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f390107d266322c58149d63d7d6ade23cc6d77414cf48332132863fad569e4c5
Evaluating adrenal nodules *See next page for hormonal workup reference Incidental adrenal nodule > 1 cm Found on non-contrast (non-con) CT? DO NOT BIOPSY adrenal mass without hormone workup and consulation Assess imaging characteristics Obtain adrenal protocol CT Suspicious appearance Hormonal workup* Abnormal DST or ...
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4419fbaa97a9f1c0b1b24bd865ba9cb6364e9bf24737b2c3d6f78a821897f791
>2x Upper Limit of Normal (ULN) • Adrenal hypercortisolism – 1mg Dexamethasone suppression test (DST) – Abnormal: >1.8 mcg/dl • Adrenal hyperaldosteronism – If patient has a history of HTN – Plasma aldosterone and renin – Abnormal:
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2c29833c1fe3d5ee1831adc19a73181caee26e67fbaf79c01621e8728e31db9a
aldosterone >10 and renin <1.0 • Size 1-4 cm in diameter • ≤10 Hounsfield units (HU) on non-con CT • CT contrast washout ≥40–60% • Signal loss on MRI chemical-shift analysis • On 18F-FDG PET-CT, SUVmax <5 or adrenal-to- spleen or adrenal-to liver signal-intensity ratio <1 • Adrenal hypercortisolism – 1mg Dexamethasone ...
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621d65ce68ae4ef079456dca5e7aec1d3b59280e9befd94526f134f7ffcce4a6
>1.8 mcg/dl • Adrenal hyperaldosteronism – If patient has a history of HTN – Plasma aldosterone and renin – Abnormal: aldosterone >10 and renin <1.0 Size > 4cm AND ≤10 HU on non-con CT • Repeat adrenal protocol CT in 1 year to confirm stability • Consider follow-up imaging at 6 months in patients younger than 40 years ...
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GS-2727550-26 Hormonal workup reference 1. Cortisol evaluation Dexamethasone Suppression Test (DST) • Prescribe 1 mg of oral dexamethasone to be taken at 11 pm • The next morning at 8 am, a cortisol and dexamethasone level are drawn • If the 8 am cortisol is < 1.8 mcg/dL, cortisol excess is ruled out • If the am cortis...
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– Morning serum corticotropin and cortisol levels – 24-hr urinary cortisol – 3 midnight/late-night salivary cortisol – Midnight serum cortisol – DHEAS (<40 mcg/dL) • Failure to suppress below 5.0 mcg/dL raises concern for cortisol excess 2.
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Screen for aldosteronoma Aldosterone level : Plasma Renin Activity (PRA) • Perform if patient has a history of hypertension or hypokalemia • Obtain mid-morning plasma aldosterone concentration and plasma renin activity – These must be drawn at the same time and should not be done with the DST • Divide the aldosterone l...
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2
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renin (ARR) • If the ARR is > 20, screen is POSITIVE or ABNORMAL for hyperaldosteronism • If aldosterone > 10 ng/dL AND renin < 1.0 ng/dL then screen is POSITIVE or ABNORMAL for hyperaldosteronism – Proceed to confirmatory testing with oral sodium load test, aldosterone suppression test or seated saline infusion test •...
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a3a7a89a79b6c4214c9e6bdf8f3f3c5e142a8334c96d3caadae12833e3eb2b0a
Screen for pheochromocytoma Plasma-free metanephrines • POSITIVE or ABNORMAL if elevated > 2x ULN • Elevations < 2x ULN may be false positives and should be considered equivocal • Elevations < 2x ULN and no classic signs of pheochromocytoma – Confirm with 24-hour urine metanephrines = less likely to be falsely positive...
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– Tricyclic antidepressants – Phenoxybenzamine – Levodopa – Beta blockers – Labetalol – Amphetamines – Buspirone – Methyldopa – Chlorpromazine • Confirmatory testing = 24-hour urine metanephrines • Consider genetic testing in confirmed pheochromocytoma
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2
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3% in patients without a history of malignancy and up to 8% in patients with a history of extra-adrenal malignancy. 8 Other features in addition to size should be considered when assess- ing risk of either a primary or secondary malignancy in an ad- renal incidentaloma (eTable 2 in the Supplement ).
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Recommendation 1.2. We recommend that all patients with an adrenal incidentaloma 1 cm or larger undergo biochemical testing for autonomous cortisol secretion. Patients with hy- pertension or hypokalemia also require biochemical evalua- tion for primary aldosteronism.
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Patients with adrenal imaging findings that have noncontrast CT with HU greater than 10 should undergo evaluation for pheochromocytoma. (Strong recommendation, low-quality evidence.) Recommendation 1.3.
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fff848405c1f3428f584ca1f5b68d5f8554aa6ef346a2d6ef79d40d1b0cbb040
We recommend that a primary ad- renal malignancy be considered in patients with an adrenal in- cidentaloma larger 4 cm and/or HU greater than 20 on non- contrast CT and in any patient younger than 18 years.
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We recommend that patients with a history of extra-adrenal ma- lignancy be recognized to be at increased risk for adrenal me- tastases. (Strong recommendation, low-quality evidence.) Most nonfunctional adrenal nodules with benign imaging characteristics remain stable in size 5,7,12 while up to 10% of ad- renal incident...
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13-15 Surgical resection may be considered for nodules that are larger than 2 cm at initial presentation and grow more than 1 cm by 12 months, while smaller nodules or those with less growth may undergo repeated short-interval imaging at 6 to 12 months.
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However, there are insufficient data to recommend specific criteria for nodule growth during sur- veillance that should prompt adrenalectomy. Topics and Questions in the Population, Intervention/Exposure, Comparison, and Outcome (PICO) Framework 1.
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38b03945d065e8cebc1cd8c38cfd81a6c457ecff868cde5800457fc6f6646e96
Incidentalomas, myelolipomas, and cysts 1. In patients with an adrenal incidentaloma, does adrenal protocol computed tomography improve diagnostic accuracy for malignancy or pheochromocytoma compared with other imaging modalities?
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1911d8373369e835215bab63b4e602335b71f60b3d5ef9ac8cd1d8e4e51775e9
In patients with an adrenal incidentaloma, should clinical and imaging characteristics influence the hormonal workup? In patients with an adrenal incidentaloma, what clinical and imaging characteristics increase the risk that malignancy is present? In patients with a nonfunctional adrenal incidentaloma, what are the ou...
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3
b7c719ec4d2089357e661bdd4498e26135df0691ef979f2e978ec3829da3551d
Does resection of a myelolipoma or an adrenal cyst improve quality of life compared with observation alone? Primary aldosteronism 1. In patients with primary aldosteronism (PA), does adrenalec- tomy compared with mineralocorticoid antagonist therapy alone improve related comorbidities and mortality?
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In patients with PA and cross-sectional imaging consistent with a unilateral adenoma, does preoperative adrenal venous sampling increase the likelihood of a clinical or biochemical cure? In patients with PA due to unilateral disease, does laparo- scopic adrenalectomy improve health-related quality of life and/or reduce...
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Hypercortisolism 1. Do patients with mild autonomous cortisol secretion (MACS) who undergo laparoscopic adrenalectomy compared with conservative medical management have improvement in cardiometabolic comorbidities without major surgical (30-day) adverse events?
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Do patients with Cushing syndrome and bilateral macronodu- lar hyperplasia who undergo unilateral laparoscopic adrenal- ectomy achieve biochemical remission of hypercortisolism when compared with patients treated with bilateral adrenalectomy? In patients with adrenocorticotropic hormone–dependent hypercortisolism, does...
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3
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Is the incidence of postoperative adrenal insufficiency after unilateral adrenalectomy different between patients with overt Cushing syndrome vs those with MACS? Adrenocortical carcinoma 1. In patients with adrenocortical carcinoma (ACC), does treat- ment at a high-volume multidisciplinary center improve survival outco...
67
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3
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In patients with ACC without evidence of distant metastatic disease at diagnosis, does operative technique affect survival? In patients with ACC and systemic disease at diagnosis, does resection of the primary tumor improve survival?
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In patients with advanced ACC, what is the role of neoadju- vant therapy followed by resection vs surgery with or without adjuvant therapy? Metastasis to the adrenal gland 1.
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a03a845c858b408f7c7ef3ed5ad8a11197a18bf29882465514048404b7292e94
In patients with an adrenal mass, does history of an extra- adrenal malignancy influence the hormonal evaluation? In a patient with a history of an extra-adrenal malignancy and an adrenal mass, when is image-guided needle biopsy recommended?
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ded2487af766d1274a0925439f83f9e14fe19545eb7c0193be9ae0863aa916b4
In patients with an adrenal metastasis, does resection improve survival compared with systemic therapy alone? Pheochromocytoma and paraganglioma 1. In patients with pheochromocytoma and paraganglioma, how does selective α blockade affect perioperative hemodynamic stability when compared with nonselective blockade with ...
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6d9d21375d7f5a1a7ee4c61fb123709e63bc3070929b9e7df793267d3df68a89
In patients with genetic mutations driving long-term develop- ment of bilateral pheochromocytomas, what is the impact of cortical-sparing adrenalectomy compared with bilateral total adrenalectomy on steroid dependence and disease recurrence?
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ac90ad95a96e7eeef47952c6f64d2aba85a9d3a0ba9264bee41adceb04b6e2ec
In patients with metastatic pheochromocytoma and paragan- glioma, does surgical resection of primary disease improve survival compared with nonsurgical treatment? Technical aspects 1. In patients undergoing adrenalectomy, what is the benefit of minimally invasive surgery compared with open surgery on perioperative outc...
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In patients who are appropriate candidates for minimally invasive adrenalectomy, does a retroperitoneal compared with a transperitoneal approach change perioperative outcomes? For surgeons performing adrenal surgery, does surgeon volume influence morbidity and mortality?
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