Incidentaloma medical therapy: Difference between revisions
Jump to navigation
Jump to search
No edit summary |
No edit summary |
||
| Line 8: | Line 8: | ||
==Medical Therapy== | ==Medical Therapy== | ||
=== Perioperative medical management of patients with subclinical <ref name="pmid20823463">{{cite journal| author=Nieman LK| title=Approach to the patient with an adrenal incidentaloma. | journal=J Clin Endocrinol Metab | year= 2010 | volume= 95 | issue= 9 | pages= 4106-13 | pmid=20823463 | doi=10.1210/jc.2010-0457 | pmc=2936073 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20823463 }}</ref> === | === Perioperative medical management of patients with subclinical === | ||
There are two approaches tp deal with cases of [[Cushing's syndrome|Cushing's syndrome:]]<ref name="pmid203752102">{{cite journal| author=Chiodini I, Morelli V, Salcuni AS, Eller-Vainicher C, Torlontano M, Coletti F et al.| title=Beneficial metabolic effects of prompt surgical treatment in patients with an adrenal incidentaloma causing biochemical hypercortisolism. | journal=J Clin Endocrinol Metab | year= 2010 | volume= 95 | issue= 6 | pages= 2736-45 | pmid=20375210 | doi=10.1210/jc.2009-2387 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20375210 }}</ref><ref name="pmid20823463">{{cite journal| author=Nieman LK| title=Approach to the patient with an adrenal incidentaloma. | journal=J Clin Endocrinol Metab | year= 2010 | volume= 95 | issue= 9 | pages= 4106-13 | pmid=20823463 | doi=10.1210/jc.2010-0457 | pmc=2936073 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20823463 }}</ref><ref name="pmid193269852">{{cite journal| author=Marko NF, Gonugunta VA, Hamrahian AH, Usmani A, Mayberg MR, Weil RJ| title=Use of morning serum cortisol level after transsphenoidal resection of pituitary adenoma to predict the need for long-term glucocorticoid supplementation. | journal=J Neurosurg | year= 2009 | volume= 111 | issue= 3 | pages= 540-4 | pmid=19326985 | doi=10.3171/2008.12.JNS081265 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19326985 }}</ref> | |||
* Patients do not require [[glucocorticoid]] therapy during surgery. Such patients can safely undergo surgical resection of their [[tumor]] and have their [[cortisol]] levels measured postoperatively. | * Patients do not require [[glucocorticoid]] therapy during surgery. Such patients can safely undergo surgical resection of their [[tumor]] and have their [[cortisol]] levels measured postoperatively. | ||
* This would provide an early evaluation of surgical success. [[Hydrocortisone]] may be given to the patient 30 mg in the morning and 10 mg in the afternoon until the result of the [[cortisol]] level becomes available.<ref name="pmid19326985">{{cite journal| author=Marko NF, Gonugunta VA, Hamrahian AH, Usmani A, Mayberg MR, Weil RJ| title=Use of morning serum cortisol level after transsphenoidal resection of pituitary adenoma to predict the need for long-term glucocorticoid supplementation. | journal=J Neurosurg | year= 2009 | volume= 111 | issue= 3 | pages= 540-4 | pmid=19326985 | doi=10.3171/2008.12.JNS081265 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19326985 }}</ref> | * This would provide an early evaluation of surgical success. [[Hydrocortisone]] may be given to the patient 30 mg in the morning and 10 mg in the afternoon until the result of the [[cortisol]] level becomes available.<ref name="pmid19326985">{{cite journal| author=Marko NF, Gonugunta VA, Hamrahian AH, Usmani A, Mayberg MR, Weil RJ| title=Use of morning serum cortisol level after transsphenoidal resection of pituitary adenoma to predict the need for long-term glucocorticoid supplementation. | journal=J Neurosurg | year= 2009 | volume= 111 | issue= 3 | pages= 540-4 | pmid=19326985 | doi=10.3171/2008.12.JNS081265 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19326985 }}</ref> | ||
| Line 22: | Line 22: | ||
==== [[Alpha blocker|Aalpha adrenoceptor blocker]] ==== | ==== [[Alpha blocker|Aalpha adrenoceptor blocker]] ==== | ||
* It is used to counteract [[hypertension]] and the [[Beta blockers|beta-1 adrenoceptor antagonist]] [[atenolol]] to reduce [[cardiac output]]. They can block the sudden release of [[adrenaline]] during surgical stress and prevent [[hypertensive crisis]]. The patient is ready for surgery after 10 to 14 days of initiation of [[Alpha-adrenergic blocking agent|alpha-adrenergic blockade]]. Patients should take high [[sodium]] diet to prevent [[orthostatic hypotension]] due to [[Alpha blocker|alpha blockers]]. After adequate [[Alpha-adrenergic blocker|alpha-adrenergic blockade]] has been achieved, a [[beta-adrenergic blocker]] is initiated 3 days before surgery. | * It is used to counteract [[hypertension]] and the [[Beta blockers|beta-1 adrenoceptor antagonist]] [[atenolol]] to reduce [[cardiac output]]. They can block the sudden release of [[adrenaline]] during surgical stress and prevent [[hypertensive crisis]]. The patient is ready for surgery after 10 to 14 days of initiation of [[Alpha-adrenergic blocking agent|alpha-adrenergic blockade]]. Patients should take high [[sodium]] diet to prevent [[orthostatic hypotension]] due to [[Alpha blocker|alpha blockers]]. After adequate [[Alpha-adrenergic blocker|alpha-adrenergic blockade]] has been achieved, a [[beta-adrenergic blocker]] is initiated 3 days before surgery.<ref name="pmid18617683">{{cite journal| author=Adler JT, Meyer-Rochow GY, Chen H, Benn DE, Robinson BG, Sippel RS et al.| title=Pheochromocytoma: current approaches and future directions. | journal=Oncologist | year= 2008 | volume= 13 | issue= 7 | pages= 779-93 | pmid=18617683 | doi=10.1634/theoncologist.2008-0043 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18617683 }}</ref> | ||
'''[[Beta blockers|Beta-adrenergic blocker]]''' | '''[[Beta blockers|Beta-adrenergic blocker]]''' | ||
* It should never be started first because unopposed [[Alpha-adrenergic agonist|alpha-adrenergic]] receptor stimulation can lead to the brisk increase in [[blood pressure]]. It should be used with caution due to the risk of [[heart failure]], [[pulmonary edema]], and [[asthma]]. | * It should never be started first because unopposed [[Alpha-adrenergic agonist|alpha-adrenergic]] receptor stimulation can lead to the brisk increase in [[blood pressure]]. It should be used with caution due to the risk of [[heart failure]], [[pulmonary edema]], and [[asthma]].<ref name="pmid17989126">{{cite journal| author=Pacak K| title=Preoperative management of the pheochromocytoma patient. | journal=J Clin Endocrinol Metab | year= 2007 | volume= 92 | issue= 11 | pages= 4069-79 | pmid=17989126 | doi=10.1210/jc.2007-1720 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17989126 }}</ref> | ||
==== [[Calcium channel blocker]] ==== | ==== [[Calcium channel blocker]] ==== | ||
* It is used to control [[blood pressure]] preoperatively and an [[intravenous injection]] is given intraoperatively. | * It is used to control [[blood pressure]] preoperatively and an [[intravenous injection]] is given intraoperatively. | ||
* Its main use is controlling [[blood pressure]] in case of failed [[Alpha blocker|alpha]] and [[beta blockers]] regimen or unaccepted side effects in that regimen.< | * Its main use is controlling [[blood pressure]] in case of failed [[Alpha blocker|alpha]] and [[beta blockers]] regimen or unaccepted side effects in that regimen.<ref name="pmid10363888">{{cite journal| author=Goldstein RE, O'Neill JA, Holcomb GW, Morgan WM, Neblett WW, Oates JA et al.| title=Clinical experience over 48 years with pheochromocytoma. | journal=Ann Surg | year= 1999 | volume= 229 | issue= 6 | pages= 755-64; discussion 764-6 | pmid=10363888 | doi= | pmc=1420821 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10363888 }}</ref> | ||
==== [[Metyrosine]] ==== | ==== [[Metyrosine]] ==== | ||
* It is the last medical line of treatment. It inhibits [[catecholamine]] synthesis. | * It is the last medical line of treatment. It inhibits [[catecholamine]] synthesis. | ||
* It is used in case of failure of other medical lines of treatment or in patients who cannot tolerate them. | * It is used in case of failure of other medical lines of treatment or in patients who cannot tolerate them. | ||
* Clinicians use combined treatment in difficult cases and if [[radiofrequency ablation]] for [[metastatic]] foci will be used. [[Metyrosine]] side effects include [[Crystalluria|crystalluria,]] <nowiki/>[[Extrapyramidal symptom|extrapyramidal]] manifestations, and high cost.< | * Clinicians use combined treatment in difficult cases and if [[radiofrequency ablation]] for [[metastatic]] foci will be used. [[Metyrosine]] side effects include [[Crystalluria|crystalluria,]] <nowiki/>[[Extrapyramidal symptom|extrapyramidal]] manifestations, and high cost.<ref name="pmid15761546">{{cite journal| author=Bravo EL| title=Pheochromocytoma: current perspectives in the pathogenesis, diagnosis, and management. | journal=Arq Bras Endocrinol Metabol | year= 2004 | volume= 48 | issue= 5 | pages= 746-50 | pmid=15761546 | doi=/S0004-27302004000500021 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15761546 }}</ref> | ||
===Preoperative medical management of patients with aldosteronoma<ref name="pmid20823463" />=== | ===Preoperative medical management of patients with aldosteronoma<ref name="pmid20823463" />=== | ||
Revision as of 15:21, 5 September 2017
|
Incidentaloma Microchapters |
|
Diagnosis |
|---|
|
Treatment |
|
Case Studies |
|
Incidentaloma medical therapy On the Web |
|
American Roentgen Ray Society Images of Incidentaloma medical therapy |
|
Risk calculators and risk factors for Incidentaloma medical therapy |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:
Overview
The mainstay of treatment for [disease name] is [therapy].
Medical Therapy
Perioperative medical management of patients with subclinical
There are two approaches tp deal with cases of Cushing's syndrome:[1][2][3]
- Patients do not require glucocorticoid therapy during surgery. Such patients can safely undergo surgical resection of their tumor and have their cortisol levels measured postoperatively.
- This would provide an early evaluation of surgical success. Hydrocortisone may be given to the patient 30 mg in the morning and 10 mg in the afternoon until the result of the cortisol level becomes available.[4]
- Another approach would be to cover all patients with glucocorticoids perioperatively.[5]
Preoperative medical management of patients with pheochromocytoma[2][6]
- All patients undergoing surgery need preoperative treatment to control hypertension during surgery and hypotension after it.
- According to Endocrine Society’s 2014 Clinical Practice Guidelines, there are three medical regimens for preoperative management of pheochromocytoma:[1][2]
- Combined alpha and beta-adrenergic blockers
- Calcium channel blockers
- Metyrosine
Aalpha adrenoceptor blocker
- It is used to counteract hypertension and the beta-1 adrenoceptor antagonist atenolol to reduce cardiac output. They can block the sudden release of adrenaline during surgical stress and prevent hypertensive crisis. The patient is ready for surgery after 10 to 14 days of initiation of alpha-adrenergic blockade. Patients should take high sodium diet to prevent orthostatic hypotension due to alpha blockers. After adequate alpha-adrenergic blockade has been achieved, a beta-adrenergic blocker is initiated 3 days before surgery.[7]
- It should never be started first because unopposed alpha-adrenergic receptor stimulation can lead to the brisk increase in blood pressure. It should be used with caution due to the risk of heart failure, pulmonary edema, and asthma.[8]
Calcium channel blocker
- It is used to control blood pressure preoperatively and an intravenous injection is given intraoperatively.
- Its main use is controlling blood pressure in case of failed alpha and beta blockers regimen or unaccepted side effects in that regimen.[9]
Metyrosine
- It is the last medical line of treatment. It inhibits catecholamine synthesis.
- It is used in case of failure of other medical lines of treatment or in patients who cannot tolerate them.
- Clinicians use combined treatment in difficult cases and if radiofrequency ablation for metastatic foci will be used. Metyrosine side effects include crystalluria, extrapyramidal manifestations, and high cost.[10]
Preoperative medical management of patients with aldosteronoma[2]
Preoperative management
- Medical therapy with mineralocorticoid receptor antagonists should be reserved for those who are unable or unwilling to undergo surgery.[11]
- Adrenalectomy in patients with a documented unilateral source of primary aldosteronism is more cost effective compared with lifelong medical therapy.
- Laparoscopic adrenalectomy compared to an open procedure is associated with a shorter hospital stay, fewer complications, and faster recovery.
- Resection of the adrenal tumor will result in resolution of hypokalemia and improvement in hypertension in almost all patients.
Postoperative management
- Potassium supplementation and mineralocorticoid receptor antagonists should be stopped postoperatively with close monitoring of serum potassium.
- A temporary state of hypoaldosteronism may also develop in some patients with primary aldosteronism postoperatively and can be managed by increasing salt intake.
References
- ↑ Chiodini I, Morelli V, Salcuni AS, Eller-Vainicher C, Torlontano M, Coletti F; et al. (2010). "Beneficial metabolic effects of prompt surgical treatment in patients with an adrenal incidentaloma causing biochemical hypercortisolism". J Clin Endocrinol Metab. 95 (6): 2736–45. doi:10.1210/jc.2009-2387. PMID 20375210.
- ↑ 2.0 2.1 2.2 Nieman LK (2010). "Approach to the patient with an adrenal incidentaloma". J Clin Endocrinol Metab. 95 (9): 4106–13. doi:10.1210/jc.2010-0457. PMC 2936073. PMID 20823463.
- ↑ Marko NF, Gonugunta VA, Hamrahian AH, Usmani A, Mayberg MR, Weil RJ (2009). "Use of morning serum cortisol level after transsphenoidal resection of pituitary adenoma to predict the need for long-term glucocorticoid supplementation". J Neurosurg. 111 (3): 540–4. doi:10.3171/2008.12.JNS081265. PMID 19326985.
- ↑ Marko NF, Gonugunta VA, Hamrahian AH, Usmani A, Mayberg MR, Weil RJ (2009). "Use of morning serum cortisol level after transsphenoidal resection of pituitary adenoma to predict the need for long-term glucocorticoid supplementation". J Neurosurg. 111 (3): 540–4. doi:10.3171/2008.12.JNS081265. PMID 19326985.
- ↑ Chiodini I, Morelli V, Salcuni AS, Eller-Vainicher C, Torlontano M, Coletti F; et al. (2010). "Beneficial metabolic effects of prompt surgical treatment in patients with an adrenal incidentaloma causing biochemical hypercortisolism". J Clin Endocrinol Metab. 95 (6): 2736–45. doi:10.1210/jc.2009-2387. PMID 20375210.
- ↑ Fassnacht M, Arlt W, Bancos I, Dralle H, Newell-Price J, Sahdev A; et al. (2016). "Management of adrenal incidentalomas: European Society of Endocrinology Clinical Practice Guideline in collaboration with the European Network for the Study of Adrenal Tumors". Eur J Endocrinol. 175 (2): G1–G34. doi:10.1530/EJE-16-0467. PMID 27390021.
- ↑ Adler JT, Meyer-Rochow GY, Chen H, Benn DE, Robinson BG, Sippel RS; et al. (2008). "Pheochromocytoma: current approaches and future directions". Oncologist. 13 (7): 779–93. doi:10.1634/theoncologist.2008-0043. PMID 18617683.
- ↑ Pacak K (2007). "Preoperative management of the pheochromocytoma patient". J Clin Endocrinol Metab. 92 (11): 4069–79. doi:10.1210/jc.2007-1720. PMID 17989126.
- ↑ Goldstein RE, O'Neill JA, Holcomb GW, Morgan WM, Neblett WW, Oates JA; et al. (1999). "Clinical experience over 48 years with pheochromocytoma". Ann Surg. 229 (6): 755–64, discussion 764-6. PMC 1420821. PMID 10363888.
- ↑ Bravo EL (2004). "Pheochromocytoma: current perspectives in the pathogenesis, diagnosis, and management". Arq Bras Endocrinol Metabol. 48 (5): 746–50. doi:/S0004-27302004000500021 Check
|doi=value (help). PMID 15761546. - ↑ Funder JW, Carey RM, Mantero F, Murad MH, Reincke M, Shibata H; et al. (2016). "The Management of Primary Aldosteronism: Case Detection, Diagnosis, and Treatment: An Endocrine Society Clinical Practice Guideline". J Clin Endocrinol Metab. 101 (5): 1889–916. doi:10.1210/jc.2015-4061. PMID 26934393.