Adrenal Incidentaloma: An Update of its Management 18 th September 2004 Dominic Tai Division of Urology Department of Surgery Pamela Youde Nethersole Eastern.

PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL

Adrenal Incidentaloma:Adrenal Incidentaloma:An Update of its ManagementAn Update of its Management

1818thth September 2004 September 2004

Dominic TaiDominic Tai

Division of UrologyDivision of Urology

Department of SurgeryDepartment of Surgery

Pamela Youde Nethersole Eastern HospitalPamela Youde Nethersole Eastern Hospital

PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL

Agenda

• Prevalence and pathologies

• Diagnostic Evaluation– Risk of malignancy– Hormonal evaluation

• Imaging

• Surgical options

• Take home messages

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Definition

• Clinically silent adrenal mass

• Incidentally discovered by imaging performed for unrelated problems

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Prevalence

• Autopsy series of more than 8500 patients from 25 series:– 5.9% (1-32%)

• CT: – 0.6-1.9%– Data obtained >10 yrs ago (thick cut CT 5mm-1cm)

• Prevalence increases with age– <30 less than 1%– Middle age 3%– Elderly>70 10%

– Kloos RT et al: Incidental discovered adrenal masses. Endocrine Rev 1995, 16:460-484

PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL PathologyDistribution of Pathologies of

380 adrenal incidentaloma

Adenoma52%

Metastasis2%

Adrenal cyst5%

Myelolipoma8%

Others6%

Ganglioneuroma4%

Phaeochromocytoma

11% Adrenal cortical carcinoma

12%F. Mantero et al J. Clinical Endocrinol Metab 85:637-644, 2000

-

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Diagnostic Evaluation

• Assessment of risk of malignancy– Primary– Secondary

• Hormonal evaluation– Subclinical endocrine activity is not uncommon

in asymptomatic patients

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Adrenocortical Carcinoma

• Rare but lethal tumor– Overall 5 yr survival ~ 16%Overall 5 yr survival ~ 16%– For small tumor confined to adrenal glanFor small tumor confined to adrenal glan

d ~42%d ~42%

• Major indicator of malignancy– Size

• Other features for adrenal malignancy in CT:

– Density >1Density >188 HU HU

– Irregular tumor marginIrregular tumor margin

– Heterogeneity/hemorrhage/necrosisHeterogeneity/hemorrhage/necrosis

– Lymphadenopathy/invasion to Lymphadenopathy/invasion to adjacent organsadjacent organs

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Distribution of diagnosis by tumor size

(8 studies with 103 diagnoses determined by histology)

PAMELA YOUDE NETHERSOLE EASTERN HOSPITALRecommendation for Non-functioning Adrenal Incidentaloma

• High risk patients surgical removal– Tumor size >6cmTumor size >6cm– Features of malignancy in imaging studiesFeatures of malignancy in imaging studies

• Low risk patients Follow-up– Tumor size <4 cmTumor size <4 cm

• Medium risk patients both approach reasonable– Tumor size between 4-6 cmTumor size between 4-6 cm

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Adrenal Metastasis

• Frequent site for metastasis– 27% in 1000 consecutive autopsies of cancer pa

tients– Incidence approaching 40% in patients with CA

lung» Abrams HL et al. Cancer 3:74-85. 1950Abrams HL et al. Cancer 3:74-85. 1950

»

• Metachronous isolated metastasis – Adrenalectomy may prolong median survival

– Cord Sturgeon et al. Surgical clinics of North America. 84:2004Cord Sturgeon et al. Surgical clinics of North America. 84:2004

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Fine needle Aspiration

• Little role in differentiating different pathologies– Potentially serious complications– Concerns of track seeding– Sampling error

• Negative biopsy unable to rule out malignancy– Inconclusive biopsy results may happen

• Useful in evaluation of suspicious adrenal secondary

• Important to rule out phaeochromocytoma first before attempting biopsy– Potentially life threatening hypertensive crisis

PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL Incidence of SubclinicalEndocrine Activities

• Hypercortisolism: 5-47%

• Hyperaldosteronism: 1.6-3.8%

• Phaeochromocytoma: 7-10%

• Sex hormone secreting tumor: rare

» George Mansmann et al. Endocrine Review25(2): 309-340

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Hormonal EvaluationSubclinical Cushing Syn

(Subclinical Autonomous Glucocorticoid Hypersecretion)

• Symptoms and signs not apparent and specific• Screening

– Low dose dexamethasone (1mg) suppression test

» NIH State of Science RecommendationNIH State of Science Recommendation

• Confirmation– High dose dexamethasone suppression– ACTH– 24 hr urine free cortisol

PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL Hormonal EvaluationPhaeochromocytoma

• Endocrine test advised in all incidentalomas– (including normotensive ones)

• 24 hr urinary free catecholamines

• its metabolites– VMA and metanephrines

• Plasma free catecholamine metabolites (?more sensitive)

» NIH State of Science RecommendationNIH State of Science Recommendation

PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL Hormonal EvaluationPrimary Aldosteronism

• Screening advised– Even patient normokalaemic

• Screening test– Aldosterone/plasma renin activity

» NIH State of Science RecommendationNIH State of Science Recommendation

• Lateralization– CT/MRI– Scintigraphy– Adrenal vein sampling

PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL Imaging studies

• CT– Still remain an accurate tool

• 97-99% sensitivity (spiral thin cut)– Solitary lesion >1cm with normal contralateral gland– Adrenal limb thickness

» Lingam et al AJR 2003;181(3): 843-9Lingam et al AJR 2003;181(3): 843-9

• MRI– Inconclusive results when compared

with CT

– May be slightly more sensitive to differentiate the pathology

– Very sensitive in detecting phaeochromocytoma

• (light bulb appearance on T2 images)

– Useful for staging for advanced carcinoma Georg et al Endocrin Review 2Georg et al Endocrin Review 2

004;25(2) 309-340004;25(2) 309-340

PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL Imaging StudiesUSG

• Less sensitive than CT and MRI– For adrenal tumor < 3cm

• Missed 35% of lesion• Almost 100% were detecte

d by CT» Suzuki K et al. J. Urol 15

4: 484-486 1995

• Operator dependent

• Limited role for diagnosis and Follow-up

PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL Imaging StudiesScintigraphy

• NP-59– Role in differentiation

• Hyperplasia/adenoma

– Use in incidentaloma controversial

• MIBG– Only indicated for suspecte

d malignant/ familial case

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Indication for adrenalectomy

• Suspicion for malignancy

• Mass with hormonal hypersecretion

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Laparoscopic Superior to Open

•Expert opinion : Superior

•Level of evidence : 1b

•Recommendation : Grade A

Adrenalectomy European Association of Urology

Guideline 2002

PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL Contraindications

• Invasive cortical carcinoma– Adjacent organ/major vessel invasion– Regional lymphadenopathy

• Solitary adrenal metastasis– Can be safely managed by Lap adrenalectomy

• Obesity and history of abdominal operation– No more contraindicated

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Role of Open Surgery

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PAMELA YOUDE NETHERSOLE EASTERN HOSPITAL

Take Home Messages

• Adrenal incidentaloma requires– Hormonal evaluation– Assessment for risk of malignancy

• Risk of malignancy is mainly determined by its size

• Laparoscopic adrenalectomy is the gold standard for adrenal gland removal– Except in invasive malignancy

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Thank You!