Adrenal accidental tumor

Introduction to adrenal accidental tumor Adrenal incidentaloma (adrenalincidentaloma) refers to those clinical manifestations of no obvious adrenal disease, adrenal space-occupying lesions accidentally found by abdominal imaging during physical examination or examination of non-adrenal diseases. Due to advances and widespread use of computed tomography (CT), magnetic resonance imaging (MRI) and ultrasound diagnostic techniques, the incidence of adrenal accidental tumors is high and is now the most common adrenal disease among clinicians. basic knowledge The proportion of illness: 0.06% Susceptible people: no special people Mode of infection: non-infectious Complications: Obesity Hypertension Osteoporosis

Adrenal accidental tumor cause

(1) Causes of the disease

The United States LMMoley statistics of nearly 20 related literature published from 1982 to 1997, the classification and frequency of occurrence of adrenal accidental tumors shown in Table 1.

As seen in Table 1, non-functional adrenal adenomas have the highest frequency, accounting for 36% to 94%. Adrenal adenomas that secrete hormones include cortisol secretory tumors, and aldosterone secreting tumors and pheochromocytoma account for a very low proportion. Primary adrenal cortical adenocarcinoma accounts for 0 to 25%, and the proportion of adrenal metastases is very high. Among them, the frequency of adrenal metastatic cancer in patients with known malignant tumors is 32% to 73%, and patients with malignant tumors are unknown. Adrenal metastatic cancer accounts for only 0-21%, and other adrenal accidental tumors are less.

(two) pathogenesis

At present, the pathogenesis of adrenal accidental tumors is not clear. It has been reported in the literature that it may be related to the long-term stimulation of adrenocorticotropic hormone (ACIH), or the secondary changes caused by long-term hypertension leading to adrenal arteriosclerosis. Many scholars have tried to Molecular genetics to explore the cause of accidental tumors, and some molecular studies on some genetic syndromes with adrenal accidental tumors have made some progress.

Adrenal accidental tumor prevention

Care should be taken to avoid the surgical treatment of an unexpected tumor once it is discovered. For a mass that has no clinically significant significance, in addition to causing physical trauma, it will undoubtedly increase the psychological and economic burden of the patient; Potentially dangerous masses, such as adrenal cancer, can cause death if not treated in time.

Adrenal accidental tumor complications Complications obesity hypertension osteoporosis

Most adrenal gland tumors are benign adenomas without high secretion function, and there is no increase in hormone secretion in clinical and laboratory tests. The disease is mainly caused by increased secretion of cortisol, androgen, estrogen, mineralocorticoid or catecholamine, which is mainly caused by the corresponding clinical manifestations of hormonal increase. For example, cortisol often has central obesity, hypertension, impaired glucose tolerance and bone. Loose and so on.

Adrenal Accidental Tumor Symptoms Common Symptoms Adrenal Metastasis Concentric Hypertension Osteoporosis

Most adrenal gland tumors are benign adenomas without high secretion function. There is no increase in hormone secretion in clinical and laboratory tests. High-functioning adrenal accidental tumors mainly secrete cortisol, androgen, estrogen, mineralocorticoid or catecholamine. The main clinical manifestations caused by the corresponding increase in hormones, such as increased cortisol often have centripetal obesity, hypertension, impaired glucose tolerance and osteoporosis, some high-secretory adrenal accidental tumors have no obvious clinical symptoms called Silent high-functioning adenomas, including cortisol secretory tumors, aldosterone secreting tumors and pheochromocytoma, are known as subclinical Cushing's syndrome for such cortisol secreting tumors.

1. Pay attention to the past history and the accompanying symptoms of the patient. Once the adrenal gland tumor is found clinically, the patient's medical records should be fully understood. If there are any suspicious clinical symptoms, the previous medical history, especially the tumor and essential hypertension.

2. It should be as clear as possible that the exact location of the tumor is important for the location of the accidentally discovered mass. It should be clear whether the tumor is located in the adrenal gland. In our hospital, a patient with a radiographic adrenal mass was examined and found to be a luteal hematoma.

3. For patients identified as adrenal accidental tumors should be further comprehensive evaluation of the hormone with or without hormone secretion, including adrenal cortex and medullary hormone, for patients suspected of pheochromocytoma, if necessary, pharmacological stimulation or inhibition test, in addition to application 131I-m-iodobenzidine imaging has certain value in the qualitative and local diagnosis of pheochromocytoma.

4. It is a complicated clinical problem for adrenal accidental tumors in cancer patients. The autopsy of these patients found that 36% had adrenal metastasis. In patients without malignant tumors, adrenal gland tumors were found by chance, which was rare and malignant.

5. Imaging examination has a certain guiding role in judging the nature of adrenal accidental tumors, especially CT including the location, size, CT value and enhanced examination of the tumor.

6. Note that some functional adrenal cortical tumors may not have caused changes in hormone levels at the time of detection. They should be observed dynamically or scanned for cholesterol iodide to determine if there is any function.

7. Note that it is not reliable to determine the benign and malignant nature of the tumor based on the size of the tumor. It should be determined based on clinical data.

Examination of adrenal accidents

Due to the uncertainty of the nature of the adrenal gland tumor, there is no absolute clinical, biochemical and pathological diagnostic criteria.

For patients identified as adrenal accidental tumors, the tumor should be further evaluated for hormone secretion, including adrenal cortex and medullary hormone. For patients with clinical pheochromocytoma, if necessary, pharmacological stimulation or inhibition test, in addition to 131I- The iodobenzyl bromide imaging has certain value in the qualitative and local diagnosis of pheochromocytoma.

Imaging examination has a certain guiding role in judging the nature of adrenal accidental tumors, especially CT including the location, size, CT value and enhanced examination of the tumor.

Diagnosis and diagnosis of adrenal accidental tumor

Most adrenal gland tumors are benign and have no hormone secretion function. For each adrenal accidental tumor patient, we must perform a series of hormone secretion tests and whether it is a malignant tumor (primary or metastatic), except There is the possibility of hormone secretion and malignant tumors. At this time, we can conclude that there is no functional benign tumor. This identification is important because its treatment and prognosis will be completely different.

1. Diagnosis of aldosterone secreting tumors Typical manifestations of primary aldosteronism are hypertension and hypokalemia. About 20% of patients with primary aldehydes may have normal potassium levels, but if given a high sodium diet (10-12 g NaCl/ d) 3 to 7 days, hypokalemia will be mostly provoked, if the adrenal accidental tumor patients have neither high blood pressure nor hypokalemia, then this accidental tumor is unlikely to secrete aldosterone, if the patient has high blood pressure and (or) hypokalemia, should further determine the plasma renin activity and aldosterone, if the plasma aldosterone (ng / ml) / renin activity [ng / (ml · h)] ratio > 20, it is highly suspected Aldehyde, 24h urine aldosterone level determination by sodium load test can determine the diagnosis of primary aldehyde. Patients should stop spironolactone for 6 weeks, diuretic for 4 weeks, sympathetic receptor blocker for 1 to 2 weeks, using calcium channel. The results of antagonistic drugs should also be noted, so the level of blood aldosterone can be artificially suppressed to the normal range, such as patients with primary aldehyde have bilateral nodules or nodules (diameter <1cm), it is best to do Renal venous cannulation was taken to measure aldosterone and cortisol to identify aldosterone Whether from the side.

2. Diagnosis of cortisol secreting tumors Adenomas secreting cortisol in adrenal non-functional tumors account for 2% to 15%. These patients do not have the typical clinical manifestations of Cushing's syndrome, but may have obesity, hypertension and diabetes. One and several manifestations, the 24-hour cortisol secretion rate and 24h urinary free cortisol (UFC) in these patients are generally in the normal range, but the blood cortisol circadian rhythm may be abnormal, overnight low-dose dexamethasone (1mg) The inhibition test may not be inhibited. After the removal of the adrenal adenoma, the clinical manifestations of adrenal insufficiency may occur. These indicate that the secretion of cortisol is autonomic. Therefore, a small dose (1 mg) of dexamethasone can be tested overnight. As a screening, if not inhibited, you can do a larger dose (2 ~ 3mg) overnight dexamethasone inhibition test, such as the next morning 8 o'clock blood F 83nmol / L (3g / dl) is not inhibited, and then do 24h UFC Determination, blood F circadian rhythm measurement and plasma ACTH measurement, such as ACTH lower than normal or in the normal range, is a cortisol autocrine tumor, such as blood ACTH higher than normal, should be considered ACTH dependent, ACTH stimulation test helps Whether the secretion of F from the adrenal gland is autonomic or secondary to ACTH, this adrenal secretory tumor that secretes cortisol can be called subclinical Cushing's syndrome or silent Cushing's syndrome. In the long-term follow-up, a few subclinical libraries Xin syndrome may develop into dominant Cushing's syndrome.

3. Diagnosis of adrenal cortical adenocarcinoma The frequency of adrenal adenocarcinoma in adrenal accidental tumors is 0 to 25%, with an average of about 4%. Of the 342 adrenal accidents reported by Mayo Clinic, only 4 (1.2%) have no Functional adrenocortical adenocarcinoma, in a group of 887 cases of adrenal gland tumors operated in Italy, adrenocortical adenocarcinoma is about 12%. In imaging examination, adrenal cortical adenocarcinoma is generally larger, more than 90% of the diameter> 6cm, uneven texture, irregular edges, often infiltrated into surrounding organs, can also be transferred to lymph nodes, lungs, bones, liver and kidneys, dehydroepiandrosterone sulfate (DHEA-S) determination for the identification of benign and malignant Some help, the majority of benign masses DHEA-S is lower than normal, malignant is higher than normal, but the two groups of patients overlap, elevated DHEA-S levels should consider the possibility of adrenal hormones secreting adrenal hormones.

4. Diagnosis of pheochromocytoma All patients with adrenal accidental tumors must be excluded from pheochromocytoma, because patients with asymptomatic pheochromocytoma may suddenly have a fatal hypertensive crisis, especially if they are not fully preoperatively prepared. Surgery, it has been reported that the operative mortality rate of patients who are not suspected before surgery but actually pheochromocytoma is 80%. As shown in Table 1, the frequency of pheochromocytoma in adrenal accidental tumors is 0-11. %, in another report (AB Porcaro et al), 28 cases of pheochromocytoma in 18 cases of surgically resected adrenal accidental tumors, 18h urinary catecholamine and metanephtines were helpful The diagnosis of chromia cell tumors, 131I-MI-BG imaging, imaging examinations such as CT and MRI will provide important information.

5. Diagnosis of non-functioning adrenal adenomas In patients with adrenal accidental tumors without a history of malignant tumors, non-functioning adrenal adenomas accounted for 36% to 94%, with the highest frequency of occurrence. These tumors appear homogeneous on radiographic images. The margins were neat but not enveloped, most of them were below 4 cm in diameter. 251 patients with non-functioning adrenal adenomas reported by Mayo Clinic were followed up for more than 1 year, and none of them were converted to functional adenomas.

Adrenal metastasis Adrenal gland is one of the most common sites for the metastasis of various malignant tumors. According to autopsy materials, primary malignant tumors other than the adrenal glands are found in the adrenal glands with metastasis accounting for 8% to 38%. Primary malignant tumors other than the adrenal gland. If a unilateral adrenal gland has a space-occupying lesion, the frequency of the lesion is 32% to 73%, and the adrenal gland diameter is >3 cm. The probability of malignancy is 43% to 100%, and the diameter is < 3cm are less likely to be malignant, and adrenal metastases are mostly bilateral. Primary malignant tumors include breast cancer, lung cancer, renal cell carcinoma, melanoma and lymphoma. Image examination is necessary to find the primary. Tumor and other metastatic tumors, CT or ultrasound-guided fine needle biopsy are useful for definitive diagnosis, but must be performed after pheochromocytoma is excluded.

7. Other adrenal diseases are more common adrenal cysts, medullary lymphoma, hematoma / hemorrhage, medullary fat containing fat and bone marrow components, in the CT and MRI examination, the performance of fat-like changes, the size varies, there are The diameter of the cyst can reach 10cm. The cyst has special performance in CT and MRI. Therefore, it is not difficult to diagnose by imaging examination. The ganglion neuroma is rare, the qualitative diagnosis is difficult, and other adrenal accidents appear in the literature. Lateral adrenal nodular hyperplasia, bilateral adrenal tuberculosis with early and adrenal insufficiency, and atypical congenital adrenal hyperplasia, which are bilateral adrenal hyperplasia or nodular hyperplasia.

As mentioned above, the diagnosis of adrenal accidental tumor mainly needs to distinguish whether the tumor has hormone secretion, whether it is benign or malignant. Whether hormone secretion mainly depends on hormone determination and functional examination, whether it is benign or malignant, mainly rely on imaging examination, and finally determine It should be based on pathology. Here, the adrenal radionuclide imaging reported by the University of Michigan in the United States is important for identifying the benign and malignant adrenal tumors. The nuclides they use are NP-59 (131I-6-iodomethyl-norcholes-terol). Benign tumors can absorb NP-59, while malignant tumors and other non-adenomatous lesions do not absorb NR-59, and the coincidence rate is 100%. In another group, 229 cases of adrenal accidental tumors have a sensitivity of 71. %, specificity is 100%, patients with Cushing's syndrome or subclinical Cushing's syndrome, only adrenal gland tumors secreting cortisol function absorb NP-59, contralateral adrenal gland is not visible, this method is still in promotion Difficulty, first, after injection of the radionuclide NP-59, it is necessary to wait 5-7 days for the adrenal gland to be imaged. Secondly, the patient must use potassium iodide to block the absorption of 131I by the thyroid gland 1 week before and after the use of the nuclides. In addition, the nuclide (NP-59) in 2001 in the United States is still in the trial, it has not yet been formally approved.

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