Incidentaloma screening
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammed Abdelwahed M.D[2]
Overview
According to the European Society of Endocrinology Clinical Practice Guideline, screening for adrenal incidentaloma includes: family screening for patients with bilateral macronodular hyperplasia, patients with asymptomatic vertebral fractures, patients with possible autonomous cortisol secretion, and patients with a hereditary syndrome leading to adrenal tumors. Screening test include 24-hour urine fractionated metanephrines for pheochromocytoma, 24-hour urinary free cortisol for patients with symptoms of Cushing's syndrome, and Plasma aldosterone concentration, plasma renin activity for patients with Primary aldosteronism.
Screening
According to the European Society of Endocrinology Clinical Practice Guideline, screening for adrenal incidentaloma includes:[1]
Indications for adrenal incidentaloma screening
- Patients with possible autonomous cortisol secretion for hypertension and type 2 diabetes mellitus.
- Patients with asymptomatic vertebral fractures.
- Screening imaging in patients with a hereditary syndrome leading to adrenal tumors.
- Family screening with 1 mg dexamethasone test can be considered in cases of bilateral macronodular hyperplasia, especially in younger patients.
Screening measures
| Disease | Laboratory tests |
|---|---|
| Pheochromocytoma[2] | 24-hour urine:
Blood: |
| Cushing's syndrome[3] | For patients with symptoms of Cushing's syndrome:
For patients lacking symptoms of Cushing's syndrome:
|
| Primary aldosteronism[4] | Plasma aldosterone concentration, plasma renin activity |
Biochemical Evaluation in Patients with Adrenal Incidentaloma
Mild Autonomous Cortisol Excess
- It refers to an abnormal increase in cortisol secretion that is independent of normal hypothalamic–pituitary control without the clinical picture of of Cushing’s syndrome, also known as subclinical Cushing’s syndrome.
- It is the most common functional disorder in patients with adrenal incidentaloma with a prevalence of 10%.[5][6]
- It is frequently associated with coexisting conditions such as obesity, insulin resistance or type 2 diabetes mellitus, dyslipidemia, hypertension, and osteoporosis than in nonfunctioning adrenal tumors.[7]
- Screening test: Overnight dexamethasone (1 mg) suppression test; an abnormal result is a serum cortisol level >1.8 μg per deciliter (50 nmol per liter) with confirmation of serum dexamethasone level (to ensure adherence); a higher serum cortisol cutoff level (e.g., 3–5 μg per deciliter) can be used to reduce the risk of a false positive.
- Confirmatory test: Measurement of levels of morning serum corticotropin and cortisol levels, 24-hr urinary cortisol, late-night salivary cortisol, midnight serum cortisol, and DHEAS.
- False positives may occur in patients receiving medications that accelerate hepatic metabolism of dexamethasone and with nonadherence to dexamethasone.
- Consider a pseudo-Cushing’s syndrome state due to diabetes, obesity, pregnancy, alcoholism, psychiatric disorders.
Pheochromocytoma
- Measurement of levels of plasma-free metanephrines or 24-hr urinary fractionated metanephrines.
- False positives may occur in patients with stress and illness warranting hospitalization; with medications that increase levels of endogenous catecholamines; with excessive caffeine; and with recreational drug use (e.g., amphetamines).
- Biochemical testing may not be necessary if the adrenal mass has CT attenuation of ≤10 Hounsfield units; genetic testing for inherited syndrome should be performed, regardless of family history, if screening test is positive.
Primary hyperaldosteronism
- Screening test: Measurement of mid-morning plasma aldosterone concentration and plasma renin activity; a ratio of plasma aldosterone concentration to plasma renin activity >20 confirms diagnosis.
- Confirmatory test: If the ratio of plasma aldosterone concentration to plasma renin activity <20, confirmatory testing includes 24-hr urinary aldosterone excretion test with patient receiving high-sodium diet, aldosterone suppression test, and testing with saline infusion while patient is sitting.
- False positives can be caused by beta-blockers, methyldopa, clonidine, nonsteroidal anti-inflammatory drugs, and oral contraceptives and estrogen; false negatives can be caused by angiotensin-converting–enzyme inhibitors, angiotensin II receptor blockers, and potassium-sparing diuretics (e.g., spironolactone, eplerenone, and amiloride).
- If patient is a candidate for adrenalectomy and >35 yr of age, adrenal venous sampling is recommended to confirm lateralization of aldosterone to the side of the adrenal mass (some patients have bilateral aldosterone hypersecretion, or the contralateral adrenal gland may be the source of excess aldosterone and the tumor detected is nonfunctioning)
References
- ↑ Fassnacht M, Arlt W, Bancos I, Dralle H, Newell-Price J, Sahdev A; et al. (2016). "Management of adrenal incidentalomas: European Society of Endocrinology Clinical Practice Guideline in collaboration with the European Network for the Study of Adrenal Tumors". Eur J Endocrinol. 175 (2): G1–G34. doi:10.1530/EJE-16-0467. PMID 27390021.
- ↑ Grumbach MM, Biller BM, Braunstein GD, Campbell KK, Carney JA, Godley PA; et al. (2003). "Management of the clinically inapparent adrenal mass ("incidentaloma")". Ann Intern Med. 138 (5): 424–9. PMID 12614096.
- ↑ Valli N, Catargi B, Ronci N, Vergnot V, Leccia F, Ferriere JM; et al. (2001). "Biochemical screening for subclinical cortisol-secreting adenomas amongst adrenal incidentalomas". Eur J Endocrinol. 144 (4): 401–8. PMID 11275951.
- ↑ Young WF (2007). "Clinical practice. The incidentally discovered adrenal mass". N Engl J Med. 356 (6): 601–10. doi:10.1056/NEJMcp065470. PMID 17287480.
- ↑ Barzon L, Sonino N, Fallo F, Palu G, Boscaro M (2003). "Prevalence and natural history of adrenal incidentalomas". Eur J Endocrinol. 149 (4): 273–85. doi:10.1530/eje.0.1490273. PMID 14514341.
- ↑ Mantero F, Terzolo M, Arnaldi G, Osella G, Masini AM, Alì A; et al. (2000). "A survey on adrenal incidentaloma in Italy. Study Group on Adrenal Tumors of the Italian Society of Endocrinology". J Clin Endocrinol Metab. 85 (2): 637–44. doi:10.1210/jcem.85.2.6372. PMID 10690869.
- ↑ Sbardella E, Minnetti M, D'Aluisio D, Rizza L, Di Giorgio MR, Vinci F; et al. (2018). "Cardiovascular features of possible autonomous cortisol secretion in patients with adrenal incidentalomas". Eur J Endocrinol. 178 (5): 501–511. doi:10.1530/EJE-17-0986. PMID 29510982.