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Orlo H. Clark - One of the best experts on this subject based on the ideXlab platform.
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Adrenal Incidentaloma does an adequate workup rule out surprises
Surgery, 2010Co-Authors: Raymon H. Grogan, Elliot J Mitmaker, Avital Harari, Jessica E Gosnell, Menno R. Vriens, Wen T. Shen, Orlo H. ClarkAbstract:Background Adrenal Incidentaloma remains a diagnostic challenge. Despite well-established management guidelines, the long-term results of following these guidelines are unknown. We sought to determine how accurately these guidelines identify functioning Incidentalomas and how often these guidelines result in Adrenalectomy for benign tumors. Methods We catalogued Adrenal Incidentalomas from a retrospective review of 500 consecutive Adrenalectomies at a single institution. The outcome measures studied were patient demographics, preoperative biochemical analysis, imaging characteristics, tumor size, type of operation performed, and postoperative histologic diagnosis. Results Eighty-one of the 500 Adrenalectomies performed were for Incidentalomas. Size was the only significant characteristic that distinguished cortical cancers from benign adenomas. Only 1 out of 26 functioning tumors was incorrectly identified on preoperative workup. We also found that 25% of cortisol-secreting Incidentalomas were cystic, and that benign adenomas accounted for 42% of all tumors resected. Conclusion Current guidelines accurately predict the functional status of Adrenal Incidentalomas. Some cystic lesions may be functioning and should therefore be screened for hormonal hypersecretion. However, even with the most up-to-date diagnostic tools available, most Adrenal Incidentalomas resected are benign tumors.
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Adrenal Incidentaloma borderline elevations of urine or plasma metanephrine levels and the subclinical pheochromocytoma
Archives of Surgery, 2007Co-Authors: Rasa Zarnegar, Wen T. Shen, Electron Kebebew, Orlo H. ClarkAbstract:Objective To assess the risk of pheochromocytoma in patients with borderline-elevated urine or plasma metanephrine levels. Design Retrospective review. Setting University tertiary care center. Patients Forty-two consecutive patients with Adrenal Incidentalomas (defined as Adrenal tumors identified during routine imaging for another condition) who were treated at the UCSF (University of California, San Francisco) Medical Center between January 1, 1995, and July 31, 2005. Patients with genetic syndromes were excluded. Intervention Laparoscopic Adrenalectomy for Adrenal Incidentaloma based on size criteria and preoperative hormonal test results. Main Outcomes Measures Urine or plasma metanephrine and catecholamine levels, tumor size, and presence of pheochromocytoma. Results Of 42 patients, 14 (33%) had a pheochromocytoma (11 of whom had clear-cut elevations in urine or plasma metanephrine levels defined as greater than 2 times the upper limit of normal) and 28 did not. Ten of the 42 patients (24%) had borderline elevations in urine or plasma metanephrine levels (defined as 1-2 times the upper limit of normal), 3 of whom had a pheochromocytoma (30%). Of patients with borderline elevations, mean ± SD tumor size was 5.4 ± 3.1 and 4.8 ± 1.9 cm for patients with and without pheochromocytoma, respectively ( P = .37). In these 10 patients, no clinical factors (age, sex, hypertension, presence of symptoms, number of antihypertensive medications, preoperative hemodynamics, or size of tumor on computed tomographic scan) allowed differentiation between those with and without pheochromocytoma. Conclusions Thirty percent of patients with Adrenal Incidentaloma and borderline-elevated urine or plasma metanephrine levels had a pheochromocytoma. Clinical factors cannot distinguish between those with and without pheochromocytoma. In this group of patients, we advocate either routine alpha-blockade preoperatively or further diagnostic tests to better characterize the tumor.
Mary G F Gilliland - One of the best experts on this subject based on the ideXlab platform.
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Adrenal schwannoma a rare type of Adrenal Incidentaloma
Archives of Pathology & Laboratory Medicine, 2013Co-Authors: Yaseen Mohiuddin, Mary G F GillilandAbstract:Adrenal schwannoma is a rare type of Adrenal Incidentaloma, an Adrenal lesion found incidentally, usually on imaging or autopsy. Computed tomography and magnetic resonance imaging are tools used to evaluate Adrenal lesions. The diagnosis of Adrenal schwannoma, however, cannot be made on imaging alone. Surgical resection is the primary means of management of Adrenal schwannomas, as it is not possible to distinguish the schwannoma from malignant entities simply based on imaging. Histopathologic features of Adrenal schwannomas are similar to those of schwannomas found at other sites. Conventional schwannomas, consisting of alternating Antoni A and Antoni B areas as well as Verocay bodies, have distinct microscopic features and can be readily distinguished from other entities. Cellular schwannomas, on the other hand, consist only of intersecting fascicles of spindle cells or Antoni A areas, resulting in a wide differential diagnosis. Ancillary studies such as immunohistochemical analysis and electron microsco...
John Newellprice - One of the best experts on this subject based on the ideXlab platform.
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subclinical hypercortisolism in Adrenal Incidentaloma
Current Opinion in Endocrinology Diabetes and Obesity, 2015Co-Authors: Miguel Debono, John NewellpriceAbstract:PURPOSE OF REVIEW: The article aims to update the reader on current developments in the area of Adrenal Incidentaloma complicated by subclinical hypercortisolism. We will discuss different diagnostic strategies and complications associated with this disease, and address the conflicting opinions related to the treatment of these patients. RECENT FINDINGS: Depending on diagnostic criteria used, between 30 and 50% of patients with adrenocortical Incidentaloma have biochemical hypercortisolism, but lack classical external features of Cushing's syndrome. The challenge facing the clinician is that in the sixth and seventh decade of life hypertension, diabetes, osteoporosis and obesity are common and establishing whether these are directly related to the low-grade excess cortisol secretion in a given individual is not straightforward. Nevertheless, this subclinical hypercortisolism has been found to be associated with multiple cardiovascular risk factors, an increased predisposition to cardiovascular events and a higher mortality rate. The dilemma is that it is not established whether surgical excision of the Adrenal adenoma in a given individual will improve these complications, and data demonstrate that surgical studies are conflicting. SUMMARY: Subclinical hypercortisolism is associated with multiple complications and definite guidelines for diagnosis are necessary. Prospective, randomized controlled studies are needed to ascertain whether medical or surgical interventions are justified, and in which patients.
Massimo Terzolo - One of the best experts on this subject based on the ideXlab platform.
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ame position statement on Adrenal Incidentaloma
European Journal of Endocrinology, 2011Co-Authors: Massimo Terzolo, Giuseppe Reimondo, Antonio Stigliano, Iacopo Chiodini, Paola Loli, Lino Furlani, Giorgio Arnaldi, Anna Pia, Vincenzo Toscano, Michele ZiniAbstract:Objective: To assess currently available evidence on Adrenal Incidentaloma and provide recommendations for clinical practice. Design: A panel of experts (appointed by the Italian Association of Clinical Endocrinologists (AME)) appraised the methodological quality of the relevant studies, summarized their results, and discussed the evidence reports to find consensus. Radiological assessment: Unenhanced computed tomography (CT) is recommended as the initial test with the use of an attenuation value of %10 Hounsfield units (HU) to differentiate between adenomas and non-adenomas. For tumors with a higher baseline attenuation value, we suggest considering delayed contrast-enhanced CT studies. Positron emission tomography (PET) or PET/CT should be considered when CT is inconclusive, whereas fine needle aspiration biopsy may be used only in selected cases suspicious of metastases (after biochemical exclusion of pheochromocytoma). Hormonal assessment: Pheochromocytoma and excessive overt cortisol should be ruled out in all patients, whereas primary aldosteronism has to be considered in hypertensive and/or hypokalemic patients. The 1 mg overnight dexamethasone suppression test is the test recommended for screening of subclinical Cushing’s syndrome (SCS) with a threshold at 138 nmol/l for considering this condition. A value of 50 nmol/l virtually excludes SCS with an area of uncertainty between 50 and 138 nmol/l. Management: Surgery is recommended for masses with suspicious radiological aspects and masses causing overt catecholamine or steroid excess. Data are insufficient to make firm recommendations for or against surgery in patients with SCS. However, Adrenalectomy may be considered when an adequate medical therapy does not reach the treatment goals of associated diseases potentially linked to hypercortisolism.
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management of Adrenal Incidentaloma
Best Practice & Research Clinical Endocrinology & Metabolism, 2009Co-Authors: Massimo Terzolo, Silvia Bovio, Giuseppe Reimondo, Alberto AngeliAbstract:Clinically inapparent Adrenal masses, or Adrenal Incidentalomas, are discovered inadvertently in the course of work-up or treatment of unrelated disorders. Cortical adenoma is the most frequent tumour detected incidentally, but adrenocortical cancer, phaeochromocytoma and metastasis are not rare. Two critical questions should be answered before trying to outline the management of Adrenal Incidentaloma: (1) which tumours may cause harm to the patient, and (2) can we recognize and effectively treat such tumours? Based on the available scientific evidence, two major recommendations should be made: (1) identify either primary (adrenocortical cancer) or secondary (Adrenal metastasis) malignancy; (2) identify phaeochromocytoma. Radiological evaluation is the key to the differential diagnosis of benign and malignant tumours. Endocrine testing is necessary to exclude phaeochromocytoma in all patients with an Adrenal Incidentaloma because this tumour may remain undiagnosed after imaging studies. The management of clinically inapparent Adrenal adenomas may vary depending whether or not they are functioning. It is reasonable to screen for primary aldosteronism all hypertensive patients and recommend Adrenalectomy when an aldosterone-producing adenoma is confirmed. A subset of adenomas secretes cortisol autonomously and may lead to mild hypercortisolism, a condition defined as subclinical Cushing's syndrome. The criteria for defining subclinical Cushing's syndrome are controversial, and we currently do not have sufficient evidence to define a gold standard for screening. Also the management of this condition is largely empirical, and data are insufficient to indicate the superiority of a surgical or non-surgical approach to managing patients with subclinical Cushing's syndrome.
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Adrenal Incidentaloma a new cause of the metabolic syndrome
The Journal of Clinical Endocrinology and Metabolism, 2002Co-Authors: Massimo Terzolo, Silvia Bovio, Giuseppe Reimondo, Giangiacomo Osella, A Ali, P Paccotti, Anna Pia, Fulvia Daffara, M Procopio, Giorgio BorrettaAbstract:A number of patients with Adrenal Incidentaloma are exposed to a slight degree of cortisol excess resulting from functional autonomy of the Adrenal mass (usually a cortical adenoma). At present, there are only scant data on the unwanted effects of this endocrine condition referred to as subclinical Cushing's syndrome. The aim of the present study was to look for some features of the metabolic syndrome in patients with incidental Adrenal adenoma. Forty-one patients (9 men and 32 women) bearing Adrenal Incidentaloma with typical computed tomography features of cortical adenoma were studied. For both patients and controls, exclusion criteria were age equal to 70 yr or greater, previous history of fasting hyperglycemia, or impaired glucose tolerance (IGT), severe hypertension, current use of medication or concomitant relevant illnesses, and body mass index (BMI) equal to 30 kg/m(2) or greater. Forty-one patients with euthyroid multinodular goiter accurately matched for sex, age, and BMI served for a 1:1 case-control analysis. The study design included an oral glucose tolerance test (75 g) and an endocrine workup aimed at the study of the hypothalamic-pituitary-Adrenal axis. Age and BMI were fully comparable between patients (54.0 +/- 10.7 yr, 23.8 +/- 2.4 kg/m(2)) and controls (52.2 +/- 11.6 yr, 23.5 +/- 2.8 kg/m(2)). Fasting glucose and fasting insulin levels were not different between the two groups (4.96 +/- 0.61 mmol/liter vs. 4.88 +/- 0.58 mmol/liter; 67 +/- 34 pmol/liter vs. 59 +/- 32 pmol/liter), but the 2-h postchallenge glucose was significantly higher in patients than in controls (7.43 +/- 2.49 mmol/liter vs. 6.10 plus minus 1.44 mmol/liter, P = 0.01). Fifteen patients (36%) reached the World Health Organization criteria for IGT and two other patients (5%) reached those for diabetes, and 14% of the controls qualified for IGT (P = 0.01). No difference in the lipid pattern was seen between the two groups, but either systolic or diastolic blood pressure were higher in patients (135.4 +/- 15.5 mm Hg vs. 125.0 +/- 15.6 mm Hg, P = 0.003; 82.9 +/- 9.1 mm Hg vs. 75.3 +/- 6.6 mm Hg, P < 0.0001). We calculated the whole-body insulin sensitivity index derived from the oral glucose tolerance test that was significantly reduced in the patients (4.3 +/- 1.7 vs. 5.7 +/- 2.5, P = 0.01). In a multiple regression analysis, 2-h glucose was associated with BMI and midnight cortisol values (r(2) = 0.36, P = 0.002). The comparison of the patients with nonfunctioning adenoma (n = 29) with those with subclinical Cushing's syndrome (n = 12) yielded significant differences as to 2-h glucose and triglyceride levels, which were significantly higher in the second group (7.02 +/- 1.76 mmol/liter vs. 8.72 +/- 3.17 mmol/liter, P = 0.03; 1.06 +/- 0.4 mmol/liter vs. 1.73 +/- 0.96 mmol/liter, P = 0.002), but the insulin sensitivity index was conversely reduced (5.2 +/- 1.4 vs. 2.9 +/- 1.2, P < 0.0001). In conclusion, many patients with incidental Adrenal adenoma display altered glucose tolerance, that may be explained by reduced insulin sensitivity, and increased blood pressure levels in comparison with carefully age- and BMI-matched controls. The slight hypercortisolism observed in some such patients may significantly contribute to this state of insulin resistance. Midnight serum cortisol appears as a sensitive marker of the metabolic effects of subclinical Cushing's syndrome.
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different patterns of steroid secretion in patients with Adrenal Incidentaloma
The Journal of Clinical Endocrinology and Metabolism, 1996Co-Authors: Massimo Terzolo, Giangiacomo Osella, A Ali, Giorgio Borretta, Giampaolo Magro, A Termine, P Paccotti, Alberto AngeliAbstract:We previously found that a remarkable number of patients with Adrenal Incidentaloma display partially autonomous cortisol secretion. The amount of hypercortisolism is insufficient to give clinical expression, but enough to inhibit, in some cases, normal Adrenal tissue. Other researchers found with high frequency a partial deficiency of 21-hydroxylase. The aim of the present study was to make a combined evaluation of these aspects of Adrenal steroidogenesis. Twenty patients (6 men and 14 women, aged 25-74 yr; median, 59 yr) with incidentally discovered Adrenal masses were studied. All had an Adrenal adenoma histologically proven or diagnosed on the basis of size (< or = 4.0 cm in all but 1) and computed tomography picture (hypodense homogeneous mass with well defined margins). The following parameters were used to evaluate the ACTH-cortisol axis: overnight 1-mg dexamethasone suppression (4 nonsuppressors), ovine CRH stimulation (blunted ACTH-cortisol response in 2 cases), circadian serum cortisol rhythm (b...
Toshihiko Yanase - One of the best experts on this subject based on the ideXlab platform.
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proposed diagnostic criteria for subclinical cushing s syndrome associated with Adrenal Incidentaloma
Endocrine Journal, 2013Co-Authors: Yuko Akehi, Hisaya Kawate, Kunitaka Murase, Ryoko Nagaishi, Takashi Nomiyama, Masatoshi Nomura, Ryoichi Takayanagi, Toshihiko YanaseAbstract:Subclinical Cushing’s syndrome (SCS) associated with Adrenal Incidentaloma is usually characterized by autonomous cortisol secretion without overt symptoms of Cushing’s syndrome (CS). Although the diagnostic criteria for SCS differ among countries, the 1 mg dexamethasone suppression test (DST) is essential to confirm the presence and the extent of cortisol overproduction. Since 1995, SCS has been diagnosed in Japan based on serum cortisol levels ≥3 μg/dL (measured by radioimmunoassay [RIA]) after a 1 mg DST. However, the increasing use of enzyme immunoassays (EIA) instead of RIA has hindered the diagnosis of SCS because of the differing sensitivities of commercially available assays, particularly for serum cortisol levels of around 3 μg/dL. One way to overcome this problem is to lower the cortisol threshold level after a 1 mg DST. In the present study, we examined the clinical applicability of lowering the cortisol threshold to 1.8 μg/dL, similar to the American Endocrine Society’s guidelines for CS, by reanalyzing 119 patients with Adrenal Incidentaloma. Our findings indicate that serum cortisol levels ≥1.8 μg/dL after 1 mg DST are useful to confirm the diagnosis of SCS if both of the following criteria are met: (1) basal ACTH level <10 pg/mL (or poor plasma ACTH response to corticotrophin-releasing hormone) and (2) serum cortisol ≥5 μg/dL at 21:00 to 23:00 h. If only one of (1) and (2) are met, we recommend that other clinical features are considered in the diagnosis of SCS, including serum dehydroepiandrosterone sulfate levels, urine free cortisol levels, Adrenal scintigraphy, and clinical manifestation.
