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Dr Daniel Wong Department of Surgery Kwong Wah Hospital.

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Presentation on theme: "Dr Daniel Wong Department of Surgery Kwong Wah Hospital."— Presentation transcript:

1 Dr Daniel Wong Department of Surgery Kwong Wah Hospital

2 Adrenal Incidentaloma- Definition Adrenal mass >1cm Detected during investigation for extra-adrenal pathology Exclude workup of Known malignancy patients Hypertensive and hypokalaemic patients

3 Adrenal Incidentaloma- Definition Prevalence % Found in up to 5% CT scan Angeli Horm Res 1997 Barzon et al Eur J Endocrinol 2003

4 Adrenal Incidentaloma- Aetiology Adrenal cortical tumours Adenoma, nodular hyperplasia, carcinoma Adrenal medullary tumours Pheochromocytoma Rare tumours Lipoma, myelolipoma Metastatic lesion Others- cyst, abscess, haematoma

5 Adrenal Incidentaloma- Aetiology Risk of malignancy & functional tumours overestimated ConditionPrevalence Adrenal cancer1.9% Metastasis0.7% Phaeochromocytoma3.1% Conn’s syndrome0.6% Subclinical Cushing’s Syndrome6.4% Cawood et al Eur J Endocrinol 2009

6 Adrenal Incidentaloma- Natural History Most are non functional adenoma Size of lesion crucial >25% malignant if >6cm 2% malignant if <4cm 20% develop subsequent hormone production 25% may increase in size NIH State of the Science guidelines 2002

7 Management Guidelines National Institute of Health State of the Science guidelines 2002 Young NEJM 2007 guidelines Singh et al ACP best practice guidelines J Clin Pathol 2008

8 Adrenal Incidentaloma Workup Whether it is functional Blood pressure, potassium (not reliable) Aldosterone/renin ratio 1mg overnight dexamethasone suppression test 24 hour urine metanephrine, catecholamines Plasma DHEAS level (optional) NIH State of the Science Guidelines 2002

9 Adrenal Incidentaloma Workup Whether it is malignant: CT scan findings >6cm high chance of malignancy Ideal lower cut off controversial 4cm cutoff- 90% sensitivity for cancer 76% of lesion excised were benign Smooth, sharp border, calcifications Angeli Hormone Res 1998 NIH State of the Science Guidelines 2002 Yong NEJM 2007

10 Adrenal Incidentaloma Workup Whether it is malignant: CT scan findings Adenoma has higher fat content Density (Hounsfield Unit): <10 likely adenoma Enhancement washout >50% at 15 minutes likely adenoma NIH State of the Science Guidelines 2002

11 Adapted from Dunnick AJR 2002 Adrenal Metastasis Adrenal Carcinoma

12 Linos Hormone x8x8cm benign adenoma 2.8x2.8x2.3cm pheochromocytoma

13 Adrenal Incidentaloma Workup CT guided biopsy Only recommended if known primary cancer i.e. not true incidentaloma Need to exclude phaeochromocytoma first! Random use give low diagnostic yield

14 Yield of CT Guided Biopsy Mazzaglia Arch Surg 2009

15 Adrenal Incidentaloma Workup MRI No proven benefit over CT scan Role of PET scan Only if known history of carcinoma 100% sensitivity in detecting metastasis Frilling et al Surgery 2004

16 Management- Surgery If hormonal active or suspicious CT scan Laparoscopic approach recommended Crucial to consider the indication of surgery Surgical Unit Nonfunctioning adenomas Secreting adenomas OthersTotal Endocrine18 (29.0)41 (66.1)3 (4.8)62 General95 (50.5)54 (28.7)39 (20.7)188 Conzo Can J Surg 2009

17 Management- Follow up CT scan at regular intervals 6/12/24 months Annual hormonal workup Discharge if static for 4 years NIH State of the Science Guidelines 2002

18 Subclinical Cushing’s Syndrome Subclinical 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

19 Subclinical Cushing’s Syndrome 5-20 % AI patients Large percentage with hyperlipidaemia, hypertension, diabetes Risk of cardiovascular diseases Lower bone density, increased fracture risk Surgery improves diabetic, BP control, lipid profile and obesity Comlekci et al Endocrine 2009 Chiodini J Clin Endocrinol Metab 2009 Toniato Ann Surg 2009

20 Conclusions AI - common radiological finding Most are benign and indolent Size good predictor of malignant risk Regular follow up needed Expanding indications for surgery in laparoscopic era


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