Nephtali R. Gomez, M.D. To The Incidental Adrenal Mass

Nephtali R. Gomez, M.D. To The Incidental Adrenal Mass

The Complete Idiot s Guide to The Incidental Adrenal Mass Defini:on Any adrenal mass 1cm or more in diameter discovered on a radiologic exam performed for indica:ons other than adrenal disease

The Complete Idiot s Guide to The Incidental Adrenal Mass Excludes - Pa5ents undergoing imaging as part of staging for extra- adrenal cancer - Pa5ents in whom the diagnosis of a symptoma5c adrenal- dependent syndrome was missed because of insufficient suspicion

The Complete Idiot s Guide to The Incidental Adrenal Mass

The Complete Idiot s Guide to The Incidental Adrenal Mass Adrenal Incidentaloma on the Rise!

The Complete Idiot s Guide to The Incidental Adrenal Mass 5% of all abdominal and chest CT scans will ID an adrenal lesion

The Complete Idiot s Guide to The Incidental Adrenal Mass 2007-72 Million 2006 1980-62 Million - 3 Million 0 20 40 60 80 CT scans in millions (annually) Arch Intern Med. 2009;169(22):2071-2077 / U.S. News and World Report / Na5onal Council on Radia5on Protec5on and Measurements (NCRP)

The Complete Idiot s Guide to The Incidental Adrenal Mass 72 Million CT scans performed in the U.S. annually 32% are CT of Abd/Pelvis 1.2 Million! 23 Million CT of Abd/pelvis Adrenal Incidentalomas 5%

The Complete Idiot s Guide to The Incidental Adrenal Mass SC cushings 5% Pheo 5% ACC 5% Mets 2% Aldo 1% Non Funct Adenoma 82%

The Complete Idiot s Guide to The Incidental Adrenal Mass What is the least expensive and fastest way to find out which camp your pa:ent is in? Non- funct Benign Adenoma Ganglioneuromas Myelolipomas Benign cysts Pheochromocytoma Cushing s Adenoma Aldosteronoma Metasta:c CA Adrenocor:cal CA

3 Ques5ons to ask yourself 3 Func5onal tumors to screen 3 Blood tests to order 3 CT scan characteris5cs to consider

The Complete Idiot s Guide to The Incidental Adrenal Mass Three ques:ons need to be addressed 1. Is the tumor hormonally ac5ve? 2. Does it have radiologic characteris5cs sugges5ve of a malignant lesion? 3. Does the pa5ent have a history of a previous malignant lesion?

The Complete Idiot s Guide to The Incidental Adrenal Mass 1. Is the tumor hormonally ac5ve? Cushing s Adenoma Pheochromocytoma Aldosteronoma

The Complete Idiot s Guide to The Incidental Adrenal Mass 1. Is the tumor hormonally ac5ve? Cushing s Adenoma Overnight Dexamethasone Suppresion Test Pheochromocytoma Plasma Metanephrines Aldosteronoma Plasma Aldosterone /Plasma Renin Ac:vity

What about 24hr Urine Collec5on? X

Pheochromocytoma Screening Urine catecholamines/metanephrines Sensi5vity- 77-97% Specificity- 69-98% Average Total Cost $4.13 Plasma Metanephrines Sensi5vity= 97-100% Specificity= 85-89% $5.89

Cushing s Adenoma Screening Urine cor:sol vs. ODST Suppression of the plasma cor5sol level to <1.8 µg/dl has the best nega5ve predic5ve value for Cushing s syndrome AACE/AAES Adrenal Incidentaloma Guidelines, Endocr Pract. 2009;15

Typical Order Set 1. Dexamethasone 1mg PO taken at 11pm 2. Cor:sol level drawn at 8 a.m. the morning a^er the dexamethasone was taken 3. Plasma metanephrines 4. Plasma aldosterone concentra:on 5. Plasma renin acitvity

Details, Details, Details Pheochromocytoma Off phenoxybenzamine, caffeine, B- blockers, TCA s, MOI, Buspar, acetaminophen 5 days prior to lab work. No nico:ne or ETOH for at least 12hrs prior to lab work

Details, Details, Details Hyperaldosteronism Off ACE inhibitors and Spirinolactone for 4-6 weeks prior to lab work.

3 Ques5ons to ask yourself 3 Func5onal tumors to screen 3 Blood tests to order 3 CT scan characteris5cs to consider

Young, WF. N Engl J Med 2007;356:601-10.

3 CT scan characteris:cs to consider 1 2 Three ques:ons need to be addressed 3 Young, WF. N Engl J Med 2007;356:601-10.

The Complete Idiot s Guide to The Incidental Adrenal Mass Three ques:ons need to be addressed 1. Is the tumor hormonally ac5ve? 2. Does it have radiologic characteris5cs sugges5ve of a malignant lesion? 3. Does the pa:ent have a history of a previous malignant lesion?

Does the pa:ent have a history of a previous malignant lesion? 2.5% prevalence of metasta:c lesions among incidentalomas - Rule out biochemical func5on - What was the primary CA? - Consult with oncologist - PET/CT - Biopsy Lung Breast Stomach Kidney Melanoma Lymphoma

Follow- up of Pa:ents With a Nonfunc:oning Adrenal Incidentaloma Radiographic reevalua:on at 6 months and then annually for 1 to 2 years. The risk of the mass enlarging during 1, 2, and 5 years is 6%, 14%, and 29%, respec5vely Hormonal evalua:on should be performed at the :me of diagnosis and then annually for up to 5 years. The risk of the mass becoming hormonally ac5ve during those 5me periods is 17%, 29%, and 47%, respec5vely.

Follow- up of Pa:ents With a Nonfunc:oning Adrenal Incidentaloma The most common hormonally ac:ve lesion in pa:ents with previously inac:ve adenomas is SCS. Should the tumor grow more than 1 cm or become hormonally ac:ve during follow- up, surgical excision should be considered. Currently, it is unclear what the recommenda:ons should be a^er 5 years of follow- up for a stable, nonfunc:oning adrenal mass.