肾上腺意外瘤指南Adrenal Incidentaloma guidelines.pptVIP

Adrenal Incidentaloma guidelines AACE/AAES A summary of the literature Nonfunctioning adenoma Approximately 80% Subclinical Cushing syndrome (SCS), 5% Pheochromocytoma 5% Aldosteronoma 1% adrenocortical carcinoma (ACC) 5 % Metastatic lesion 2.5% Ganglioneuromas, myelolipomas,or benign cysts 考虑是否手术治疗之前准确的功能诊断非常必要 嗜铬细胞瘤要进行认真的术前准备以避免术中和术后的发作和死亡。 原发性醛固酮增多症的患者需要明确是否存在肾上腺皮质增生及无功能的肾上腺腺瘤。肾上腺源性Cushing综合征的患者在行切除术后可能发生肾上腺皮质功能不全，激素的替代以及增减治疗需要非常仔细。亚临床Cushing综合征的患者是否需要手术治疗仍存在争议。 肾上腺皮质癌的患者手术前需要外科医师和内分泌科医师或肿瘤科医师共同协商决定切除的方式，因为首次切除的效果是生存率的主要预测因素。 超过4cm的肾上腺无功能瘤可以考虑切除。小的髓脂肪瘤或良性的囊肿一般影像学检查即可确诊，通常不需要治疗，除非有症状可以考虑手术治疗。 Algorithm for the evaluation and management of an adrenal incidentaloma * The ARR is most sensitive when blood samples are collected in the morning, after patients have been out of bed for at least 2 hours and have been seated for 5 to 15 minutes. * * * * * * * * complex solid and cystic, calcified mass * * * Algorithm Thank you for your attention Questions? * * * * * * * * * * * * * * * Best test to assess adrenal automony * * * 90% in adrenal medulla, 90% under the diaphrams * * * Note the vascular and inhomogenous imaging characteristics of this mass * * * * * * * * * Literature Search “The first initial test of choice for low risk patients is the 24-hour urinary fractionated metanephrines and catecholamines.” Although elevated levels of fractionated plasma metanephrines have high sensitivity for pheo (99%), the test has a low specificity (85%) and thus should be used when suspicion is high. What to do? Plasma fractionated metanephrines Sens: 97-100%, Spec 85-89% Urinary fractionated metanephrines and catecholamines Sens: 91%, Spec 98% Hyperfunctioning Hormonal Evaluation Subclinical Cushing’s Syndrome Pheochromocytoma Primary Aldosteronism Sex hormone-secreting adrenocortical tumors Primary Aldosteronism 1% of adrenal incidentaloma characterized by: high blood pressure Refractory to treatment hypokalemia Weakness, cramps suppressed renin activity metab