Dr Daniel Wong Department of Surgery Kwong Wah Hospital.
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Transcript of Dr Daniel Wong Department of Surgery Kwong Wah Hospital.
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Dr Daniel WongDepartment of SurgeryKwong Wah Hospital
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Adrenal Incidentaloma- DefinitionAdrenal mass >1cm Detected during investigation for extra-
adrenal pathologyExclude workup of
Known malignancy patientsHypertensive and hypokalaemic
patients
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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
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Adrenal Incidentaloma- AetiologyAdrenal cortical tumours
Adenoma, nodular hyperplasia, carcinoma
Adrenal medullary tumoursPheochromocytoma
Rare tumours Lipoma, myelolipoma
Metastatic lesionOthers- cyst, abscess, haematoma
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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
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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
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Management GuidelinesNational Institute of Health State of the
Science guidelines 2002Young NEJM 2007 guidelinesSingh et al ACP best practice guidelines
J Clin Pathol 2008
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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
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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
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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
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Adapted from Dunnick AJR 2002
Adrenal Metastasis
Adrenal Carcinoma
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Linos Hormone 2003
9x8x8cm benign adenoma
2.8x2.8x2.3cm pheochromocytoma
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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
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Yield of CT Guided Biopsy
Mazzaglia Arch Surg 2009
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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
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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
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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
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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
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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
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ConclusionsAI - common radiological findingMost are benign and indolentSize good predictor of malignant riskRegular follow up neededExpanding indications for surgery in
laparoscopic era