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![Suggested evaluation of an adrenal incidentaloma [18, 19]; *metastasectomy should be considered in the case of an isolated adrenal metastatic lesion; **all hormonally active lesions (especially pheochromocytomas) require appropriate pharmacological treatment before surgery; ***there is no consensus on appropriate follow-up evaluation. The first imaging re-evaluation may be performed early (after 3–6 months). Afterwards, imaging re-evaluation may be performed annually for 2–4 years. Biochemical re-evaluation should be performed annually for 3–5 years. Should the tumour extensively grow or become hormonally active during follow-up, adrenalectomy should be considered; US — ultrasonography; CT — computed tomography; MR — magnetic resonance; HU — Hounsfield units](profile/Joanna-Podgorska-3/publication/221873773/figure/fig2/AS:393931507421191@1470931998942/Suggested-evaluation-of-an-adrenal-incidentaloma-18-19-metastasectomy-should-be.png)
Suggested evaluation of an adrenal incidentaloma [18, 19]; *metastasectomy should be considered in the case of an isolated adrenal metastatic lesion; **all hormonally active lesions (especially pheochromocytomas) require appropriate pharmacological treatment before surgery; ***there is no consensus on appropriate follow-up evaluation. The first imaging re-evaluation may be performed early (after 3–6 months). Afterwards, imaging re-evaluation may be performed annually for 2–4 years. Biochemical re-evaluation should be performed annually for 3–5 years. Should the tumour extensively grow or become hormonally active during follow-up, adrenalectomy should be considered; US — ultrasonography; CT — computed tomography; MR — magnetic resonance; HU — Hounsfield units
Source publication
The differentiation of adrenal nodules is wide and varies from primary benign neoplasia, through hormone secreting lesions, to primary and secondary malignant masses. With the rapid development of cross-sectional imaging, incidental detection of adrenal nodules has become an everyday practice, leaving clinicians with the necessity of further invest...
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Citations
... In order to determine the character of the lesion, especially in cases non-qualified primarily for the surgery, imaging studies, mainly computed tomography, magnetic resonance and positron emission tomography are of the greatest significance. The imaging modalities complement one another and enable qualitative assessment of adrenal lesions with high specificity [8]. As a consequence, a safe routine follow-up of small and hormonally inactive lesions is feasible. ...
Introduction
Incidentaloma is defined as an tumor diagnosed accidentally using imaging studies performed due to other indications. The aim of this paper was to describe the diagnostic and treatment problems experienced by patients with adrenal incidentaloma in a clinical practice.
Material and methods
In years 2009-2012 there were 33(16,5%) adrenal tumors diagnosed incidentally out of 200 cases treated due to adrenal pathology. The group consisted of 54 patients aged 27-77. In 15(45,5%) patients the diagnosis was made based on ultrasound examination, while in 18(54,5%) the tumor was visualized in CT/MRI.
Results
Only after the diagnostics was finalized, in which in all cases no signs of hormonal activity were detected, 26(78,8%) patients were qualified for the surgery. In 7(21,2%) cases no indications for such a management were found. The latter group was followed-up and in all patients the indications for the surgery arose due to enlargement of the tumor or/and the existence of hormonal activity. Our observations suggest that the incident finding of adrenal tumor is an indication of long-term observation. The analysis of our material shows that all patients observed needed surgical treatment.
Conclusions
The small adrenal tumors under follow-up have a tendency to enlarge and acquire hormonal activity. Long-term observation significantly increases the costs of treatment in that group, which eventually results in surgical management.
... In the diagnosis of abnormalities in adrenal glands, the methods of greatest importance are computed tomography, magnetic resonance, positron emission tomography, MIBG scintigraphy, and ultrasound examination as a screening tool. The imaging modalities may be complementary to each other and in 95% of cases are diagnostically positive in terms of localization and qualitative aspect (9). Based on a common finding that malignant pheochromocytomas account for 5-26% of cases, and in case of paragangliomas up to 36%, the matter of greatest importance in the treatment of such patients is a strict, routine follow-up [4,10]. ...
Introduction: We present a case of a 29-year-old patient treated due to fully symptomatic pheochromocytoma of the right adrenal gland.
Case presentation: Patient was operated on and an open right-sided adrenalectomy was performed. At the time of the surgery, a rupture of the tumor capsule occurred. Five years post-operatively, a recurrence of the symptoms of chromaffin-cell tumor was noted. After the exact localization of the multiple recurrences, the patient was reoperated on.
Conclusion: The case of pheochromocytoma is presented due to the possibility of chromaffin-cell seeding into the peritoneum, with no signs of distal metastases so far.
... Though the visualization of retroperitoneal structures like adrenals is difficult on USG, it still has a role in incidentally detecting adrenal masses, in monitoring the changes during treatment of already established pathology and enables visualization of other abdominal organs at the same setting without any risk of radiation exposure and is cost effective. [3,4] USG shows adrenal glands quite accurately in infants and children [ Figure 1] as compared to adults where they may be obscured due to bowel gas and obesity. On USG, if no mass is seen with or without visualization of normal adrenals, it is considered to be specific for the absence of malignancy. ...
... The two limbs are thinner as compared to the apex where two limbs join. Mean thickness of gland is 5-6 mm with maximum width of 10 mm and approximate length is 2-4 cm in one section of CT. [4,8,9] Paucity of retroperitoneal fat may render visualization of adrenals difficult due to overlap of surrounding structures. ...
... [25] Anatomic imaging cannot differentiate functioning from non-functioning adenomas; however; it has been postulated that functioning tumors cause suppression of release of ACTH (adrenocorticotrophin hormone) which causes atrophy of contralateral adrenal gland. [4] Adrenocortical carcinoma ACC is overall a rare tumor but represents the most common malignant adrenal tumor in a patient without an underlying malignancy. It has a bimodal age of presentation, affecting children in their first decade and adults in their fourth and fifth decades. ...
Adrenal glands can be affected by a variety of lesions. Adrenal lesions can either be primary, of adrenal origin, or secondary to other pathologies. Primary adrenal lesions can further be either of cortical or medullary origin. Functioning adrenal lesions can also give clues to the histologic diagnosis and direct workup. Over the years, various imaging techniques have been developed that have increased diagnostic accuracy and helped in better characterization of adrenal lesions non‑invasively. In the first part of the two part series, we review adrenal imaging techniques and adrenal cortical tumors such as adenomas, adrenocortical tumors, adrenal hyperplasia and oncocytomas.
... An absolute washout coefficient that is greater than 50% after 10 minutes, 60% after 15 minutes and a relative washout coefficient that is greater than 40% indicates a mild character of the lesion. This allows the diagnosis of a lipid-poor adenoma, i.e. a lesion that requires surgery only in case of confirmed hormonal activity (ACTH-independent hypercortisolemia or primary hyperaldosteronism) [10,15,19,21,[24][25][26]. ...
The term "adrenal incidentaloma" refers to clinically unapparent adrenal mass detected during imaging examination performed for reasons other than the evaluation of adrenal glands. These tumors must be carefully examined in order to assess the indications for surgical treatment. The main method of finding evidence of potential malignancy in these lesions is computed tomography (CT), before and after i.v. contrast media enhancement. Density of a malignant lesion is higher than 10 HU and the relative percentage washout is less than 40% at 10 min. Other useful methods utilized in tumor assessment, include magnetic resonance imaging (MRI), scintigraphy techniques (SPECT) and PET. Basal hormonal investigations include urine and plasma catecholamines with their metabolites, plasma cortisol before and after dexamethasone administration, plasma renin activity and aldosterone level. Cases not suitable for surgery should be followed with repeat imaging techniques and hormonal testing at the recommended 6, 12, and 24 months. Surgery should be performed when tumor growth rate exceeds 0,8 cm per year.
Adrenal incidentaloma is at present one of the commonest diagnostic/therapeutic dilemmas in endocrinology. It mainly occurs in the 50 to 70 years age group and is associated to higher frequency of obesity, diabetes mellitus and blood hypertension. Its etiology is varied, but around 80% of them are benign non-functioning adenomas. Despite the above-mentioned, the occurrence of carcinoma (based on aggressiveness) and hormonal dysfunction (negative impact on some cardiovascular risk factors and on the osseous system) can make prognosis gloomy. The behavior to be adopted will consider the stated definitions: nature and function, and the most used variants are adrenal surgery (mainly laparoscopic, except for a tumor with imaging-based malignancy criteria) and conservative surgery that implies at least five-year follow-up of the patient. Knowledge about the characteristics of adrenal incidentaloma may support a best treatment for patients suffering incidental adrenal tumor and assure them a better quality of life
Primary adrenal insufficiency (PAI) consists one of the most critical life-threatening conditions in paediatric endocrinology. Authors present PAI pathophysiology and current Endocrine Society Clinical Practice Guideline for diagnosis and treatment in children.
Adrenocortical carcinoma (ACC) is a malignant endocrine tumour. The rarity of the disease has stymied therapeutic development. Age distribution shows two peaks: the first and fifth decades of life, with children and women more frequently affected. Although 60-70% of ACCs are biochemically found to overproduce hormones, it is not clinically apparent in many cases. If present, endocrine symptoms include signs of hypercortisolaemia, virilisation or gynaecomastia. ACC carries a poor prognosis, and a cure can be achieved only by complete surgical resection. Mitotane is used both as an adjuvant treatment and also in non-operative patients. The role of radio- and chemotherapy is still controversial. The post-operative disease free survival is low and oscillates around 30% due to high tumour recurrence rate. The diagnosis is based on tumour histological assessment with the use of the Weiss score, however urinary steroid profiling (if available) can serve to differentiate between ACC and other adrenal tumours. Conventional prognostic markers in ACC include stage and grade of disease, and, as currently reported, the presence of hypercortisolaemia. Molecular analysis has had a significant impact on the understanding of the pathogenetic mechanism of ACC development and the evaluation of prognostic and predictive markers, among which alterations of the IGF system, the Wnt pathway, p53 and molecules involved in cancer cell invasion properties and angiogenesis seem to be very promising. We here summarise our own experience related to the management of ACC and present a literature overview. We have not aimed to include a detailed summary of the molecular alterations biology described in ACC, as this has already been addressed in other papers. (Endokrynol Pol 2014; 65 (6): 492-512).
The aim of this study was to evaluate in patients with resistant hypertension (RHTN) enrolled in the RESIST-POL study the relationship between primary aldosteronism (PA) and obstructive sleep apnoea (OSA) and their effect on metabolic abnormalities and cardiac structure.
We included 204 patients (123 M, 81 F, mean age 48.4 yrs) with true RHTN, eGFR > 60 mL/min/1,73 m2 and no known diabetes. OSA was defined as an apnoea/hypopnoea index of 15/h or more. Metabolic syndrome components were assessed. On echocardiography, left ventricular hypertrophy (LVH), concentric remodelling (RWT > 0.45), E' velocity, E/E' index and global strain (GLS) were evaluated.
PA was diagnosed in 32 patients (15.7%). OSA occurred more frequently in patients with PA (59.4 v. 42.4%; p = 0.058). Patients were divided into four groups: PA+ OSA+ , PA+ OSA-, PA-OSA+ and PA-OSA-. Newly diagnosed diabetes, impaired glucose tolerance and increased fasting glucose were most frequent in the PA+ OSA+ group compared to other groups. The presence of OSA was associated with concentric remodelling, and the presence of PA was associated with higher left ventricular mass and higher frequency of left ventricular hypertrophy. In the PA+ OSA+ and PA+ OSA- groups, the most frequent geometry patterns were concentric hypertrophy (68.4%) and eccentric hypertrophy (54.5%) respectively. E' velocity was lowest and E/E' was highest in PA+ OSA+ compared to other groups. GLS was lower in patients with OSA compared to those without OSA.
Both metabolic abnormalities and target organ damage are more pronounced in patients with RHTN, PA and OSA. OSA and PA influence differently left ventricular geometry.(Endokrynol Pol 2013; 64 (5): 363-367).
Von der zunehmenden Weiterentwicklung der Magnetresonanztomographie (MRT)-Technik in den letzen Jahrzehnten hat auch die Bildgebung bei Nieren- und Hochdruckkrankheiten profitiert. Die MRT bietet neben dem Fehlen von radioaktiver Strahlung die Möglichkeit einer exzellenten Abbildung pathologischer Prozesse in allen Raumebenen. MR-Angiographie und MR-Urographie sind bereits klinisch fest etablierte Spezialanwendungen der MRT, die in der Genauigkeit der Computertomographie (CT)-Untersuchung gleichzusetzen, in manchen Fragestellungen sogar exakter sind. Erweitert werden diese Verfahren durch spezielle, teils noch zu evaluierende, MRT-Untersuchungsmethoden, die eher funktionelle Aspekte messen bzw. ohne die Gabe von Kontrastmittel auskommen. Die MRT ist kostenintensiv, zeitaufwändig und nicht überall verfügbar, sodass eine strenge Indikationsprüfung auf Grundlage einer guten Kommunikation zwischen klinisch tätigen Ärzten und Radiologen unabdingbar ist.
Introduction:
Pheochromocytoma is a rare tumour, but one of great clinical importance as a risk factor of malignancy, cardiovascular diseases and sudden death.
Material and methods:
15 consecutive patients (eight women and seven men) were hospitalised and submitted for adrenalectomy with pheochromocytoma confirmed by histopathologic examination. Adrenalectomies were performed laparoscopically in 14 cases (93.3%): in nine by the retroperitoneal posterior mode and in five by the transperitoneal lateral approach.
Results:
Molecular-genetic examination of VHL, RET, SDHB, SDHC and SDHD genes revealed inherited predisposition for PHEO in three of 15 patients (20%): RET mutations typical for MEN 2a in two patients and VHL mutation in one patient. Disturbances of the carbohydrate metabolism occurred in nine patients (60%). Ten patients (66%) reported paroxysmal symptoms. In all cases, with the exception of a von Hippel-Lindau patient, density of tumours exceeded 20 HU. In all studied patients, urine concentration of normetanephrines exceeded their normal range and greatly prevailed over metanephrines values, which were increased in six of them (40%).
Conclusions:
Urine metoxycatecholamines and increased tissue density are sufficient in pheochromocytoma detection. However, taking into account clinical and supplemental biochemical data may be helpful in the diagnostic process. Laparoscopic adrenalectomy is a fully sufficient and safe method of pheochromocytoma excision.
