S8 - Doenças da Suprarrenal (Hiperaldosteronismo, Feocromocitoma) Flashcards
Adrenal Incidentalomas?
Adrenal mass (>1 cm), which is discovered incidentally on an imaging examination performed for unrelated reasons
Assessment of the risk of malignancy?
Establish if an adrenal mass is benign or malignant at the time of initial detection.
Adrenal incidentalomas undergo an imaging procedure to determine if the mass is homogeneous and lipid-rich and therefore benign (noncontrast CT)
What non-contrast CT characteristics are consistent with a benign adrenal mass?
Homogeneous and smaller than 4 cm
Size and relation with risk?
Size remains an important predictor of the risk of adrenal cortical cancer and needs to be taken into account during evaluation.
If the adrenal mass is indeterminate on non-contrast CT and the results of the hormonal work-up do not indicate significant hormone excess?
Immediate additional imaging with another modality
Interval imaging in 6– 12 months (non-contrast CT or MRI)
Surgery without further delay
Biopsy?
Recommend against the use of an adrenal biopsy in the diagnostic work-up of patients with adrenal masses unless there is a history of extra-adrenal malignancy and additional criteria are fulfilled
Assessment for hormone excess?
All patients with adrenal incidentalomas undergo a 1 mg overnight DST to exclude cortisol excess
Serum cortisol levels post dexamethasone (≤1.8 μg/dL) as a diagnostic criterion for the exclusion of autonomous cortisol secretion
1 mg overnight DST results?
Serum cortisol levels post dexamethasone (≤1.8 μg/dL) as a diagnostic criterion for the exclusion of autonomous cortisol secretion.
Cortisol levels of 1.9–5.0 μg/dL should be considered as evidence of ‘possible autonomous cortisol secretion’
Cortisol levels post dexamethasone >5.0 μg/dL) should be taken as evidence of ‘autonomous cortisol secretion’.
Screening de comorbilidades?
Screening patients with ‘possible autonomous cortisol secretion’ or ‘autonomous cortisol secretion’ for hypertension and type 2 Diabetes Mellitus, and asymptomatic vertebral fractures
What should be considered in all patients considered for surgery?
ACTH-independency of cortisol excess should be confirmed
The recommended way to exclude pheochromocytoma?
Measurement of plasma-free metanephrines or
urinary fractionated metanephrines
Patients with concomitant hypertension or
unexplained hypokalemia?
Use of the aldosterone/renin ratio to exclude primary
aldosteronism
Patients with clinical or imaging features suggestive of adrenocortical carcinoma?
Measurement of sex hormones and steroid precursors
Metastases to the adrenal glands?
Primary tumors of the lung, breast, kidney, and gastrointestinal tract and melanoma or lymphoma
Typically bilateral and large (>3 cm)
History of malignant disease
Risk of pheochromocytoma in the autopsy?
Hypertensive crisis
Diagnosis of Glucocorticoids Hypersecretion?
1mg overnight dexamethasone test
Urine 24h cortisol
Salivary cortisol
Cushing Syndrome ACTH dependency?
Plasma ACTH
Efeitos estrogénios em niveis homronais?
Aumentam proteínas de transporte o que aumenta frações hormonais na corrente sanguínea
Prova de frenação com dose baixa? Dose alta?
Síndrome de Cushing. Hipofisária ou Primária
Case detection of Hyperaldosteronism?
Sustained BP above 150/100 mm Hg
BP 140/90 resistant to 3 conventional antihypertensive drugs
Controlled BP (140/90 mm Hg) on four or more antihypertensive drugs
Hypertension (HT) and spontaneous or diuretic-induced hypokalemia
HT and adrenal incidentaloma
HT and sleep apnea
HT and a family history of early-onset HT
HT 1st degree relatives of patients with PA
Detect possible cases of PA?
Plasma aldosterone/renin ratio (ARR)
Algorithm for the detection, confirmation, subtype testing, and treatment of PA?
ARR, ARR (confirmativo), CT adrenal, MR Antagonist or Laparocsopic Adrenalectomy
Spontaneous hypokalemia?
concentration (PAC)> 20 ng/dL, we suggest that there may is no need for further confirmatory testing.
PA Confirmatory Tests?
Oral sodium loading test
Sodium Infusion Test
Fludrocortisone Suppression Test
Captopril Challenge Test
Problemas com TAC/RM?
Falsos positivos (1/3 são incidentalomas) Falsos negativos (1/3 dos adenomas não são visualisáveis devido às pequenas dimensões)
Cateterismo dos seios petrosos inferiores?
Diagnóstico entre ectópicos e hipofisários
Ratio entre central e perfiférico
Cateterismo das veias suprarrenais?
Blood from both adrenal veins and a peripheral vein (labeled peripheral) is taken and assayed for aldosterone and cortisol concentrations
Avaliação bioquímica para diagnóstico de Feocromocitomas e Paragangliomas?
Teste inicial para FeoPGL seja a determinação das metanefrinas plasmáticas e as metanefrinas fraccionadas urinárias (colheita do doente na posição supina)
Estudos de Imagem de Feocromocitomas e Paragangliomas?
Iniciados logo que haja evidência bioquímica clara de um FeoPGL. TC em vez da RM como modalidade de imagem de escolha.
Uso de cintigrafia MIBG como modalidade functional em doentes FeoPGL metastáticos.
18F-FDGPET/CT é a modalidade preferencial sobre a cintigrafia com MIBG.
Testes Genéticos de Feocromocitomas e Paragangliomas?
Paraganglioma sejam testados para mutações da succinato desidrogenase (SDH) e que doentes com doença metastática a sejam testados para mutações SDHB.
Tratamento Médico Perioperatório de Feocromocitomas e Paragangliomas?
Doentes com FeoPGL funcionantes devem ser submetidos a bloqueio pré-operatório.
Tratamento médico durante 7 a 14 dias para permitir adequada normalização da PA e frequência cardíaca.
Doseamento de metanefrinas plasmáticas e urinárias no seguimento para diagnóstico persistência da doença.
Cirurgia de Feocromocitomas e Paragangliomas??
Suprarrenalectomia minimamente invasiva
Prognóstico de uma lesão suprarrenal?
Variável com o diagnóstico.
O prognóstico é bastante favorável caso a cirurgia seja bem sucedida.
Mau no carcinoma suprarrenal.
