Adrenal malignancies

Published on 02/03/2015 by admin

Filed under Endocrinology, Diabetes and Metabolism

Last modified 02/03/2015

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Adrenal malignancies

1. What types of cancers occur in the adrenal glands?

2. Do adrenocortical carcinomas produce hormones?

3. What are the clinical features of functioning adrenocortical carcinomas?

4. What are the clinical features of nonfunctioning adrenocortical carcinomas?

5. What imaging procedure is best for evaluating an adrenal mass?

Computed tomography (CT) is the method of choice to determine the size and physical characteristics of the mass. Features that most strongly suggest ACC are size greater than 6 cm, heterogeneity, calcifications, irregular borders, local invasion, lymphadenopathy, and decreased lipid content. The last feature is assessed by signal attenuation, expressed in Hounsfield units (HU). An adrenal mass CT protocol is employed in many institutions; this consists of a non-contrast CT, a contrast-enhanced CT, a delayed contrast-enhanced CT, and calculation of the relative washout percentage (RWP) of enhancement. Table 29-1 shows the typical CT findings for some commonly seen adrenal masses. MRI can also be used to assess the size, features, and lipid content of adrenal masses but is more expensive. Fluorodeoxyglucose (18F) positron emission tomography (FDG-PET) or PET-CT fusion scanning may also be useful, especially for masses with high HU or low RWP on CT. High sensitivities and specificities have been reported with this technique using a standard uptake value (SUV) cutoff of 3.1. Other PET tracers, such as metomidate 11C, may offer even better sensitivity in the future.

6. What hormone tests should be used to evaluate an adrenal mass?

The goal is to determine whether the mass is producing hormones that may cause symptoms or that may be indicative of malignancy (androgens). Many experts recommend a focused evaluation consisting of an overnight 1-mg dexamethasone suppression test, measurement of plasma free metanephrines or fractionated urinary catecholamines and metanephrines, and, for hypertensive patients, measurement of plasma aldosterone and renin. Tests currently recommended by the European Network for the Study of Adrenal Tumors (ENSAT) are shown in Table 29-2.

TABLE 29-2.


Cortisol testing (3 of 4 tests) Dexamethasone suppression test (1-mg)
  Urine cortisol (24-hour)
  Serum cortisol, basal
  Plasma ACTH, basal
Sex steroid testing (all) Serum testosterone
  Serum dehydroepiandrosterone sulfate (DHEA-S)
  Serum androstenedione
  Serum 17-OH progesterone
  Serum estradiol (men, postmenopausal women)
Aldosterone testing (if hypertension present) Plasma aldosterone
  Plasma renin activity
  Serum potassium
Pheochromocytoma testing (1 or 2 tests) Plasma metanephrines
  Urine metanephrines (24-hour)

ENSAT (European Network for the Study of Adrenal Tumors).

Adapted from Lacroix A: Approach to the patient with adrenocortical carcinoma. J Clin Endocrinol Metab 95: 4812-4822, 2010

7. How should the incidentally discovered adrenal mass be managed?

8. Describe a useful staging system for adrenocortical carcinoma.

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