Management of adrenal incidentalomas: European Society of Endocrinology Clinical Practice Guideline in collaboration with the European Network for the Study of Adrenal Tumors
Tóm tắt
By definition, an adrenal incidentaloma is an asymptomatic adrenal mass detected on imaging not performed for suspected adrenal disease. In most cases, adrenal incidentalomas are nonfunctioning adrenocortical adenomas, but may also represent conditions requiring therapeutic intervention (e.g. adrenocortical carcinoma, pheochromocytoma, hormone-producing adenoma or metastasis). The purpose of this guideline is to provide clinicians with best possible evidence-based recommendations for clinical management of patients with adrenal incidentalomas based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. We predefined four main clinical questions crucial for the management of adrenal incidentaloma patients, addressing these four with systematic literature searches: (A) How to assess risk of malignancy?; (B) How to define and manage low-level autonomous cortisol secretion, formerly called ‘subclinical’ Cushing’s syndrome?; (C) Who should have surgical treatment and how should it be performed?; (D) What follow-up is indicated if the adrenal incidentaloma is not surgically removed?
(i) At the time of initial detection of an adrenal mass establishing whether the mass is benign or malignant is an important aim to avoid cumbersome and expensive follow-up imaging in those with benign disease. (ii) To exclude cortisol excess, a 1mg overnight dexamethasone suppression test should be performed (applying a cut-off value of serum cortisol ≤50nmol/L (1.8µg/dL)). (iii) For patients without clinical signs of overt Cushing’s syndrome but serum cortisol levels post 1mg dexamethasone >138nmol/L (>5µg/dL), we propose the term ‘autonomous cortisol secretion’. (iv) All patients with ‘(possible) autonomous cortisol’ secretion should be screened for hypertension and type 2 diabetes mellitus, to ensure these are appropriately treated. (v) Surgical treatment should be considered in an individualized approach in patients with ‘autonomous cortisol secretion’ who also have comorbidities that are potentially related to cortisol excess. (vi) In principle, the appropriateness of surgical intervention should be guided by the likelihood of malignancy, the presence and degree of hormone excess, age, general health and patient preference. (vii) Surgery is not usually indicated in patients with an asymptomatic, nonfunctioning unilateral adrenal mass and obvious benign features on imaging studies. We provide guidance on which surgical approach should be considered for adrenal masses with radiological findings suspicious of malignancy. Furthermore, we offer recommendations for the follow-up of patients with adrenal incidentaloma who do not undergo adrenal surgery, for those with bilateral incidentalomas, for patients with extra-adrenal malignancy and adrenal masses and for young and elderly patients with adrenal incidentalomas
Từ khóa
Tài liệu tham khảo
Tabarin, 2008, Exploration and management of adrenal incidentalomas. French Society of Endocrinology Consensus, Annales d’Endocrinologie, 69, 487, 10.1016/j.ando.2008.09.003
Zeiger, 2009, American Association of Clinical Endocrinologists and American Association of Endocrine Surgeons Medical Guidelines for the Management of Adrenal Incidentalomas: executive summary of recommendations, Endocrine Practice, 15, 450, 10.4158/EP.15.5.450
Zeiger, 2009, The American Association of Clinical Endocrinologists and American Association of Endocrine Surgeons medical guidelines for the management of adrenal incidentalomas, Endocrine Practice, 15, 1, 10.4158/EP.15.S1.1
Ross, 1994, Epidemiology of Cushing’s syndrome and subclinical disease, Endocrinology and Metabolism Clinics of North America, 23, 539, 10.1016/S0889-8529(18)30082-3
Nieman, 2015, Update on subclinical Cushing’s syndrome, Current Opinion in Endocrinology Diabetes and Obesity, 22, 180, 10.1097/MED.0000000000000159
Morelli, 2010, Subclinical hypercortisolism: correlation between biochemical diagnostic criteria and clinical aspects, Clinical Endocrinology, 73, 161, 10.1111/j.1365-2265.2010.03794.x
Reincke, 1996, Adrenal incidentalomas: a manifestation of the metabolic syndrome?, Endocrine Research, 22, 757, 10.1080/07435809609043773
Eller-Vainicher, 2012, Bone quality, as measured by trabecular bone score in patients with adrenal incidentalomas with and without subclinical hypercortisolism, Journal of Bone & Mineral Research, 27, 2223, 10.1002/jbmr.1648
Morelli, 2011, Risk of new vertebral fractures in patients with adrenal incidentaloma with and without subclinical hypercortisolism: a multicenter longitudinal study, Journal of Bone & Mineral Research, 26, 1816, 10.1002/jbmr.398
Deandreis, 2011, FDG PET in the management of patients with adrenal masses and adrenocortical carcinoma, Hormones and Cancer, 2, 354, 10.1007/s12672-011-0091-5
Szolar, 1998, Adrenal adenomas and nonadenomas: assessment of washout at delayed contrast-enhanced CT, Radiology, 207, 369, 10.1148/radiology.207.2.9577483
Young, 2011, Conventional imaging in adrenocortical carcinoma: update and perspectives, Hormones and Cancer, 2, 341, 10.1007/s12672-011-0089-z
Korobkin, 1996, The incidental adrenal mass, Radiologic Clinics of North America, 34, 1037, 10.1016/S0033-8389(22)00684-4
Korobkin, 1996, Adrenal adenomas: relationship between histologic lipid and CT and MR findings, Radiology, 200, 743, 10.1148/radiology.200.3.8756925
Vogel, 2004, PET/CT: panacea, redundancy, or something in between?, Journal of Nuclear Medicine, 45, 15S
Bollerslev J Rejnmark L Marcocci C Shoback DM Sitges-Serra A van Biesen W Dekkers OM. European Society of Endocrinology Clinical guideline: treatment of chronic hypoparathyroidism in adults. European Journal of Endocrinology 2015 173 G1–G20. (doi:10.1530/EJE-15-0628)
Ferreira, 2005, [Prevalence of adrenal incidentaloma at computed tomography (chest and abdominal) in a general hospital in Brazil], Arquivos Brasileiros de Endocrinologia & Metabologia, 49, 769, 10.1590/S0004-27302005000500017
Dinnes J Bancos I Ferrante di Ruffano L Chortis V Davenport C Bayliss S Sahdev A Guest P Fassnacht M Deeks JJ Imaging for the diagnosis of malignancy in incidentally discovered adrenal masses – a systematic review and meta-analysis. European Journal of Endocrinology 2016. In press (doi:10.1530/EJE-16-0461)
Bancos I Tamhane S Shah M Delivanis DA Alahdab F Arlt W Fassnacht M Murad MH. The diagnostic performance of adrenal biopsy: a systematic review and meta-analysis. European Journal of Endocrinology 2016. In press. (doi:10.1530/EJE-16-0297)
Angelelli G Mancini ME Moschetta M Pedote P Pignataro P Scardapane A. MDCT in the differentiation of adrenal masses: comparison between different scan delays for the evaluation of intralesional washout. Scientific World Journal 2013 2013 957680.
Marin, 2012, Effectiveness of a three-dimensional dual gradient echo two-point Dixon technique for the characterization of adrenal lesions at 3 Tesla, European Radiology, 22, 259, 10.1007/s00330-011-2244-x
Maurea, 2004, Imaging characterization of non-hypersecreting adrenal masses. Comparison between MR and radionuclide techniques, Quarterly Journal of Nuclear Medicine and Molecular Imaging, 48, 188
Vilar, 2008, Adrenal incidentalomas: diagnostic evaluation and long-term follow-up, Endocrine Practice, 14, 269, 10.4158/EP.14.3.269
Burt, 1994, Prospective evaluation of unilateral adrenal masses in patients with operable non-small-cell lung cancer. Impact of magnetic resonance imaging, Journal of Thoracic and Cardiovascular Surgery, 107, 584, 10.1016/S0022-5223(94)70106-7
Lang, 2015, High false positivity in positron emission tomography is a potential diagnostic pitfall in patients with suspected adrenal metastasis, World Journal of Surgery, 39, 1902, 10.1007/s00268-015-3035-3
Ream, 2015, Characterization of adrenal lesions at chemical-shift MRI: a direct intraindividual comparison of in- and opposed-phase imaging at 1.5 T and 3 T, American Journal of Roentgenology, 204, 536, 10.2214/AJR.14.12941
Schwartz, 1995, Adrenal masses in patients with malignancy: prospective comparison of echo-planar, fast spin-echo, and chemical shift MR imaging, Radiology, 197, 421, 10.1148/radiology.197.2.7480686
Kunikowska, 2014, What parameters from 18F-FDG PET/CT are useful in evaluation of adrenal lesions?, European Journal of Nuclear Medicine and Molecular Imaging, 41, 2273, 10.1007/s00259-014-2844-1
Villar Del Moral, 2010, Sanchez Sanchez R & Ferron Orihuela JA. [Diagnostic efficacy and discriminatory capacity of positron emission tomography combined with axial tomography of adrenal lesions], Cirugía Española, 88, 247, 10.1016/j.ciresp.2010.07.007
Aksakal, 2013, Nonfunctional adrenal lesions without loss of signal intensity on MRI: whose problem is it? The patient’s? The surgeon’s?, International Journal of Surgery, 11, 169, 10.1016/j.ijsu.2012.12.014
Boraschi, 1999, Diagnosis of adrenal adenoma: value of central spot of high-intensity hyperintense rim sign and homogeneous isointensity to liver on gadolinium-enhanced fat-suppressed spin-echo MR images, Journal of Magnetic Resonance Imaging, 9, 304, 10.1002/(SICI)1522-2586(199902)9:2<304::AID-JMRI23>3.0.CO;2-R
Ichikawa, 1993, Adrenal tissue characterization with 0.5-T MR imaging: value of T2*-weighted images, Journal of Magnetic Resonance Imaging, 3, 742, 10.1002/jmri.1880030509
Launay N Silvera S Tenenbaum F Groussin L Tissier F Audureau E Vignaux O Dousset B Bertagna X Legmann P. Value of 18-F-FDG PET/CT and CT in the diagnosis of indeterminate adrenal masses. International Journal of Endocrinology 2015 2015 213875.
Park, 2015, CT sensitivities for large (>/=3 cm) adrenal adenoma and cortical carcinoma, Abdominal Imaging, 40, 310, 10.1007/s00261-014-0202-1
Park, 2007, Differentiation of adrenal adenoma and nonadenoma in unenhanced CT: new optimal threshold value and the usefulness of size criteria for differentiation, Korean Journal of Radiology, 8, 328, 10.3348/kjr.2007.8.4.328
Zettinig, 2004, Positron emission tomography imaging of adrenal masses: (18)F-fluorodeoxyglucose and the 11beta-hydroxylase tracer (11)C-metomidate, European Journal of Nuclear Medicine and Molecular Imaging, 31, 1224, 10.1007/s00259-004-1575-0
Zielonko, 2008, Value of MRI in differentiating adrenal masses: quantitative analysis of tumor signal intensity, Polish Journal of Radiology/Polish Medical Society of Radiology, 73, 7
Deville, 2002, Conducting systematic reviews of diagnostic studies: didactic guidelines, BMC Medical Research Methodology, 2, 9, 10.1186/1471-2288-2-9
Macaskill P Gatsonis C Deeks JJ Harbord RM Takwoingi Y. Analysing and presenting results. In Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy. Version 10, ch 10. Eds Deeks JJ Bossuyt PM Gatsonis C . The Cochrane Collaboration 2010. Available from: http://srdta.cochrane.org/.
Moher, 2009, Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement, Open Medicine, 3, e123
Puri, 2015, Endoscopic ultrasound-guided fine-needle aspiration of the adrenal glands: analysis of 21 patients, Clinical Endoscopy, 48, 165, 10.5946/ce.2015.48.2.165
Martinez, 2014, Role of endoscopic ultrasound fine-needle aspiration evaluating adrenal gland enlargement or mass, World Journal of Nephrology, 3, 92, 10.5527/wjn.v3.i3.92
Rana, 2012, Spectrum of adrenal lesions on fine needle aspiration cytology, Indian Journal of Pathology & Microbiology, 55, 461, 10.4103/0377-4929.107781
Hussain, 1996, Gantry angulation in CT-guided percutaneous adrenal biopsy, American Journal of Roentgenology, 166, 537, 10.2214/ajr.166.3.8623623
Wu, 1998, Fine needle aspiration cytology of benign adrenal cortical nodules. A comparison of cytologic findings with those of primary and metastatic adrenal malignancies, Acta Cytologica, 42, 1352, 10.1159/000332167
Kocijancic, 2004, Role of sonographically guided fine-needle aspiration biopsy of adrenal masses in patients with lung cancer, Journal of Clinical Ultrasound, 32, 12, 10.1002/jcu.10220
Lumachi, 2007, High risk of malignancy in patients with incidentally discovered adrenal masses: accuracy of adrenal imaging and image-guided fine-needle aspiration cytology, Tumori, 93, 269, 10.1177/030089160709300307
Tsitouridis, 2008, CT guided percutaneous adrenal biopsy for lesions with equivocal findings in chemical shift MR imaging, Hippokratia, 12, 37
Bodtger, 2009, Clinical impact of endoscopic ultrasound-fine needle aspiration of left adrenal masses in established or suspected lung cancer, Journal of Thoracic Oncology, 4, 1485, 10.1097/JTO.0b013e3181b9e848
Tirabassi, 2012, Fine-needle aspiration cytology of adrenal masses: a re-assessment with histological confirmation, Journal of Endocrinological Investigation, 35, 590
Androulakis, 2014, Patients with apparently nonfunctioning adrenal incidentalomas may be at increased cardiovascular risk due to excessive cortisol secretion, Journal of Clinical Endocrinology and Metabolism, 99, 2754, 10.1210/jc.2013-4064
Vassilatou, 2014, Bilateral adrenal incidentalomas differ from unilateral adrenal incidentalomas in subclinical cortisol hypersecretion but not in potential clinical implications, European Journal of Endocrinology, 171, 37, 10.1530/EJE-13-0848
Debono, 2014, Cortisol as a marker for increased mortality in patients with incidental adrenocortical adenomas, Journal of Clinical Endocrinology and Metabolism, 99, 4462, 10.1210/jc.2014-3007
Di Dalmazi, 2014, Cardiovascular events and mortality in patients with adrenal incidentalomas that are either non-secreting or associated with intermediate phenotype or subclinical Cushing’s syndrome: a 15-year retrospective study, Lancet Diabetes & Endocrinology, 2, 396, 10.1016/S2213-8587(13)70211-0
Morelli, 2014, Long-term follow-up in adrenal incidentalomas: an Italian multicenter study, Journal of Clinical Endocrinology and Metabolism, 99, 827, 10.1210/jc.2013-3527
Iacobone, 2012, Adrenalectomy may improve cardiovascular and metabolic impairment and ameliorate quality of life in patients with adrenal incidentalomas and subclinical Cushing’s syndrome, Surgery, 152, 991, 10.1016/j.surg.2012.08.054
Fossa, 2013, Laparoscopic versus open surgery in stage I-III adrenocortical carcinoma – a retrospective comparison of 32 patients, Acta Oncologica, 52, 1771, 10.3109/0284186X.2013.765065
Cho, 2013, Clinical characteristics and follow-up of Korean patients with adrenal incidentalomas, Korean Journal of Internal Medicine, 28, 557, 10.3904/kjim.2013.28.5.557
Comlekci, 2010, Adrenal incidentaloma, clinical, metabolic, follow-up aspects: single centre experience, Endocrine, 37, 40, 10.1007/s12020-009-9260-5
Kim, 2005, Clinical study of adrenal incidentaloma in Korea, Korean Journal of Internal Medicine, 20, 303, 10.3904/kjim.2005.20.4.303
Muth, 2013, Patient-reported impacts of a conservative management programme for the clinically inapparent adrenal mass, Endocrine, 44, 228, 10.1007/s12020-012-9856-z
Yener, 2009, Natural course of benign adrenal incidentalomas in subjects with extra-adrenal malignancy, Endocrine, 36, 135, 10.1007/s12020-009-9191-1
Tsvetov, 2007, Adrenal incidentaloma: clinical characteristics and comparison between patients with and without extraadrenal malignancy, Journal of Endocrinological Investigation, 30, 647, 10.1007/BF03347444
Rodacki, 2014, Combined chemical shift imaging with early dynamic serial gadolinium-enhanced MRI in the characterization of adrenal lesions, American Journal of Roentgenology, 203, 99, 10.2214/AJR.13.11731
Seo, 2014, Characterization of lipid-poor adrenal adenoma: chemical-shift MRI and washout CT, AJR. American Journal of Roentgenology, 202, 1043, 10.2214/AJR.13.11389
Fassnacht, 2004, Adrenal tumors: how to establish malignancy ?, Journal of Endocrinological Investigation, 27, 387, 10.1007/BF03351068
Lafont, 2015, Per-operative hemodynamic instability in normotensive patients with incidentally discovered pheochromocytomas, Journal of Clinical Endocrinology and Metabolism, 100, 417, 10.1210/jc.2014-2998
Schalin-Jantti, 2015, A 5-year prospective follow-up study of lipid-rich adrenal incidentalomas: no tumor growth or development of hormonal hypersecretion, Endocrinology and Metabolism, 30, 481, 10.3803/EnM.2015.30.4.481
Kerkhofs, 2015, Diagnostic value of urinary steroid profiling in the evaluation of adrenal tumors, Hormones and Cancer, 6, 168, 10.1007/s12672-015-0224-3
Nogueira, 2015, Radiographic characteristics of adrenal masses preceding the diagnosis of adrenocortical cancer, Hormones and Cancer, 6, 176, 10.1007/s12672-015-0225-2
Ozsari, 2016, Preexisting adrenal masses in patients with adrenocortical carcinoma: clinical and radiological factors contributing to delayed diagnosis, Endocrine, 51, 351, 10.1007/s12020-015-0694-7
Del Monte, 1995, Increased 17 alpha-hydroxyprogesterone response to ACTH in silent adrenal adenoma: cause or effect?, Clinical Endocrinology, 42, 273, 10.1111/j.1365-2265.1995.tb01875.x
Vassiliadi, 2011, High prevalence of subclinical hypercortisolism in patients with bilateral adrenal incidentalomas: a challenge to management, Clinical Endocrinology, 74, 438, 10.1111/j.1365-2265.2010.03963.x
Vassiliadi, 2011, Aberrant cortisol responses to physiological stimuli in patients presenting with bilateral adrenal incidentalomas, Endocrine, 40, 437, 10.1007/s12020-011-9490-1
Lacroix, 2010, Aberrant G-protein coupled receptor expression in relation to adrenocortical overfunction, Clinical Endocrinology, 73, 1, 10.1111/j.1365-2265.2009.03689.x
Mannelli, 2012, Perioperative management of pheochromocytoma/paraganglioma: is there a state of the art?, Hormone and Metabolic Research, 44, 373, 10.1055/s-0032-1306275