肾上腺意外瘤指南课件.ppt

1、肾上腺意外瘤指南（优选）肾上腺意外瘤指南Management of the clinically inapparent adrenal mass(incidentaloma).NIH State-of-the-Science Conference Statement Feb 4-6,2002.024680910192029303940495059606970Age(y)Patient(%)Endocrine and Metabolism Clinics of North America.2000;29(1):159-185Primary AldosteronismCushings Syndro

2、meDHEA-sPheochromocytomaMantero et al.85(2):637.(2000)Pheochromocytoma 5%A summary of the literatureWhen the test is negative,no other tests are needed.Incidence Increases with AgeSex hormonesecreting adrenocortical tumorsIncidence Increases with AgeTypically occur in the presence of clinical manife

3、stations(hirsutism or virilization)Very rare:5 cases per 1 million populationAbdominal CT(61,054 CT scans reviewed):4%with adrenal adenomas1976%of pheo are undiagnosed until after deathSurgery 1991 Dec;110(6):101421Most common primaryEqually effective as CTImaging Phenotype(features)Plasma aldostero

4、ne concentration and plasma aldosterone concentration/plasma renin activity ratio(PAC/PRA).Image Phenotype CT ScanAllolio,B.,Adrenal Incidentalomas.Adrenal Disorders,ed.C.G.Margioris AN.2001,Totowa:Humana Press Inc.A summary of the literaturevNonfunctioning adenoma Approximately 80%vSubclinical Cush

5、ing syndrome(SCS),5%vPheochromocytoma 5%vAldosteronoma 1%vadrenocortical carcinoma(ACC)5%vMetastatic lesion 2.5%vGanglioneuromas,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 v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。v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

6、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。v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。v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*Reimage in 3 to 6 months and annually for 1 to 2 years;repeat

7、 functional studies annually for 5 years.If mass grows more than 1cm or becomes hormonally active,then adrenalectomy is recommended.Subclinical Cushings Syndrome2000;29(1):159-185monitoringPurple striaeProbability of malignancy increases with sizeWhat to do?Sex hormonesecreting adrenocortical tumors

8、Literature SupportsSubclinical Cushings syndrome:9%Adrenal Disorders,ed.Incidence Increases with AgeMayo Clinic StudyPheochromocytomaMass 4 cm can be monitoredPatient with Known MalignancyHyperfunctioning Hormonal Evaluation1040%of patients with known malignancy have adrenal metastases at autopsyMay

9、o Clinic StudyOsteoporosis?Tauchmanova L,et.al.Patients with subclinical Cushings syndrome due to adrenal adenoma have increase cardiovascular risk.JCEM 2000;85:1440.DyslipidemiaProminent vascularityNIH State-of-the-Science Conference Statement Feb 4-6,2002.2000;29(1):159-185Abdominal CT(61,054 CT s

10、cans reviewed):4%with adrenal adenomasAutopsies:87,065 cases:6%with adrenal adenomas“Plasma free metanephrines are recommended as the test of choice for excluding or confirming the diagnosis of pheochromocytoma.Cytology from FNA cannot distinguish benign adrenal mass vs.Sex hormonesecreting adrenoco

11、rtical tumorsUrinary fractionated metanephrines and catecholaminesPalpitationsIs it metastatic?Sex hormonesecreting Adrenocortical TumorsImage Phenotype CT ScanMass 30 and PAC 20 ng/dL“Fractionated plasma free metanephrines were the best test for excluding pheochromocytoma and should be the diagnost

12、ic test of first choice.Image Phenotype CT Scan3 hormonal tests necessary for workup of adrenal incidentaloma:Imaging metastasesRule of 10s:Hyperfunctioning Hormonal EvaluationNo prospective,randomized trials for Subclinical Cushings Syndrome but concensus is to proceed with surgery if the patient is youngNIH Stateofthe Science Conference StatementDexamethasone Suppression TestVery rare:5 cases per 1 million population