Adrenal&Incidentaloma:& Clinical&Pathological&Correla9on& Paul Gustafson Dr. Edward Jones, Dr. Charles Zwirewich, Dr. Marshal Dahl Outline& Review&Incidence,&Epidemiology& Case&presenta9on& Dr.$Charles$Zwirewich,$Radiology& &&&&&&&&&%Review&of&Imaging$ Dr.$Marshall$Dahl,$Endocrinology& &&&&&&&&&%Biochemical&Evalua9on& Dr.$Edward$Jones,$Pathology& &&&&&&&&&%Review&of&Pathology& Surgical&Management& Follow%Up& 1&
Adrenal&Incidentaloma&%&Defini9on& Adrenal&&lesions&&larger&&than&&1cm&&found& serendipitously&&&during&&imaging&&studies& performed&&for&&reasons&&other&&than& evalua9on&&of&&adrenal&&disease. & Young Endorinol Metab Clin North Am 2000; 29:159-85 Incidence&and&Epidemiology& Frequency&of&adrenal&adenoma&6%&on&autopsy&&&&& Incidentaloma&in&up&to&5%&pts&undergoing& abdominal&or&thoracic&ct&&& Probability&increases&with&age&(0.2%&age&&20%29&yrs,& 7%&age&>&70yrs)& Detec9on&increasing&with&higher&&resolu9on&imaging& & & & Young.&&N""Eng""J""Med.&&2007;&&356:601& Davenport&Endocrine&2011;40:&80%83& 2&
Incidence&and&Epidemiology& Non%func9oning&benign&lesion&82.5%&& &&&&&%61%&adenoma& &&&&&%10%&myolipoma& &&&&&%&6%&adrenal&cyst& &&&&&%&5.5%&ganlioneuroma& Cor9sol%secre9ng&adenoma&5.3%& Pheochromocytoma&5.1%& Adrenocor9cal&carcinoma&4.7%& Metastases&2.5%& Aldosteronoma&1%& Turner.&&Curr""Opin""Oncol.&&2009;&&21:34& Bi^ner.&Surg&onc&2012;&106:&557%564& Incidence&and&Epidemiology& Offer&tes9ng&to:& %Rule&out&func9onal&secretory&lesion& %Rule&out&malignancy&(primary&or&metastases)& 3&
Case&%&HPI& ID:&69&year&old&male& %CT&chest&ordered&to&inves9gate&dyspnea,& possible&inters99al&lung&disease& %incidentally&discovered&lea&adrenal&mass& %no&other&new&signs&or&symptoms&sugges9ve&of& func9onal&adenoma,&acc,&metastases& History&and&Physical& 4&
Case&%&PMHx& PMHx:& OSA&%&prescribed&CPAP,¬&compliant& COPD,&?ILD&%&requiring&home&O2,&2.5&L/min&at& night& HTN&%&20&yrs,&controlled&with&HCTZ& Obesity&%&BMI&30& DM2& &insulin%dependent& Dyslipidemia& Depression& PSHx:& &open&cholecystectomy,&appendectomy& Case&%&Meds/Allergies& Meds:& Mehormin&500&mg&BID& Glyburide&5&mg&BID& Insulin&NPH&36/0/0/0& Lipitor& HCTZ& Prozac& Allergies:& NKDA& & 5&
Case&%&Imaging& CT&chest&%&4.7&cm&heterogeneous&adrenal&mass& suspicious&for&primary&malignancy&or&mets& CT&Adrenal&protocol& &5.4&cm&mass&with&57%& washout&at&60&sec,&could&represent&primary& malignancy&or&mets,& amenable&to& percutaneous&biopsy & Limited&role& Biopsy&indica9ons:& %suspected&infec9on& %supected&adrenal&mets&& Biopsy& Oaen&non%diagnos9c,&may¬&differen9ate& benign&from&malignant& Risk&of&hypertensive&crisis&with&pheo& 6&
Percutaneous&Biopsy&& Case&%&Biopsy& Referral to VGH given patients co-morbidities Dr.&Zwirewich&%&Radiology& 7&
CGH&&12/2011&CT&chest&+C& Lt&Adrenal&mass&>&4.8cm&117HU& CGH&&1/2012&Adrenal&Washout&CT&& Lt&&Adrenal&mass&6.5cm&& NC&39.4HU & &1&min&100HU & &15&min&62.6HU& Absolute&Percentage&Washout&(APW)&=&62%& 8&
CGH&&2012&13mm&Rt&Renal&Mass& NC&30.2HU & & &60&sec&80.9&HU && >20HU&enhancement&strongly&suggests&malignancy& CGH&&2/2012&CT&Guided&biopsy& Lt&&Adrenal&mass&6.5cm&& 9&
VGH&&5/2012& 123 I%MIBG&scan& Non&MIBG&avid&6cm&mass.&1cm&focus&uptake&likely&normal&& Incidentally Detected Adrenal Mass (IDAM) Mass &1cm discovered incidentally on cross-sectional imaging performed for another reason 3-7% of adult population Pathology: 71.2% non-functioning adenoma Frequently investigated to exclude potentially serious (malignant) lesion: metastasis, pheo, ACC, lymphoma IDAMs <2cm with no Hx of cancer are rarely malignant IDAMs in cancer patients are frequently mets (45-73%) 10&
Imaging Parameters Size CT Internal architecture Pre contrast attenuation Post contrast enhancement and washout MRI Chemical shift imaging (CSI) T2 SI Gd Enhancement 11&
Fat attenuation < -30HU 12&
Adrenal&Myelolipoma& CT of Lipid Rich Adrenal Adenomas Non-contrast attenuation <2HU Sensitivity 47% Specificity 100% Non-contrast attenuation <10HU (ACR) Sensitivity 71% Specificity 98% Johnson&PT&&Radiographics&2009&29:1319& & 13&
Lipid&Rich&Adenoma& NC: 8HU NC: -3HU MRI of Adrenal Adenoma Lipid rich Opposed phase imaging In phase (TE=4.2ms) Relatively hyperintense Out of phase (TE=2.1,6.6) Signal drop out (microscopic fat) Sensitivity 81-100% Specificity 94-100% 14&
Characterization of IDAMs with Adrenal washout CT Technique: NC, 1 and 15 minutes post IV contrast Absolute percentage washout (APW) used at VGH APW 60% confirms adenoma* APW sensitivity 98% and specificity 92% *Caveats: APW only applicable to IDAMs 4cm Analysis most valuable for homogeneous masses Consider pheo if IDAM >100HU enhancement at 1 minute regardless of APW Berland&LL&JACR&2010&7:754& Horton&KM&AJR&2010&194:660& 15&
Adrenal&washout&CT& NC: 19H 1 min: 76H 15 min: 32H Lipid poor adrenal adenoma: APW 77% 16&
CGH&&1/2012&Adrenal&Washout&CT&& Lt&&Adrenal&mass&6.5cm&& NC&39.4HU & &1&min&100HU & &15&min&62.6HU& Absolute&Percentage&Washout&(APW)&=&62%& Adrenal&malignancies& Adrenal cortical carcinoma Adrenal metastases from lung cancer 17&
Sag&T2& Pheochromocytoma Ax&T2& Ax&T1& Ax&T1+gad& Non-functioning Pheochromocytoma Ax$T2$fat$sat$ Cor$T2$ Ax$T1$with$gad$ 18&
Key points: IDAMs are common Size is not a reliable indicator of malignancy No cancer Hx: most IDAMs <2-3cm are benign Cancer Hx: 45-73% of masses are metastases Bilaterality favors mets, lymphoma, hemorrhage Key points (2): NC CT attenuation <10HU: lipid rich adenoma < -30HU: myelolipoma Signal loss on CSI MR: lipid rich adenoma Peak CT enhancement < 100HU and APW >60% suggests lipid-poor adenoma Peak CT enhancement >100HU always consider pheo Hi intensity T2 MR and strong enhancement with Gd: always consider pheo 19&
Extramedullary&Hematopoeisis& Adrenal mass Gallstones, splenomegaly T1: Iron overload, Paraspinal EMH Case& &Hormonal&Evalua9on& 20&
Marshall Dahl MD PhD FRCPC cert Endo Clinical Professor, Endocrinology, UBC Alternate&Title:& What&could&possibly&go&wrong...?& 21&
Defini9on& & Adrenal&incidentaloma:& &! Mass&lesion&>&1cm&discovered&by&radiologic& examina9on&in&the&absence&of&symptoms&or& clinical&findings&sugges9ve&of&adrenal& disease& Thompson&&&Young.&Curr&Opin&Oncol&Jan&2003& Epidemiology& Prevalence&of&adrenal&masses&varies&according&to& criteria&and&circumstances& Autopsy&series:& 1.4%2.9%&>&1cm& 8.7%&>&2&mm& CT&series:& 0.6%1.9%&in&general&popula9on& 4.0%&in&pa9ents&with&lung&cancer& & & Mansmann&et&al.&Endo&Rev&2004&& & 22&
Differen9al&Diagnosis& 2% & && 2% 5% 8% 8% 11% 12% 52% Adenoma 52% Carcinoma 12% Pheochromocytoma 11% Myelolipoma 8% Subclinical Cushings 5% Metastases 2% Aldosterone PA 2% Other 8% Mantero&et&al.&J&Clin&Endocrinol&Metab&2000& Two&Ques9ons& Is&it&malignant?& Size&and&imaging&phenotype& & Is&it&func9oning?& History&and&Physical& Hormonal&assessment& 23&
Adrenocor9cal&Carcinoma& 88% Other Carcinoma 12% Prevalence&of&carcinoma&based&on&size:& Masses&<&4&cm&:&2%& Masses&4%6&cm:&6%& Masses&>&6&cm:&25%& Vierhapper&et&al.&Clin&Endocrinol&Diabetes&2003& Cushing s&syndrome& Spectrum&of&symptoms&from&asymptoma9c&to& classic&phenotype& Hypertension,&osteoporosis,&diabetes,& dyslipidemia& Overnight&1&mg&dexamethasone&suppression& test.&&am&cor9sol&should&be&below&130& Confirmatory&tes9ng&with&2&day&high&dose& tes9ng& 24&
Primary&hyperaldosteronism& Hypertension& Hypokalemia&oaen¬&present& Upright&morning&aldosterone&renin&ra9o&off& intefering&meds:&spironlactone,&acei& Saline&suppression&tes9ng&+/%&adrenal&vein& sampling& Pheochromocytoma& Spectrum&from&asymptoma9c&to&paroxysmal& hyperadrenergic& Hypertension,&orthosta9c&hypotension,&pallor,& re9nopathy& 24&hour&metanephrines&best&screen.& False&posi9ves&with&drugs:&tricyclics,&clozapine,& sympathomime9cs,&buspirone&and&lesser& effect&with&beta&and&alpha&blockers& 25&
Adrenocor9cal&carcinoma& Mass&effect& Possible&Cushing s&syndrome&or& Androgen&secre9on&(viriliza9on&in&women)& Estrogens&secre9on&(gynecomas9a)& Hyperaldosteronism& Young W. N Engl J Med 2007;356:601-610 26&
(Surgery&2009;146:1158%66.)& Mayo&Biopsy&Experience& 20&consecu9ve&pa9ents& Retrospec9ve&record&review& 14&pheos&and&6¶gangliomas&biopsied&prior& to&referral& No&pre%biopsy&biochemical&tes9ng&in&90%,&and& nega9ve&in&remainder& 70%&developed&a&biopsy%related&complica9on& 27&
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Summary& Adrenal&incidentalomas&common& Imaging&phenotype&for&malignancy&poten9al& 24&hour&metanephrines& Overnight&1&mg&dex&suppression&test& +/%&morning&aldosterone%renin&ra9o& 29&
Case&%&Management& Anesthesia&and&Endocrinology&consults& Normal&Echocardiogram& Mixed&alpha/beta&blockade&with&labetolol& 100mg&BID&pre%opera9vely& Intended&Lea&MIS&Adrenalectomy& Appeared&Invasive&into&upper&pole& MIS&Nephrectomy&and&Adrenalectomy&en&bloc& Well&at&last&f/u,&5&months&post%op& Pathology& &Dr.&Jones& 30&
Pathology& 31&
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Thank&you& 36&
Surgical&Management& Surgical&&approaches:& &Open&&& &Laparoscopic& &&&&&%transperitoneal& &&&&&%retroperitoneal& &Robo9c& Surgical&Management& Laparoscopic&adrenalectomy&standard&of&care& Equivalent&outcomes&with&open& Less&morbidity,&pain,&shorter&LOS& Size&threshold&con9nuously&challenged&(10,& 15cm?)& Open&for:& &&&&&%larger&&or&&invasive&&tumors&&& &&&&&%vein&&involvement& &&&&&%emergent&&open&&surgical&&conversion& & 37&
Follow%Up& 1&mg&DXT,&urinary&metanephrines&and& catecholamines,&k&and&renin/aldo&those&with& HTN&annually&for&4&years& Monitor&lesions&<&4&cm&with&CT&at&6,&12&and&24& months& Pheo&%&Follow%Up& Long%term&follow%up&& &&&&&%10%year&recurrence&rates&up&to&16%& Biochemical&tes9ng&6&months&post%op,&then& annually& Post%op&imaging&to&document&resec9on& 38&