Overview of adrenal incidentaloma PPT- PPTX

Discussed regarding Classification, workup, diagnosis, management plan, follow up

1. Overview of adrenal incidentaloma By Irfat Mahjabeen

2. Introduction : Adrenal mass found on imaging, not performed for any adrenal disease.​ Prevalence increases with age ​ Usually rare in young individuals but can be found in up to 7% in patients 70 years of age and older. 6% based on autopsy studies, and  4% based on CT/ MRI​

3. Aetiology :

4. Approach Benign / Malignant ? F unctioning or non functioning ? Evaluation for clinical findings of hormonal excess? Treatment modalities ? Rate of progression ? to cancer or hyper function

5. Benign or Malignant ? Non contrast CT is the 1 st line investigation of choice Size : < 4 cm => usually benign 4 cm or more => malignancy / pheochromocytoma Imaging characteristics on CT Density on unenhanced CT : HU on a non contrast CT ≥ 10 : Malignancy/ pheochromocytoma contrast Washout On enhanced CT in 10 min : Adenomas takes out contrast easily , and washout quickly. < 50% : Malignancy/ pheochromocytoma Adenoma - smooth, lipid rich , homogenous Carcinoma : irregular, mostly unilateral , bilateral in metastasis Pheochromocytoma : Increased vascularity, heterogenous, necrosis

6. 2. A left adrenal mass measuring 3 cm, attenuation of 40 HU, indicating low fat content; therefore, contrast enhancement washout should be measured. 1.  A left adrenal mass , 2 cm with attenuation of – 10 Hounsfield units, consistent with a benign adenoma .

7. Adrenal gland and hormone

8. Clinical features of excess hormonal secretion :

9. Hormonal workup : In all patient :

10. Mild autonomous cortisol secretion (MACS) : Most common hormonal abnormality 30% - 50% Absence of overt disease A higher prevalence of HTN , obesity, dyslipidaemia, type 2 DM , and osteoporosis . Abnormalities of HPA axis Lack of cortisol suppression during a 1-mg DST subtle cortisol hypersecretion > 50 nmol MACS considered, < 50 MACS excluded. Low or suppressed ACTH level

11. Adrenal incidentaloma - Aim is to establish a definitive diagnosis and formulate a management plan Is appearance benign or malignant on initial imaging i.e non contrast CT?  Is it functionally active? Clinical assessment (History and exam) Hormonal workup MACS Indeterminate mass Non functioning, benign mass: No further investigations/ No follow up Clinically hormone excess or tumor with malignant features

12. Conclusion 70% nonfunctioning adrenal adenoma and benign Each cases needs a proper and individual assessment. Most patients can be discharged once malignancy and hormone hypersecretion have been excluded Adrenal FNAC and biopsy usually not suggested unless there is extra adrenal malignancy and pheochromocytoma must be ruled out prior to that.

13. Reference : European Society of Endocrinology clinical practice guidelines on the management of adrenal incidentalomas , in collaboration with the European Network for the Study of Adrenal Tumors | European Journal of Endocrinology | Oxford Academic (oup.com) Adrenal Incidentaloma : Practice Essentials, Anatomy, Pathophysiology (medscape.com) Assessment of incidental adrenal mass - Differential diagnosis of symptoms | BMJ Best Practice Recent Updates on the Management of Adrenal Incidentalomas - enm-2023-1779.pdf (e-enm.org) Suspected Adrenal ' Incidentaloma ' (nbt.nhs.uk)

14. Questions 1 A 73-year-old man was incidentally detected to have a 3 cm right adrenal mass on a non-contrast CT abdomen done to assess his dyspepsia related symptoms. Which of the following radiological features is in keeping with a diagnosis of a likely benign adrenal lesion? A. 10 HU density on non-contrast CT B. Contrast wash out < 50% C. Low lipid content D. Non-homogeneous borders E. Size 2–4 cm

15. Questions 2   A 50-year-old man was incidentally detected to have a 2.5-cm left adrenal homogeneous mass with well-defined borders on CT Abdomen, which was done to exclude renal stone as a part of treatment of UTI. On examination, he had a BMI of 32 kg/m2 and blood pressure of 134/70 mmHg. Rest of his general physical and systemic examination was unremarkable. Which one of the following is the most appropriate next step for his further management? A. Dexamethasone suppression test (overnight) and urinary metanephrines B. PET CT scan C. MRI adrenals D. Serum ARR E. Surgical referral

16. Questions 3 A 16-year-old student was incidentally detected to have a 2.8-cm left adrenal gland mass, while she underwent a CT abdomen to rule out acute appendicitis. She had no significant past history of any medical disease. Blood pressure was 110/70 mmHg, pulse rate of 90 beats/minute with no clinical stigmata of Cushing’s disease. Investigations: urinary metanephrine 1.5 µmol/24 h (< 4.00)  9 a.m. cortisol < 50 nmol/L (after 1 mg overnight dexamethasone) Which one of the following is the most appropriate next step in her further management? A. Discharge from the clinic B. MRI adrenals C. Repeat CT abdomen and biochemistry in 6–12 months D. Repeat only CT abdomen in 6–12 months E. Repeat only biochemistry in 6–12 months

17. Question 4 A 55-year-old man was incidentally detected to have a 5.5-cm adrenal lesion on CT abdomen done to evaluate symptoms of abdominal pain and weight loss. He had no past history of any significant medical disorder. Investigations: urinary  metanephrine 0.8 µmol/24 h (< 4.00) 9 a.m. cortisol < 50 nmol/L (after 1 mg overnight dexamethasone) Which one of the following is the most appropriate step in his further management? A. Biopsy B. Discharge from clinic C. Laparoscopic FNAC D. Surgical referral E. Whole body CT scan

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