| What is an adrenal incidentaloma? | Adrenal mass >1cm radio discovered by chance, it is increasingly seen due to advances in radio techniques , occurs for 10% of elderly, diabetics, obese and hypertensive patients
It is essential to discover whether it is malignant or benign, secreting or non-secreting |
| What are the imaging criteria of adrenal masses? | Size --> if >4cm in favor of malignancy
CT scan --> Spontaneous density if >10UH then sus of malignancy, density with contrast high >37 at 30 min then malignancy, washout if <50% after 10 min in favor of malignancy (else 100% adenoma)
MRI -->Max contrast and low washout in malignancy
PET --> maybe FDG or MTO useful in case of sus |
| Why do we use fine needle cytology? | It is not very recommended, used to distinguish between adrenal carcinoma and metastasis (not carcinoma and adenoma)
Rule out pheochromocytoma before this procedure. |
| How to distinguish secreting vs. non-secreting adrenal masses? | Majority are non-secreting (90%), we distinguish by seeing Subclinical Cushing's, pheochromocytoma (increased catecholamines), and hyperaldosteronism (but not usually seen only with HTN or hypokalemia) |
| How is subclinical Cushing's seen? | 5-6% It is the most frequently seen condition of secretory mass, asymptomatic often, sometimes HTN, dyslipidemia, diabetes, weight gain...
Dx: minute brake test with dexamethasone 1mg, rule out pheochromo before it to not have catecholaminergic crisis.
Low DHEAs -->Chronic ACTH suppression |
| How is pheochromocytoma seen? | 3% spontaneous density >10UH, may be normal biology if <1.5 cm |
| What are aldosteronomas? | <1% of incidentalomas, look for arterial HTN, and spontaneous hypokalemia. |
| What is the treatment course of action in case of incidentalomas? | Surgery done for secreting ones (pheo, hyperaldo, auto cushings (if young pt or comorbidities), sus cirteria masses (>4cm size))
Myelolipomas (xray followup for pruning, if >6cm operate)
Bilateral masses (Macronodular hyperplasia, bilateral adrenalectomy if clinical, unilateral if subclinical guided by catheterization))
Surgery may be laparoscopic if mass <10cm, or open if >10cm |
| How is the follow up of incidentaloma tx? | benign (repeat imaging after 1 year - resect if size >4cm or size increased >1cm between two imagings)
For subclinical cushing's annual screening for 4 years |
