Approach to Adrenal Incidentaloma Alice Y.Y. Cheng, MD, FRCP
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Learning Objectives By the end of this session, you will be able to: 1. Identify risk factors / worrisome features of adrenal incidentaloma 2. Appropriately investigate and follow adrenal incidentaloma
Mr CX 55M found incidentally to have a 1.5cm Left adrenal nodule on CT abdo Feels well PMH: hypertension well controlled Meds: ACE-inhibitor, CCB
Adrenal incidentaloma 8.7% incidence on autopsy series Is the tumour hormonally active? Radiologic features of malignancy? History of previous malignancy? Zeiger MA et al.. Endocrine Practice 2009; 15(S1) :1-20.
Differential Diagnosis Nonfunctioning adenoma (80%) Subclinical Cushing syndrome (5%) Pheochromocytoma (5%) Adrenocortical carcinoma (<5%) Metastatic lesion (2.5%) Aldosteronoma (1%) Ganglioneuroma, myelopimoa, benign cysts Zeiger MA et al.. Endocrine Practice 2009; 15(S1) :1-20.
History: r/o functional tumour Cushings: weight gain, centripal obesity, bruising, hypertension, diabetes, prox muscle weakness, fatigue Pheo: episodes of headache, sweating and palpitations, pallor, weight loss, anxiety, hypertension, family hx, Hyperaldo: uncontrolled HTN, hypok Met / cancer: weight loss, hx of cancer, smoking Zeiger MA et al.. Endocrine Practice 2009; 15(S1) :1-20.
Cushing s Syndrome CORTISOL EXCESS ACTH-independent or ACTH adrenal source (tumour, hyperplasia) exogenous source of cortisol (steroids) ACTH-dependent or ACTH pituitary source (tumour) - Cushing s disease ectopic ACTH source CRH-producing tumour
Clinical Manifestations Fat distribution (central obesity) Moon facies Plethora Thin skin, easy bruising, striae Proximal muscle weakness Metabolic (DM, HTN, dyslipid, infection, hypercoagulable) Osteoporosis, psychiatric
Physical exam Rule out functional tumour Blood pressure Cushingoid appearance, ecchymoses, striae, wasting, hirsutism, virilization Zeiger MA et al.. Endocrine Practice 2009; 15(S1) :1-20.
Investigations 1mg overnight dexamethasone suppression test 24 hour urine metanephrines, catecholamines Electrolytes, renin, aldosterone Zeiger MA et al.. Endocrine Practice 2009; 15(S1) :1-20.
1 mg overnight Dex Day 1: 2300h take 1 mg Dexamethasone Day 2: 0800h measure CORTISOL Normal <50 nmol/l cortisol Caution with OCPs Zeiger MA et al.. Endocrine Practice 2009; 15(S1) :1-20.
24h urine catechols, metanephs Remember the creatinine Diet to follow before collection Meds to hold x 2 weeks before Tricyclics, levodopa, methyldopa, acetaminophen, decongestants, amphetamines, phenoxybenzamine Major stress Lenders WJM, et al. Lancet 2006;266:665-675.
Hyperaldosteronism Stop spironolactone, eplerenone, amiloride, HCTZ, licorice x 4 weeks Correct hypokalemia, eat high Na diet BB, methyldopa, clonidine, NSAID, ACE, ARB, DRI can also interfere High aldo, low renin adrenal vein sampling may be needed Funder JW et al. JCEM 2008;93:3266-3281.
Radiology Benign CT characteristics Homogenous Regular borders HU <10 <4cm Zeiger MA et al.. Endocrine Practice 2009; 15(S1) :1-20.
CT in 3-6m, 1y, 2y Hormonal test every year x 5y Growth = 1cm After 5 years? Zeiger MA et al.. Endocrine Practice 2009; 15(S1) :1-20.
Kapoor A et al. Can Urol Assoc 2011;5(4):241-7.
Fassnacht M et al. Eur J Endocrinol 2016;175(2):G1-34.
Mr CX 55M found incidentally to have a 1.5cm Left adrenal nodule on CT abdo Feels well PMH: hypertension well controlled Meds: ACE-inhibitor, CCB OE: BP 120/75 mmhg, nil else Investigations negative
Take home points Benign vs malignant/met Function vs non-function History and physical 4cm and CT features 1mg overnight dex 24h urine catechols, metanephrines Renin, aldosterone, potassium (if HTN)