Incidentaloma laboratory findings: Difference between revisions
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{{Incidentaloma}} | {{Incidentaloma}} | ||
{{CMG}}; {{AE}} {{MAD}} | |||
{{CMG}}; {{AE}} | |||
==Overview== | ==Overview== | ||
Laboratory findings consistent with the diagnosis of incidentaloma include an abnormal 1 mg overnight dexamethasone for subclinical Cushing's syndrome that should be confirmed with 24-hour urinary free cortisol, serum ACTH concentration, and dehydroepiandrosterone sulfate (DHEAS). In patients with adrenal masses that have a probability for pheochromocytoma, routine measurement of 24-hour urinary fractionated metanephrines and catecholamines should be done. All patients with hypertension and an adrenal incidentaloma should be evaluated by measurements of plasma aldosterone concentration and plasma renin activity. | Laboratory findings consistent with the diagnosis of incidentaloma include an abnormal 1 mg overnight [[dexamethasone]] for subclinical [[Cushing's syndrome]] that should be confirmed with 24-hour urinary free [[cortisol]], serum [[Adrenocorticotropic hormone|ACTH]] concentration, and [[dehydroepiandrosterone sulfate]] ([[DHEAS]]). In patients with [[Adrenal gland|adrenal]] masses that have a probability for [[pheochromocytoma]], routine measurement of 24-hour urinary fractionated [[Metanephrine|metanephrines]] and [[catecholamines]] should be done. All patients with [[hypertension]] and an [[Adrenal gland|adrenal]] incidentaloma should be evaluated by measurements of plasma [[aldosterone]] concentration and plasma [[renin]] activity. | ||
==Laboratory Findings== | ==Laboratory Findings== | ||
=== Subclinical Cushing's syndrome === | === Subclinical Cushing's syndrome === | ||
*Subclinical Cushing's syndrome should be ruled out by performing the 1 mg | *[[Subclinical]] [[Cushing's syndrome]] should be ruled out by performing the 1 mg overnight [[dexamethasone suppression test]] (DST).<ref name="pmid18334580">{{cite journal| author=Nieman LK, Biller BM, Findling JW, Newell-Price J, Savage MO, Stewart PM et al.| title=The diagnosis of Cushing's syndrome: an Endocrine Society Clinical Practice Guideline. | journal=J Clin Endocrinol Metab | year= 2008 | volume= 93 | issue= 5 | pages= 1526-40 | pmid=18334580 | doi=10.1210/jc.2008-0125 | pmc=2386281 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18334580 }}</ref><ref name="pmid19797503">{{cite journal| author=Eller-Vainicher C, Morelli V, Salcuni AS, Torlontano M, Coletti F, Iorio L et al.| title=Post-surgical hypocortisolism after removal of an adrenal incidentaloma: is it predictable by an accurate endocrinological work-up before surgery? | journal=Eur J Endocrinol | year= 2010 | volume= 162 | issue= 1 | pages= 91-9 | pmid=19797503 | doi=10.1530/EJE-09-0775 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19797503 }}</ref><ref name="pmid16127216">{{cite journal| author=Katabami T, Obi R, Shirai N, Naito S, Saito N| title=Discrepancies in results of low-and high-dose dexamethasone suppression tests for diagnosing preclinical Cushing's syndrome. | journal=Endocr J | year= 2005 | volume= 52 | issue= 4 | pages= 463-9 | pmid=16127216 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16127216 }}</ref> | ||
*An abnormal 1 mg overnight dexamethasone should be confirmed with 24-hour urinary free cortisol, serum ACTH concentration, and dehydroepiandrosterone sulfate (DHEAS). | *An abnormal 1 mg overnight [[dexamethasone]] should be confirmed with 24-hour urinary free [[cortisol]], [[Adrenocorticotropic hormone|serum ACTH]] concentration, and [[dehydroepiandrosterone sulfate]] ([[DHEAS]]). | ||
* An undetectable level of serum [[Adrenocorticotropic hormone|ACTH]] is also supportive of the diagnosis of subclinical [[Cushing's syndrome|Cushing’s syndrome]]. | |||
* An undetectable level of serum ACTH is also supportive of the diagnosis of subclinical Cushing’s syndrome. | * Hormonal evaluation in the patients with subclinical [[Cushing's syndrome]] showed the following: | ||
**Low baseline secretion of [[Adrenocorticotropic hormone|ACTH]] | |||
* Hormonal evaluation in the patients with subclinical Cushing's syndrome showed the following | **Lack of suppressibility of [[cortisol]] secretion after 1 mg [[dexamethasone]] | ||
**Supranormal 24-hour urinary [[cortisol]] excretion | |||
* Low baseline secretion of ACTH | **Disturbed [[cortisol]] [[circadian rhythm]] | ||
* Lack of suppressibility of cortisol secretion after 1 | **Blunted plasma [[Adrenocorticotropic hormone|ACTH]] responses to [[corticotropin-releasing hormone]] [[Corticotropin-releasing hormone|(CRH]]) | ||
* Supranormal 24-hour urinary cortisol excretion | |||
* Disturbed cortisol circadian rhythm | |||
* Blunted plasma ACTH responses to corticotropin-releasing hormone (CRH) | |||
=== Pheochromocytoma === | === Pheochromocytoma === | ||
In patients with adrenal masses that have a probability for pheochromocytoma, routine measurement of 24-hour urinary fractionated metanephrines and catecholamines should be done. | * In patients with [[Adrenal gland|adrenal]] [[Mass|masses]] that have a probability for [[pheochromocytoma]], routine measurement of 24-hour urinary fractionated [[Metanephrine|metanephrines]] and [[catecholamines]] should be done.<ref name="pmid17287480">{{cite journal| author=Young WF| title=Clinical practice. The incidentally discovered adrenal mass. | journal=N Engl J Med | year= 2007 | volume= 356 | issue= 6 | pages= 601-10 | pmid=17287480 | doi=10.1056/NEJMcp065470 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17287480 }}</ref> | ||
=== '''Aldosteronomas''' === | === '''Hyperaldosteronism|Aldosteronomas''' === | ||
All patients with hypertension and an adrenal incidentaloma should be evaluated by measurements of plasma aldosterone concentration and plasma renin activity. | * All patients with [[hypertension]] and an [[Adrenal gland|adrenal]] incidentaloma should be evaluated by measurements of plasma [[aldosterone]] concentration and plasma [[renin]] activity.<ref name="pmid12796282">{{cite journal| author=Mosso L, Carvajal C, González A, Barraza A, Avila F, Montero J et al.| title=Primary aldosteronism and hypertensive disease. | journal=Hypertension | year= 2003 | volume= 42 | issue= 2 | pages= 161-5 | pmid=12796282 | doi=10.1161/01.HYP.0000079505.25750.11 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12796282 }}</ref><ref name="pmid185522882" /><ref name="pmid18063074">{{cite journal| author=Mitchell IC, Auchus RJ, Juneja K, Chang AY, Holt SA, Snyder WH et al.| title="Subclinical Cushing's syndrome" is not subclinical: improvement after adrenalectomy in 9 patients. | journal=Surgery | year= 2007 | volume= 142 | issue= 6 | pages= 900-5; discussion 905.e1 | pmid=18063074 | doi=10.1016/j.surg.2007.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18063074 }}</ref><ref name="pmid185522882">{{cite journal| author=Funder JW, Carey RM, Fardella C, Gomez-Sanchez CE, Mantero F, Stowasser M et al.| title=Case detection, diagnosis, and treatment of patients with primary aldosteronism: an endocrine society clinical practice guideline. | journal=J Clin Endocrinol Metab | year= 2008 | volume= 93 | issue= 9 | pages= 3266-81 | pmid=18552288 | doi=10.1210/jc.2008-0104 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18552288 }}</ref> | ||
* Measurement of plasma [[aldosterone]] to [[renin]] ratio (ARR) is the best initial test for the evaluation of primary [[Hyperaldosteronism|aldosteronism]]. | |||
* A serum [[aldosterone]] level below 0.25 nmol/liter (9 ng/dl) makes a diagnosis of primary [[aldosteronism]] highly unlikely. | |||
*Borderline values should be repeated in below situation: | |||
# After correcting [[hypokalemia]], | |||
# While the patient is on salt restriction, | |||
# In the morning and in a sitting position, | |||
# After resting for at least 15 minutes before proceeding with confirmatory tests. | |||
* Patients with an elevated ARR should proceed with a confirmatory test such as the [[salt]] loading test or [[saline]] suppression test. | |||
==References== | ==References== | ||
Latest revision as of 00:25, 8 November 2017
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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
Laboratory findings consistent with the diagnosis of incidentaloma include an abnormal 1 mg overnight dexamethasone for subclinical Cushing's syndrome that should be confirmed with 24-hour urinary free cortisol, serum ACTH concentration, and dehydroepiandrosterone sulfate (DHEAS). In patients with adrenal masses that have a probability for pheochromocytoma, routine measurement of 24-hour urinary fractionated metanephrines and catecholamines should be done. All patients with hypertension and an adrenal incidentaloma should be evaluated by measurements of plasma aldosterone concentration and plasma renin activity.
Laboratory Findings
Subclinical Cushing's syndrome
- Subclinical Cushing's syndrome should be ruled out by performing the 1 mg overnight dexamethasone suppression test (DST).[1][2][3]
- An abnormal 1 mg overnight dexamethasone should be confirmed with 24-hour urinary free cortisol, serum ACTH concentration, and dehydroepiandrosterone sulfate (DHEAS).
- An undetectable level of serum ACTH is also supportive of the diagnosis of subclinical Cushing’s syndrome.
- Hormonal evaluation in the patients with subclinical Cushing's syndrome showed the following:
- Low baseline secretion of ACTH
- Lack of suppressibility of cortisol secretion after 1 mg dexamethasone
- Supranormal 24-hour urinary cortisol excretion
- Disturbed cortisol circadian rhythm
- Blunted plasma ACTH responses to corticotropin-releasing hormone (CRH)
Pheochromocytoma
- In patients with adrenal masses that have a probability for pheochromocytoma, routine measurement of 24-hour urinary fractionated metanephrines and catecholamines should be done.[4]
Hyperaldosteronism|Aldosteronomas
- All patients with hypertension and an adrenal incidentaloma should be evaluated by measurements of plasma aldosterone concentration and plasma renin activity.[5][6][7][6]
- Measurement of plasma aldosterone to renin ratio (ARR) is the best initial test for the evaluation of primary aldosteronism.
- A serum aldosterone level below 0.25 nmol/liter (9 ng/dl) makes a diagnosis of primary aldosteronism highly unlikely.
- Borderline values should be repeated in below situation:
- After correcting hypokalemia,
- While the patient is on salt restriction,
- In the morning and in a sitting position,
- After resting for at least 15 minutes before proceeding with confirmatory tests.
- Patients with an elevated ARR should proceed with a confirmatory test such as the salt loading test or saline suppression test.
References
- ↑ Nieman LK, Biller BM, Findling JW, Newell-Price J, Savage MO, Stewart PM; et al. (2008). "The diagnosis of Cushing's syndrome: an Endocrine Society Clinical Practice Guideline". J Clin Endocrinol Metab. 93 (5): 1526–40. doi:10.1210/jc.2008-0125. PMC 2386281. PMID 18334580.
- ↑ Eller-Vainicher C, Morelli V, Salcuni AS, Torlontano M, Coletti F, Iorio L; et al. (2010). "Post-surgical hypocortisolism after removal of an adrenal incidentaloma: is it predictable by an accurate endocrinological work-up before surgery?". Eur J Endocrinol. 162 (1): 91–9. doi:10.1530/EJE-09-0775. PMID 19797503.
- ↑ Katabami T, Obi R, Shirai N, Naito S, Saito N (2005). "Discrepancies in results of low-and high-dose dexamethasone suppression tests for diagnosing preclinical Cushing's syndrome". Endocr J. 52 (4): 463–9. PMID 16127216.
- ↑ Young WF (2007). "Clinical practice. The incidentally discovered adrenal mass". N Engl J Med. 356 (6): 601–10. doi:10.1056/NEJMcp065470. PMID 17287480.
- ↑ Mosso L, Carvajal C, González A, Barraza A, Avila F, Montero J; et al. (2003). "Primary aldosteronism and hypertensive disease". Hypertension. 42 (2): 161–5. doi:10.1161/01.HYP.0000079505.25750.11. PMID 12796282.
- ↑ 6.0 6.1 Funder JW, Carey RM, Fardella C, Gomez-Sanchez CE, Mantero F, Stowasser M; et al. (2008). "Case detection, diagnosis, and treatment of patients with primary aldosteronism: an endocrine society clinical practice guideline". J Clin Endocrinol Metab. 93 (9): 3266–81. doi:10.1210/jc.2008-0104. PMID 18552288.
- ↑ Mitchell IC, Auchus RJ, Juneja K, Chang AY, Holt SA, Snyder WH; et al. (2007). ""Subclinical Cushing's syndrome" is not subclinical: improvement after adrenalectomy in 9 patients". Surgery. 142 (6): 900–5, discussion 905.e1. doi:10.1016/j.surg.2007.10.001. PMID 18063074.