Adrenal Incidentaloma Management

Transcription

1 Adrenal Incidentaloma Management Full Title of Guideline: Author Management of Incidentally-discovered Adrenal Lesions ( Incidentalomas ) Mr David Chadwick Consultant Endocrine Surgeon david.chadwick2@nuh.nhs.uk Division & Speciality: Scope (Target audience, state if Trust wide): Review date (when this version goes out of date): Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis): Trust-wide General Practitioners April 2022 Patients with an adrenal mass reported on imaging (CT, MRI), where imaging was not performed specifically to assess adrenal disease. Excludes cases where imaging is performed to investigate, or follow up, known adrenal disease or dysfunction Changes from previous version Summary of evidence base this guideline has been created from: N/A European Society of Endocrinology Clinical Practice Guideline in collaboration with the European Network for the Study of Adrenal Tumors 2016 This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date or outside of the Trust. 1

2 1. Introduction Management of Incidentally-discovered Adrenal Lesions ( incidentalomas ). 1.1 An adrenal incidentaloma is defined as an adrenal mass, detected on imaging which was not performed for suspected adrenal disease. Most are benign and non-functioning, but it is important not to miss the diagnosis of functioning or potentially malignant lesions, as such lesions require treatment, to avoid serious complications, including death. Decisions on the management of the condition which necessitated the imaging in the first place may also be affected greatly by the adrenal abnormality. Detailed guidelines exist on management of adrenal incidentalomas 1, but this guideline provides a brief summary for clinicians not familiar with adrenal pathology, and a suggested referral pathway specific to NUH. 1.2 General principles: Patients with adrenal masses require an assessment of adrenal function (unless other co-morbidities make this unreasonable e.g. advanced malignancy, extreme frailty). It is particularly important to exclude phaeochromocytoma (which has a very high mortality if undiagnosed) and excess cortisol secretion (which, untreated, carries risks of cardiovascular complications, and of inability to mount an appropriate response to acute illness, or to any planned surgery/chemotherapy etc.). Investigation should comprise at least: clinical assessment for features of hormone excess, an overnight Dexamethasone suppression test, and at least one 24hr urine collection for metanephrines. Serum aldosterone and renin should be measured in patients who have either hypokalaemia or hypertension. 2

3 1.2.2 Radiological features can be used to assess the probability of malignancy. Lesions with all of the following features are considered benign: o Well-defined, homogeneous lesions o Diameter <4cm o Pre- or non-contrast CT density <10 HU or lipid-rich on MRI o No extra-adrenal extension 1.3 Clinicians faced with an imaging report which details an adrenal incidentaloma may decide to investigate this further themselves, or to seek advice from a core member of the adrenal MDT. This will depend on personal experience/preference, and may be guided by the following flow diagrams. In some cases, establishing the diagnosis of the adrenal lesion will not alter clinical management (e.g. advanced malignancy, patient frailty), and no additional action is required. 1.4 Core members of the adrenal MDT may be contacted for advice whenever required. Contact details are as follows: Dr Jenny Clayton Consultant Endocrinologist Sec: Ext Jenny.Clayton@nuh.nhs.uk Dr Kaustubh Nisal Consultant Endocrinologist Sec: Ext Kaustubh.Nisal@nuh.nhs.uk Mr David Chadwick 3

4 Consultant Endocrine Surgeon Sec: Ext Dr Mark Glover Consultant Hypertension Physician (contact for hyperaldosteronism only) Sec: Ext Investigation and Management 2.1 Suggested investigations and management are outlined in the following flow diagrams. These are intended as a guide (principally for clinicians not experienced in management of adrenal pathology), and should not replace clinical judgement. 2.2 Figure 1 summarises investigation of adrenal masses in patients without a history of extra-adrenal malignancy. 2.3 Adrenal lesions are also frequently detected on staging tests performed in patients with a variety of extra-adrenal cancers, and suggested management of these is summarised in Figure 2. The principles of management are similar to those in non-cancer patients. However, there are special considerations, in the frequent need for rapid treatment of the presenting malignancy, and in determining whether or not the adrenal lesion may represent a metastasis. Some adrenal lesions in cancer patients will be co-incidental phaeochromocytomas. Without appropriate treatment, any invasive investigation or surgery may risk an adrenergic crisis and death. Management of the phaeochromocytoma should usually take precedence, or occur concurrently with, that of the presenting malignancy. Early advice from a core member of the adrenal MDT is recommended, in order to expedite safe treatment. 4

5 If cancer treatment would be altered by knowledge that a nonfunctioning adrenal mass is a metastasis, then options include: FDG-PET (or MRI) Adrenal biopsy (percutaneous or via EUS if sufficiently large/accessible) Adrenalectomy (particularly if the adrenal lesion is the only suspected site of metastasis, or where resection of presumed oligo-metastatic disease is considered appropriate by the relevant MDT) 2.4 Notes on functional tests: Overnight Dexamethasone suppression test: Patient takes 1mg Dexamethasone orally at 2300, and serum cortisol is measured at 0900 the following morning. (Easily performed as an outpatient, if the patient is able to follow the appropriate instructions). A normal response is suppression of serum cortisol to <50nmol/l. Values over 50nmol/l may indicate autonomous cortisol secretion, and merit further investigation. NB Only suitable for patients not currently taking steroids: testing of patients on steroids should be discussed with an adrenal MDT core member hour urinary metanephrines: Must be collected into the correct (acidified) 24hr collection bottle, which must be labelled with the patient s details and time of collection, and returned ASAP to the Pathology lab (can be via GP surgery, if arrangements are in place for prompt delivery). Any values for metanephrines outside the reference range merit further investigation. Metanephrines within the normal range do not always exclude phaeochromocytoma, and the test may need repeating, if clinical/radiological features suggest this diagnosis Aldosterone:renin ratio: 5

6 Blood is taken as a random ambulatory sample at any time of day into a purple-top EDTA blood tube. This sample can only be taken in hospital and must reach the biochemistry lab within 2 hours of being taken. Serum U+E and bicarbonate should also be measured (yellow-top serum separator tube), and a list of medications recorded on the request form, to aid interpretation. Patients on beta-blockers or who are of black African or Afro-Caribbean ancestry may have physiologically low renin. An aldosterone:renin ratio of >35 pmol/miu, with an aldosterone of >300pmol/L is likely to represent primary hyperaldosteronism. 3. Notes for Radiologists: radiological evaluation and reporting of adrenal incidentalomas 3.1 Incidentally detected adrenal masses generally merit further evaluation unless age, infirmity or inter-current illness makes this inappropriate. Most are detected on contrast CT, occasionally MRI. Slightly prominent adrenal glands without an identifiable mass do not require further action. A clearly identifiable mass of whatever size should be given a recommendation for further evaluation in the conclusion of the report. This should be accompanied by the statement if clinically appropriate (to allow discretion of the managing clinician), and sign-post to these guidelines. The mass should be inspected for (a) size (b) border (well defined or poorly defined) (c) internal texture (homogenous or heterogenous) (d) vascularity (hyper-vascular lesions, often associated with phaeochromocytoma or malignancy) (e) density ( <10 HU = most likely adenoma) (f) evidence of local lymphadenopathy. In a small lesion it may not be possible to evaluate all of these features. If previous CT or MRI scans are available they should be reviewed, as confirmation that a lesion is longstanding and unchanged can confirm benignity. Myelolipomas of the adrenal gland usually have a diagnostic imaging appearance at CT, and are considered benign (though a small proportion can be associated with hypercortisolism). When an incidental adrenal mass is identified in a patient being staged for cancer or with a history of recent cancer the priorities are to identify a 6

7 metastasis or incidental phaeochromocytoma. Biochemical testing, as above, should be advised in the first instance. Discussion at the appropriate MDT is likely to be necessary before a decision on any further imaging is made. Where the patient is not being staged for cancer the priorities are to identify hormone producing lesions and adrenal carcinomas. Biochemical testing, as above, should be advised, and most functioning lesions will require excision. If non-functioning, an assessment of the likelihood of malignancy can be made from radiological features, to aid in planning management. If all radiological features are benign (size <4cm, well defined, homogenous internally, <10 HU density and no local invasion or lymphadenopathy) then further radiological evaluation is not required. If there are equivocal features a single 6 month follow up unenhanced CT scan of the adrenal glands is usually performed. If there is no significant change over that time, the lesion is considered benign. If the initial examination was an MRI, then follow up with the same modality is appropriate. 4 References. 1. Management of adrenal incidentalomas: European Society of Endocrinology Clinical Practice Guideline in collaboration with the European Network for the Study of Adrenal Tumors. Fassnacht M et al, European Journal of Endocrinology, 175 (2), G1-G34 7

8 Figure 1: Adrenal Incidentaloma pathway Imaging shows adrenal mass Assess adrenal function (or refer to adrenal MDT core member if preferred) Clinical Overnight Dexamethasone suppression test 24hr urinary metanephrines Assess radiological features: Homogeneous and welldefined? Size <4cm diameter? Lipid-rich/<10HU density? Any extra-adrenal extension? (Aldosterone:renin and U+E if hypertensive/hypokalaemic) Radiological features all benign (see section 1.2) Non-functioning Radiology equivocal/unclear /OR Functional studies abnormal/equivocal Radiology suspicious of Adrenal Malignancy No action required Usual management of condition for which imaging performed Refer to Core member of Adrenal MDT Refer 2ww to Core member of Adrenal MDT 8

9 Figure 2: Adrenal Incidentaloma detected on Staging for Other Cancer Imaging shows adrenal mass Assess adrenal function: (or refer to adrenal MDT core member if preferred) Clinical 24hr urinary metanephrines Overnight Dexamethasone suppression test Assess radiological features: Homogeneous and welldefined? Size <4cm diameter? Lipid-rich/<10HU density? Extra-adrenal extension? Radiological features all benign Non-functioning 24hr urinary metanephrines suggest phaeochromocytoma Radiology equivocal/suspicious Non-functioning Will knowledge of the adrenal pathology alter management of the presenting cancer? No additional action required Usual management of presenting cancer Seek advice from Core member of Adrenal MDT before any invasive investigation or treatment No Usual Management of presenting cancer Yes Consider: FDG-PET/MRI Adrenal biopsy (percutaneous/eus) 9 Adrenalectomy

10 Appendix 1 Clinical Assessment and Features of Adrenal Dysfunction. Typical/Classical features of the main functional syndromes are outlined below, for information. It is important to realise, however, that these typical features are frequently absent (or subtle) in patients with functional tumours; hence, unless the burden of co-morbidities makes any investigation futile, adrenal function must be biochemically assessed in all patients with incidentaloma, irrespective of the presence or absence of these clinical features. Phaeochromocytoma Potential Symptoms: Headache, palpitations, sweating, tremor, anxiety/panic attacks. Symptoms, when present, may frequently be paroxysmal. Family history: several genetic syndromes substantially raise the risk of phaeochromocytoma: hereditary phaeochromocytoma/paraganglioma syndrome, neurofibromatosis type I, von Hippel Lindau disease, multiple endocrine neoplasia type 2. Signs/Clinical features: Usually none, though hypertension, impaired glucose tolerance, pallor, tachycardia, tremor may be present. Autonomous Cortisol Secretion (Cushing s syndrome) Clinical features: Central obesity, muscle weakness/wasting, striae, thin skin/bruising, osteoporosis, hypertension, impaired glucose tolerance, hirsutism, tiredness, psychological/mood disturbance. Primary Hyperaldosteronism 10

11 Clinical features: Usually, sole feature is hypertension. Sometimes, there may be associated hypokalaemia (the combination of hypertension and hypokalaemia should raise the suspicion of hyperaldosteronism), headache, tiredness, muscle weakness, polyuria, impaired glucose tolerance. Feminizing/Masculinizing syndromes Automatically imply adrenal dysfunction and a higher risk of adrenal malignancy, and should be immediately referred to endocrinology. 11