forms is a recognized secondary cause of hypertension, yet the frequency of these disorders and the appropriate evaluation of suspected patients remain controversial. This review will summarize recent literature concerning the frequency of hyperaldosteronism in the hypertensive population, insight from uncommon forms of hyperaldosteronism, and new developments in the diagnosis and treatment of this condition. RECENT FINDINGS Several series report that around 10% of hypertensive patients have some form of hyperaldosteronism, but aldosterone-producing adenomas are rare. Diagnostic criteria for idiopathic hyperaldosteronism remain controversial, as is the wisdom of widespread screening. Patients with even mild hyperaldosteronism, however, which could be a continuum with low-renin hypertension, may respond exceptionally well to mineralocorticoid antagonism. Eplerenone, a new mineralocorticoid receptor antagonist without antiandrogen side effects, has been an effective antihypertensive in clinical trials and appears to be particularly suitable for low-renin hypertensives. Accumulating evidence suggests that aldosterone excess is cardiotoxic and nephrotoxic, suggesting that mineralocorticoid blockade has specific benefits beyond blood pressure reduction. For patients with severe, confirmed hyperaldosteronism, selective adrenal vein sampling is the only reliable method for determining the source of the aldosterone. SUMMARY Hyperaldosteronism, when defined with liberal criteria, could account for a substantial portion of hypertension. Few of these patients will harbor adrenal adenomas, but those with severe hypertension and hypokalemia often require adrenal vein sampling to direct surgery. With more precise diagnostic strategies, better treatments, and evolving evidence of pathological consequences of aldosterone excess, subtle disorders of aldosterone excess demand precise definition and specific treatment.
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Affiliation(s)
- Richard J Auchus
- Division of Endocrinology and Metabolism, UT Southwestern Medical Center, Dallas, Texas 75390, USA.
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