1. K. Poppe Endocrinologie
Adrenal masses
K. Poppe
Endocrinologie

5. Incidentaloma

6. Serendipitiously discovered by radiologic examinations (CT / MRI)
Definition
Mass lesion > 1 cm
Serendipitiously discovered by radiologic examinations (CT / MRI)

7. Prevalence

9. Incidentaloma’s are bilateral in 10-15%

10. Work-up

11. Q1: Benign vs Malign?

12. W. Young NEJM 2007

13. Evaluate for malignancy
Size and imaging characteristics (imaging phenotype)
The maximum diameter is predictive of malignancy
Adenocortical carcinomas
- significantly association with mass size
90% > 4 cm
- sensitivity 93 %
- specificity 76 %
The National Italian Study Groups

14. Benign adenoma Round & homogenous density  < 4 cm, unilateral
Low unenhanced CT attenuate values (<10HU)
Rapid contrast washout (10 min)
Absolute contrast washout >50%
Isointensity with liver on both T-1 & T-2 (MRI)
Chemical shift : lipid on MRI

15. Adrenocortical carcinoma
Irregular shape
Inhomogenous density (central necrosis)
> 4 cm, unilateral, calcify
High unenhanced CT (>20HU)
Delayed contrast washout (10 min)
Absolute contrast washout < 50 %
Hypointensity compared with liver T-1 and high to intermidiate intensity T-2 MRI
Evidence of local invasion or Mets

16. MRI has advantages in certain situations:
1- Conventional spin-echo MRI
- T1 and T2
- distinguish benign from malignancy and pheochromocytoma
2- Gadolinium-DPTA-enhanced MRI
- adenoma : mild enhancement and rapid washout of contrast
- malignancy : marked enhancement and a slower washout
3- Chemical shift imaging (CSI)
- in-phase : water & lipid are aligned: signal intensity high
- out of phase : opposite from each other: signal intensity low

18. Others
Adrenal cysts
Adrenal hemorrhage
Myelolipoma

20. Others PET (Positron Emission Tomography)
- fluoro-2-deoxy-D-glucose (FDG)
- high sensitivity for detecting malignancy
- however : 16% benign cortical lesions may
have FDG-PET uptake
- metomidate (MTO)
: lack of MTO – specific to non-adrenal
cortical origin (metastasis & pheochromocytoma)
FDG-PET and MTO-PET are not routinely recommend
---> lack of data

22. Fine-needle aspiration biopsy
Cannot distinguish a benign adrenal mass from adrenal carcinoma, but between an adrenal and a metastatic tumor.
sensitivity of 81–96 % and a specificity of 99–100 %
inconclusive biopsies were reported in 6–50 %
Complications of FNAB is ranging from % (pneumothorax, bleeding, infection, and pancreatitis).
FNAB is useful in selected cases only:
in patients with a history of an underlying extra-adrenal malignancy
In case of inconclusive results of imaging tests
if there is suspicion of a rare tumor (infiltrative, infection)
! It is mandatory to biochemically exclude a pheochromocytoma before FNAB is performed !

23. Q2: Functional ?

25. 24-25 % =
secreting

26. Hormonal hypersecretion is most likely if mass is ≥ 3 cm in diameter
Occurs mostly within the first 3 years after diagnosis

30. Cushing’s disease 3 major causes: Cushing dsease 68 %
Adrenal origin 20 %
Para Neoplastic 12 %

31. Cushing

32. Cushing's syndrome. Howlett TA et al. Clin Endo Metab 1985
Symptoms
Cushing's syndrome. Howlett TA et al. Clin Endo Metab 1985

33. Cushing’s syndrome
5-20 % of pt with adrenal incidentaloma are reported to have subclinical Cushing syndrome
Subclinical Cushing's syndrome
mild hypercortisolism without clinical
manifestations of Cushing's syndrome

34. Hormonal evaluation Cushing's syndrome
Lack of suppressibility of cortisol after 1 mg overnight dexamethasone intake (NL: cortisol < 1.8 mcg/dL )
Supranormal 24-hour urinary cortisol excretion
Disturbed cortisol circadian rhythm (midnight salivary cortisol)
Low baseline secretion of ACTH
Confirmatory (second line) tests:
Blunted plasma ACTH responses to CRH
Overnight 8 mg dexamethasone

35. Diagnosis - Cushing

36. Pheochromocytoma
Screening for pheochromocytoma is mandatory in all case
because high rate morbidity and mortality
It is symptomatic up to 15% of case

38. Pheo: Signs & Symptoms
PHEO is easily suspected in someone with paroxysmal hypertension, resistant hypertension
& in the presence of the so-called “Spells”
the “5 P’s”
Pressure (HTN) 90%
Pain (Headache) 80%
Perspiration 71%
Palpitation 64%
Pallor 42%
Paroxysms (the sixth P!)

39. Plasma free metanephrines
Screening test is measurement of plasma free or 24 hrs urines metanephrines
Plasma free metanephrines
sensitive 99 %
specific %

41. Confirmatory test

42. Primary Hyperaldosteronism (Conn’s syndrome)
% of adrenal incidentalomas
Pts with hypertension should be evaluated
Hypokalemia suggests hyperaldosteronism (~ 40 %), this means that a normal K+ doesn’t exclude it !
The best screening test is the ratio of the plasma aldosterone : renin activity (> 20)

44. Confirmatory test Saline infusion test —
IV 2l NaCl 0,9 % / 4h (from 8 AM to noon)
the PAC will fall below 5 ng/dL (139 pmol/L) in normal subjects, whereas values above 10 ng/dL (277 pmol/L) are consistent with primary aldosteronism.
Ahmed AH et al. Seated saline suppression testing for the diagnosis of primary aldosteronism: JCEM 2014

45. Management of adrenal incidentaloma

46. Natural evolution
Some adrenal incidentalomas followed for an average of 4 years can:
increase (range 0–26%)
decrease (~ 4%) and/or can develop
hyperfunction (range 0–11%)
EJE (2015) 173, 275–282

47. W.Young NEJM 2007;356:601-10

48. Bilateral adrenal masses
The management of bilateral adrenal masses is different from that for unilateral masses!

49. SUMMARY

50. Benign versus Malign ?
Functional ?
Bilateral ≠ Unilateral

51. Merci de votre attention