Morbidity & Mortality. Mark H. Tseng MD SUNY Downstate Medical Center Lutheran Medical Center December 16, 2005

Transcription

1 Morbidity & Mortality Mark H. Tseng MD SUNY Downstate Medical Center Lutheran Medical Center December 16, 2005

2 Case presentation Pt is a xx year old Asian woman who present to the ED with cc of epigastric pain and tenderness for the past 2 days. Pt denies any previous history of abdominal pain, nausea/vomiting, nor radiation to back. Pt denies any weight loss, headaches, palpitations, and diaphoresis. Surgery was consult after CT scan was performed.

3 Case presentation PMH: none PSH: none Shx: denies etoh, smoking, ivdu Fhx: none Allergy: nkda

4 Case presentation Vital Signs T: 98.6 BP: 110/70 HR: 80 RR:18

5 Case presentation Physical Exam A x O x 3, calm, age appropriate, average wt for height Abdomen: soft, right flank tenderness, negative murphy s sign, no mass appreciated, normal bowel sounds

6 Case presentation Lab Wbc 4.2 H/H 12/36 Plt 209 Na 141 K 4.0 Glucose 95 LFT within normal limits Cortisol 13.3 (nl) VMA 3.3 (nl <6) metanephrine 199 (nl 95 to 475)

7 Case presentation Lab: Wbc: 4.2 H/H: 12/36 Plt: 209 Na: 141 K: 4.0 Glucose: 95 LFT: within normal limits Lab: Cortisol: 13.3 (nl) VMA: 3.3 (nl <6) metanephrine: 199 (nl 95 to 475)

8 Case presentation CXR: unremarkable Sono: large mass in RUQ

9 Case presentation CT scan: 6.4 x 7.5 right cystic adrenal mass

10 Case presentation MRI: well defined right suprarenal hyperdensity with thin wall. Compression of IVC. Non invasive

11 Case presentation Pt was taken to OR Right adrenalectomy was performed via a right flank incision Fluid fill cyst was identified and resected Pt tolerated the procedure well

12 Case presentation POD #1 start on clears POD #2 pain management POD #3 discharge planning POD #4 discharged home

13 Case presentation Pathology: benign endothelial vascular cyst of the adrenal gland

14 Adrenal Incidentaloma Mark H. Tseng MD SUNY Downstate Medical Center Lutheran Medical Center December 16, 2005

15 Overview Embryology Anatomy and Physiology Epidemiology Incidentaloma Conclusion References

16 Adrenal Gland The adrenal cortex and medulla are anatomically and functionally distinct endocrine units that are contained in a single capsule 1563 Eustachius describes the anatomy of the adrenal gland 1855 Addison correlates clinical features of adrenal disease with pathology found in autopsies 1886 Frankel describes pheochromocytoma 1912 Cushing presents clinical features of hypercortisolism 1955 Conn describes hyperaldosteronism

17 Embryology Cortex is mesodermal in origin Week 4 to 6 begin development from coelomic mesoderm adjacent to urogenital ridge Week 8 differentiates into thin outer definitive cortex and thick inner fetal cortex Fetal cortex produces fetal steroids during gestation then involutes at birth Definitive cortex develops into functional adrenal cortex Zona glomerlulosa and fasiculata present at birth Zona reticularis develops during the first year of life

18 Medulla derived from neural crest cells Develops with sympathetic nervous system Week 5 neural crest cells migrate to paraaortic and para-vertebral regions and along adrenal vein toward medial aspect of fetal cortex Extra-adrenal chromaffin cells which persist form the organ of Zuckerkandl located to the left of the aortic bifurcation near the origin of IMA Embryology

19 Bilateral retroperitoneal organs on superomedial aspect of the upper pole of each kidney Approximately 4 grams each, L>R Right adrenal lies close to IVC and beneath diaphragm and liver Left adrenal located between kidney and aorta near tail of pancreas and splenic artery Anatomy

20 Blood supplied by inferior phrenic artery superiorly, aorta medially, and renal artery inferiorly Right adrenal supplied by superior and inferior adrenals, drains to IVC via right adrenal vein Left adrenal supplied by middle and inferior adrenals, drains into left renal vein or directly to IVC Lymphatic drainage to paraaortic and paracaval lymph nodes Important when operating for malignant adrenal lesions Anatomy

21 Anatomy The location of the adrenal gland deep in the retroperitonium has in the past made them relatively inaccessible Understanding the anatomical relationships and appreciate their relationship to the arterial supply and venous drainage are important and have significant surgical ramifications

22 Three distinct zones Zona glomerulosa Small cells with intermediate number of lipid inclusions Zona fasiculata Large foamy cells secondary to lipid inclusions 75% of cortex Zona reticularis Compact cytoplasm and few lipid inclusions Histology

23 Physiology Composed of two distinct organs Adrenal cortex and adrenal medulla Three major biosynthetic pathways produce *glucocorticoids, mineralocorticoids, and adrenal androgens Zona glomerulosa synthesizes mineralocorticoids Zona fasiculata synthesizes glucocorticoids * Zona reticularis synthesizes adrenal androgens * Absolutely required for life

24 Epidemiology Figures Vary From O.4-6% Of CT Scans % Of Autopsy Series Incidence Increases With Age; 7% After 70 Seen More Commonly In Women NATIONAL INSTITUTES OF HEALTH Management of the Clinically Inapparent Adrenal Mass (Incidentaloma). Final Statement. July 16, 2002

25 Adrenal Incidentaloma The evaluation and decision paradigm for an incidentaloma hinges on three issues: IS IT MALIGNANT? IS IT METASTATIC? IS IT FUNCTIONAL?

26 Major Causes Benign Adenoma 50% Cyst 10% Myelolipoma 10% Pheochromocytoma 10% Metastases 6-30% Adrenal Cancer 0.01% The incidental adrenal mass. Am J Med 1996

27 Is It Malignant? An important and unresolved issue in the management if incidentalomas is the determination of what size of adrenal tumor has malignant potential and requires surgical resection.

28 Is It Malignant? Useful in determining malignant potential: Size of the mass Radiological Findings

29 The Mayo Clinic Study 342 Patients With Adrenal Incidentaloma Retrospectively Evaluated Tumor Diameter Averaged 2.5 cm. Most Malignant Tumors Measured > 5 cm. Removing All Tumors > 4 cm Would Have Removed Eight Benign Tumors For Every Carcinoma Incidentally discovered adrenal tumors: an institutional perspective. Herrera MF; Grant CS; van Heerden JA; Sheedy PF; Ilstrup DM. Surgery 1991 Dec;110(6):

30 Mass Masses > 6 cm Usually Are Treated Surgically Masses < 4 cm Are Generally Monitored Masses Between 4 And 6 cm: Criteria Other Than Size Should Be Considered In Making The Decision To Monitor Or Proceed To Surgery Experienced investigators now recommend excision of all tumors >4 cm National Institutes Of Health Management Of The Clinically Inapparent Adrenal Mass (Incidentaloma) 2002

31 Computed Tomographic Scans Attenuation On CT Scan Is Measured In Hounsfield Units (HU) >20 HU likely malignant Lipid-Rich Masses Are Usually Benign Lipid-Rich Lesions Have Low Attenuation Low Attenuation Lesions Have Low HU (<20)

32 Computed Tomographic Scans Unenhanced CT: Adenomas: < 10 HU Malignancies: > 20 HU Sensitivity: 73% Specificity: 96% Delayed Enhanced CT: Adenomas: < 30 HU Malignancies: > 30 HU Sensitivity 95% And Specificity: 100%

33 MRI Equally Effective As CT Adenomas Are Iso-Intense With The Liver On T2-weighted Images Carcinomas Have A Hyper-Intense Signal Compared With The Liver

34

35 Fine-Needle Aspiration Biopsy CANNOT Distinguish A Benign Adrenal Mass From Adrenal Carcinoma

36 Other Tests Iodinated Cholesterol Derivative (NP-59): Show Uptake In Functioning Lesions I-131 Metaiodobenzyl Guanidine (MIBG): Evaluating Pheochromocytoma Positron Emission Tomography (PET):

37 Is It Metastatic? The adrenal gland, although relatively small, has the highest blood flow of any endocine organ on a gram per flow basis. It is therefore not surprising that metastatic diseases, particularly from lung, esophageal, and breast cancer, occurs in the adrenal gland. Majority has history of malignant diseases and metastases to multiple additional sites.

38 Is It Metastatic? Patients with bilateral adrenal metastases are at some risk for adrenal insufficiency. Patients with isolated adrenal metastases pose a diagnostic dilemma. Tissue diagnosis may affect subsequent care or an adrenalectomy might be indicated. FNA is controversial The only situation where FNA appears indicated is when metastatic disease is not only likely, but its detection would alter patient management.

39 IS IT HYPERSECRETORY? Cortisol Catecholamines Mineralcorticoids Androgens

40 Patients Non-Secretory Sub-Clinical Cushings Syndrome (SCC) Pheochromocytoma Aldosterone-Producing Adenoma (85%) 92 (9.2%) 42 (4.2%) 15 (1.6%) Journal of Clinical Endocrinology & Metabolism 85 (2) , 2000

41 Non-Secretory All evaluations begin with a detailed history and physical examination. If there are signs and symptoms suggesting a functional adrenal neoplasm, in addition to routine screening evaluation, specific hormone studies are indicated Most patients are asymptomatic, CT findings can be pathognomonic Hormone screening studies are therefore not required. Ross NS. Hormonal evaluation of the patient with an incidentally discovered adreanl mass. NEJM 1990:323:

42 Patients Non-Secretory Sub-Clinical Cushings Syndrome (SCC) Pheochromocytoma Aldosterone-Producing Adenoma (85%) 92 (9.2%) 42 (4.2%) 15 (1.6%) Journal of Clinical Endocrinology & Metabolism 85 (2) , 2000

43 Subclinical Hypercortisolism Cushing s syndrome is important to consider in all patients with adrenal tumors Some patients has obvious signs and symptoms and are not difficult to diagnose However, some patients presents with subtle stigmata of Cushing s syndrome or subclinical and require additional testing. Approximately 15% of patients with incidentalomas have subclinical features.

44 Clinical presentations include hypertension, edema, proximal muscle weakness, diabetes, tuncal obesity, hirsutism Caused by exogenous steroids or excess endogenous cortisol secretion Most commonly iatrogenic Cushing Disease is the most common pathologic form of endogenous hypercortisolism Cushings

45 Subclinical Hypercortisolism Defined By Any Two Of The Following: Increased Urinary Free Cortisol (UFC) Unsuppressed Serum Cortisol Levels After 1-mg Overnight Dexamethasone Low ACTH Levels No Clinical Signs Of Cushing Syndrome Mantero F, Masini AM, Opocher G, Giovagnetti M, Arnaldi G. Horm Res 47: , 1997

46 Subclinical Hypercortisolism It is important to rule out subclinical Cushing s syndrome for two reasons: 1) if one elects not to peform an adrenalectomy, then the endocrinopathy will continue and deleterious effects will occur 2) if one does perform an adrenalectomy, the contralateral adrenal will be suppressed and if perioperative glucocorticoids are not administered, the patient will be at risk for Addisonian crisis

47 Hypercortisolism 24 Hour Urinary Free Cortisol Positive: More Than 3-4 Times The Upper Limit Of Normal Range Mildly Elevated Levels Can Be Seen In Anxiety, Depression, Alcoholism

48 When the 24 hr UFC Is Not Conclusive..

49 Dexamethasone Suppression Test 1 mg Dexamethasone At 11 pm Measure Cortisol At 8 am Normal: Cortisol < 5 ug/dl Specificity Is Reduced In Acute Or Chronic Illness

50 Subclinical cushings syndrome? Increased Incidence Of: HTN Obesity DM IGT Increased CV Risk Bone Disease

51 Patients Non-Secretory Sub-Clinical Cushings Syndrome (SCC) Pheochromocytoma Aldosterone-Producing Adenoma (85%) 92 (9.2%) 42 (4.2%) 15 (1.6%) Journal of Clinical Endocrinology & Metabolism 85 (2) , 2000

52 Pheochromocytoma Rare Arise From Neuroectodermally Derived Chromaffin Cells Secretion of Norepinephrine Most Common 19-76% Of Pheochromocytomas Not Diagnosed Until After Death 80% Of Patients With Unsuspected Pheochromocytomas Who Underwent Surgery Or Anesthesia Died Not Possible To Determine Which Will Present With Crisis Not Possible To Determine The Malignant Potential Of Pheochromocytoma

53 Hypertension In Pheochromocytoma Paroxysmal in 48%--episodically secreted Persistent in 29%-- continually secreted Normal in 13%

54 Clinical Presentation Attacks of Headaches (80%) Palpitations (64%) Diaphoresis (57%) Symptomatic Triad Of Headache, Sweating, And Tachycardia In A Hypertensive Patient Sensitivity 90.9% And Specificity 93.8%

55 How To Screen Because the risk of complications associated with an occult pheochromocytoma is significant, all incidentaloma should be screened for pheochromocytoma Urine Collection Of Catecholamines and Metabolites Plasma Collection Of Catecholamines And Metabolites Collections are analyzed for metanephrines, vanillylmandelic acid (VMA), and fractional catecholamines.

56 Which Is Better?

57 Catecholamine-Secreting Tumors Histologically Proven In 31 of 340 Patients: Sensitivity Of Plasma Free Metanephrine 97% Specificity 98% Sensitivity Of Urinary Total Metanephrine And Catecholamines 90%; Specificity 85% Sawka et al. JCEM 88(2):

58 Pheochromocytoma Plasma-Free Metanephrines Are Recommended As The Test Of Choice For Excluding Or Confirming The Diagnosis Of Pheochromocytoma NATIONAL INSTITUTES OF HEALTH Management of the Clinically Inapparent Adrenal Mass (Incidentaloma). Final Statement. July 16, 2002

59 Pre-operative Treatment Because of chronic hypersecretion of catecholamines, pt with pheochromocytomas are often severely volume contracted and severely hemodynamically unstable after general anesthesia selective Alpha 1 adrenergic receptor blocker Phenoxybenamine-increase dosage until pt experience orthostatic hypotension Given 1-4 weeks before surgery Beta blocker- for breakthrough tachycardia Alpha blocker before beta blocker Fear of unapposed alpha recepter would induced malignant hypertension

60 Cleveland Clinic study 63 pts with pheochromocytoma can undergo successful surgical treatment without preoperative preparation with alpha adrenergic blockade

61 Patients Non-Secretory Sub-Clinical Cushings Syndrome (SCC) Pheochromocytoma Aldosterone-Producing Adenoma (85%) 92 (9.2%) 42 (4.2%) 15 (1.6%) Journal of Clinical Endocrinology & Metabolism 85 (2) , 2000

62 Aldosterone Producing Adenoma Rare Most Common Cause of Hyperaldosteronism Twice as Common in Women Mean Age Years Old Conn in 1955 First Curative Treatment of APA by Unilateral Adrenalectomy Mostly Unilateral Mostly < 2 cm in size

63 Signs, Symptoms, and Laboratory Data in Primary Hyperaldosteronism Hypertension Headache Weakness/ Fatigue Paresthesias Muscle Cramps Polyuria/ Polydipsia Arrhythmias Hypokalemia No Other Cause For Hypertension Or Hypokalemia Metabolic Alkalosis Hyperaldosteronism Hyporeninemia

64 Aldosterone-Producing Adenoma Serum Potassium And Aldosterone /Plasma Renin Activity Ratio Should Be Determined To Evaluate For Primary Aldosteronism Less Affected by Physiological or Pharmacological Variables NATIONAL INSTITUTES OF HEALTH Management of the Clinically Inapparent Adrenal Mass (Incidentaloma). Final Statement. July 16, 2002

65 Aldosterone/PRA Ratio Normals < 20 Primary Aldosteronism > 30 > 90% Sensitivity And Specificity

66 Adenoma (APA) vs Hyperplasia (IHA) Very Important to Distinguish APA from IHA (occurs in 25% of pts with primary aldosteronism, bilateral adrenal hyperplasia)

67 Adenoma (APA) vs Hyperplasia (IHA) Very High aldosterone/plasma Renin Activity Adenoma Surgical resection of unilateral adenoma is curative Increased 18-OH-Corticosterone Adenoma if >100 mg/dl and hyperplasia if <50 ng/dl Treatment is with spironolactone

68 Decision Matrix of the Incidental Adrenal Mass on CT or MRI Scan Solid Or With Cystic Degeneration >6 Cm <6 Cm Pure Cyst Remove Fluid Evaluate Biochemically And Operate Evaluate Biochemically Clear Bloody Biochemically Active Operate Biochemically Inactive Repeat Scan In 3, 6, 18, and 36 Months Observe Evaluate Biochemically And Follow As For Solid Tumor Larger Evaluate Biochemically And Operate Unchanged Observe

69 If the Decision is to Observe? Will The Mass Become Malignant? Will The Mass Become Hypersecretory?

70 Incidental Adrenal Mass Risk of Progression Adrenal Hyperfunction: Unlikely If Lesion < 3 cm Cortisol Hypersecretion Most Likely Disorder 4% After 1 Year 9.5% Within 3 Years The Risk Of Tumor Hyperfunction Appears To Plateau After 3 Years Mass Enlargement: 8% After 1 Year 18% After 5 Years Most Enlargement Occurred Within 3 Years National Institutes Of Health: Management Of The Clinically Inapparent Adrenal Mass (Incidentaloma). Final Statement. July 16, 2002

71 Take Home Points Incidental Adrenal Mass Good history and physical exam Size and HU units Important >4 cm Surgical Removal after workup Exclude Hypersecretion: 24 Urine Free Cortisol Plasma Free Metanephrines Potassium and Aldo/Renin