Evaluating and managing adrenal incidentalomas

Adrenal masses that are found incidentally should be evaluated with both imaging and hormonal studies. The attenuation coefficient on noncontrast computed tomography (CT), expressed in Hounsfield units (HU), is better than tumor size in differentiating adrenal adenomas and hyperplastic lesions from nonadenomas. All patients should undergo hormonal evaluation for Cushing syndrome and pheochromocytoma. Those with hypertension should also be evaluated for hyperaldosteronism.     

Management of pituitary incidentalomas: according to a survey of pituitary incidentalomas in Japan.

The development of computed tomography (CT) and magnetic resonance imaging (MRI) has resulted in the discovery of unsuspected endocrinologically silent pituitary masses (pituitary incidentalomas). The aim of this study was to clarify the natural history of pituitary incidentalomas in order to establish an appropriate approach to them. Five hundred fifty patients with pituitary incidentalomas were analyzed in this study; 261 patients (47.4%) underwent surgery (surgical group; SG), whereas 289 patients (52.6%) were followed up conservatively (nonsurgical group; NSG) for a mean period of 27.3 months (range, 6-173 months). Clinical and biochemical assessment, CT or MRI of the pituitary, and visual field testing were assessed at baseline and at 6 months and yearly thereafter. A total of 261 tumors in the SG group consisted of 211 (80.8%) nonfunctioning pituitary adenomas and 42 (16.1%) Rathke's cysts. During a follow-up period, of 289 tumors in the NSG group, 209 (72.3%) tumors stayed the same size as before, 35 tumors (12.1 %) increased in size, and 41 tumors (14.2%) decreased in size. The estimated diagnoses of the tumors that increased consist of 28 nonfunctioning pituitary adenomas, 5 Rathke's cyst, and 2 others. The decreased tumors consist of 11 nonfunctioning adenomas, 21 Rathke's cysts, and 3 others. Pituitary incidentalomas usually follow a benign course. We recommend transsphenoidal adenomectomy for a solid mass attached to the optic chiasma estimated to be a pituitary adenoma by MRI. Other patients should be followed up by MRI and biochemical assessment. Especially asymptomatic cystic masses (including Rathke's cleft cysts) could be followed up without surgical intervention because they tend to stay the same size or sometimes be cured spontaneously.     

Clinical aspects of pituitary incidentalomas

The development of computed tomography(CT) and magnetic resonance imaging (MRI) has resulted in the discovery of unsuspected endocrinologically silent pituitary masses(pituitary incidentalomas). The management of these pituitary incidentalomas is controversial. Some lesions may increase in size, compress optic chiasm while others will remain unchanged in size. Five hundred and six patients with pituitary incidentalomas were obtained by questionnaire from March 1999 to May 2000 under the auspices of the Ministry of Health, Labor and Welfare in Japan. In thirty-three patients with pituitary incidentalomas (13.3%) developed tumor enlargement during the mean follow-up period of 45.5 months. Of 115 estimated non-functioning adenomas, 23(20.0%) tumor increased during mean follow up period of 50.7 months (range 10 to 173 months), while 5(5.4%) of 94 estimated Rathke's cysts increased in size during follow up. Pituitary apoplexy was occurred in one patient of 248 patients (0.4%). Pituitary incidentalomas usually follow a benign course. Transsphenoidal adenectomy is indicated for a solid mass attached to optic chiasma. For other patients, MRI every 6 months for the first 2 years, and then yearly may be recommended.     

Pituitary incidentalomas: a single-centre experience

Aim: Pituitary incidentalomas (PIs) are diagnosed in about 10% of the patients undergoing radiological investigation for non‐pituitary disorders. The aim of this study was to describe the morphological and hormonal characteristics of PIs in a cohort of patients, followed up in a single centre from 1982–2009. Methods: Retrospective analysis of electronic medical records of patients with PIs was carried out. All patients underwent basal and dynamic evaluation of the hypothalamus‐pituitary axis. Mass size was assessed at yearly intervals. Results: Sixty‐one patients (38 men/23 women, aged 53 ± 2 years) were studied. The mean follow‐up time was 48 ± 8 months, and mean size of PIs was 20 ± 2 mm. Twelve PIs (20%) were microadenomas, 48 (78%) were macroadenomas and one (2%) was a Rathke’s cyst. The most common reasons that led to their discovery were headaches, dizziness, syncope, stroke and head injury. Forty‐seven of the 61 PIs (77%) were non‐functioning, 11 (18%) prolactinomas, and two (3%) GH‐secreting adenomas. Hypopituitarism was present in 12% at diagnosis. Forty‐eight per cent of the patients were submitted to surgery with conventional radiotherapy in 8%. Relapse in size was observed in 48% of the surgically treated patients. Of the PIs followed conservatively, 78% remained stable, 11% showed decrease and 11% increase in size during follow up. Hypopituitarism rose to 57% postoperatively. Conclusions: Majority of PIs are non‐functioning adenomas that remain stable in size. Relapse in size and hypopituitarism postoperatively are common. PIs, for which conservative management was initially considered appropriate, did not progress in size.     

肾上腺偶发瘤的诊治(附30例报告)

目的 提高肾上腺偶发瘤的诊治水平.方法 结合文献讨论30例肾上腺偶发瘤未被早期发现的原因,潜在的手术危险性,及需警惕恶性病变等临床特点.结果 30例患者均经内分泌功能测定、B超、CT等检查,23例手术中15例(65%)患者行后腹腔镜肾上腺肿瘤摘除术,8例(35%)行经腹或经腰肾上腺肿瘤摘除术.结论 对于肾上腺偶发瘤必须结合内分泌检查,影像学检查,以排除有无内分泌功能及是否为恶性,后腹腔镜手术为肾上腺良性疾病的首选.     

Frequency and clinical relevance of PET/CT incidentalomas

Rationale and objectives

To assess the frequency of clinically significant incidental CT findings on PET/CT.

Materials and methods

Reports of 345 cases of baseline standard skull base to thighs PET/CT exams done over the course of a 6 month period at an outpatient facility affiliated with a large tertiary care level 1 trauma medical center were retrospectively reviewed. Incidental CT findings were assigned a level of clinical significance on a scale of 1–5, from doubtful significance to very significant. CT findings already known from prior CT reports were not included. CT findings corresponding to PET findings were also excluded. A score of 3 or greater was considered significant and reportable.

Results

Out of 345 cases, 171 (50%) had a least one CT finding rated at or above a score of 3 on our scale of significance, while 96 (28%) were found to have at least one CT finding with score at or above 4, and 25 cases (7%) showed at least one CT finding rated 5.

Conclusion

A substantial percentage of baseline PET/CT studies contain previously undiagnosed, significant incidental findings on the CT images.     

Endocrine autoantibodies

The autoantibody assays that exist and that are being refined are of increasing importance to a broad spectrum of endocrine disorders. This is particularly true for type IA diabetes, which is one of the best-studied organ-specific autoimmune diseases. Autoantibodies are used as valuable markers in prediction and prevention studies of type IA diabetes.Autoantibodies related to other endocrine organs are also important because multiple related autoimmune endocrine and non-endocrine disorders are increased in frequency in patients and their families with autoimmunity. The availability of highly sensitive and specific autoantibody assays for the various endocrine disorders can allow physicians to better diagnose and promptly treat these conditions.     

Detection and diagnosis of parathyroid incidentalomas during thyroid sonography.

PURPOSE: The aim of our study was to evaluate the incidence of incidentally found parathyroid adenomas (incidentalomas) in patients undergoing sonography of the neck for thyroid disease. METHODS: A total of 1,686 patients (305 men and 1,381 women) underwent sonography of the neck; the mean age was 49.6 +/- 21.7 years. In 38 patients (2.3%; 7 men and 31 women) with a mean age of 48.7 +/- 14.7 years, hypoechoic, homogeneous, oval nodules (mean volume, 1.0 +/- 0. 9 cm(3)) adjacent to the thyroid parenchyma were observed. All these lesions, compatible with the shape of an enlarged parathyroid gland, underwent ultrasound-guided fine-needle aspiration biopsy (FNAB), with measurement of parathyroid hormone (PTH) and thyroglobulin (Tg) levels in the needle washings (FNAB-PTH and FNAB-Tg). Biochemical screening for hyperparathyroidism was also performed. RESULTS: Cytologic examination plus FNAB-PTH/FNAB-Tg measurements revealed the presence of cellular material consistent with parathyroid tissue in 9 patients (24%), thyroid tissue in 22 patients (58%), and lymphoid tissue in 4 patients (11%). A tissue diagnosis was not established in 3 patients (8%). Five of 9 patients with parathyroid enlargement had high serum PTH and calcium levels. CONCLUSIONS: Enlarged parathyroid glands may be incidentally discovered during sonography of the thyroid. In patients with thyroid disease, the positive-predictive value of sonography in the identification of parathyroid tissue was low. Ultrasound-guided FNAB-PTH determination should be carried out when parathyroid adenoma is suspected. The incidental finding of an enlarged parathyroid may or may not be associated with yet undiagnosed hyperparathyroidism.     

Endocrine emergencies

Endocrine emergencies are relatively infrequent events in clinical practice. Correct management requires prompt recognition and treatment, frequent without supporting laboratory studies. An understanding of the pathophysiology of these acute states of hormone excess or deficiency assists in establishing the correct diagnosis and initiating the proper therapy.     

Endocrine hypertension

Many endocrine abnormalities may lead to hypertension. An awareness of these disorders is important for clinicians caring for hypertensive patients, as direct therapy of the endocrine abnormality is frequently successful in reversing the hypertension. All patients with hypertension should be screened for hypokalemia and hypercalcemia, but other screening tests should be performed only under specific circumstances. Biochemical diagnosis of the endocrine abnormality must be established before localization or visualization procedures are undertaken. Therapy of endocrine hypertension is disorder specific, and frequently rests upon surgical correction of the underlying disorder. Despite this, antihypertensive medications are effective in controlling hypertension in many instances.     

Endocrine crises

Pituitary apoplexy, diabetes insipidus, thyroid storm, myxedema coma, parathyrotoxic crisis, hypocalcemia tetany, pheochromocytoma and Addison crisis, diabetic ketoacidosis, diabetic hyperosmolar nonketotic coma, hypoglycemia and carcinoid crisis are the most important endocrine crises. Some of them are common, others very rare. All physicians nevertheless need to have at least a basic knowledge of all of them, since symptoms and signs of endocrine crises overlap with those of other severe disease states, and the failure to recognise endocrine crises as such and to begin rapidly the specific therapy can have fatal consequences.