17/4/02 NDRLEARN TO HEAL

Prof. N. DORAIRAJANMS, FRCS (EDIN), FICS, FACS, FICA

Dr. K. KAMARAJ MSDr. PREETHA MUTHAYYA

MADRAS MEDICAL COLLEGE & GOVT. GENERAL HOSPITAL, CHENNAI - 3

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IS A WELL DEFINEDTUMOUR DISCOVERED RADIOLOGICALLYEITHER INCIDENTALLY OR DURING WORKUP FOR A DISEASE POTENTIALLYRELATED TO ADRENALS. APPEARS NONFUNCTIONING BASED ON CLINICALFEATURES.

• INCREASED DETECTION OF INCIDENTALOMAS DUE TO RECENT PLETHORA OF IMAGING MODALITY [0.3 % OF ALL ABDOMINAL IMAGING PROCEDURES]

[O.H Clarke, Textbook of endocrine surgery 1997]

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AIM

• TO ANALYSE THE PREVALENCE OFINCIDENTALOMAS AMONG ALLADRENAL TUMOURS

• TO MAP OUT A COST EFFECTIVETREATMENT PROTOCOL SUITABLEFOR AN INDIAN HOSPITAL SET UP.

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• REVIEW OF ALL CASES OF ADRENAL TUMOURS AT MADRAS MEDICAL COLLEGE & GOVT. GENERAL HOSPITAL & PRIVATE PRACTICE FROM 1999- 2000

• DATA BASE – 58 CASES

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ALL SUBJECTED TO:1. USG ABDOMEN2. CT ABDOMEN3. BIO CHEMICAL INVESTIGATIONS SERUM POTASSIUM 24 HOURS URINARY VMA OVER NIGHT DEXA METHASONE

SUPPRESSION TEST SERUM CORTISOL

USG

ABDOMEN

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• PATIENTS WITH VIRILISING FEATURES SUBJECTED TO ESTIMATION OF – SERUM TESTOSTERONE– DHEA SULPHATE

• PATIENT WITH PHEO SUBJECTED TO MIBG SCAN DURING LAST 3 YEARS OF THE STUDY.

MIBG

SCAN

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FACTORS ANALYSED1. SYMPTOMATOLOGY 2. INVESTIGATIONS USED FOR PRIMARY

DIAGNOSIS 3. HISTOPATHOLOGY4. BIOCHEMICAL FEATURES5. BENIGN VS MALIGNANT NATURE6. TREATMENT – SURGERY VS FOLLOWUP7. OUTCOME

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MANAGEMENT POLICYDETERMINED BY SIZE, BIOCHEMISTRY AND CT

FINDINGS OF IRREGULARITY, NECROSIS, LYMPHADENOPATHY ETC

• FOLLOW UP - < 3 CM, NORMAL BIOCHEM- CT SCAN 3 MONTHLY FOR 6

MONTHS AND 6 MONTHLY FOR 3 YEARS• ADRENALECTOMY - > 5 CM, BIOCHEMICAL

FEATURES OF HYPERSECRETION OR CT FINDINGS SUGGESTIVE OF MALIGNANCY

• 3-5 CM – SURGERY DECIDED BASED ON NON COMPLIANCE TO FOLLOW UP , FINANCIAL CONSTRAINTS PREVENTING SERIAL CT SCAN IN THE ABSENCE OF MAJOR MEDICAL ILLNESS

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PRESENTING COMPLAINT

• UPPER ABDOMINAL DISCOMFORT MOST COMMON PRESENTING COMPLAINT (PROVEN APD IN ONLY 12%)

• ABSENCE OF SYMPTOMS AND NORMAL BIOCHEMICAL LEVELS OF ESTIMATED HORMONES DOES NOT RULE OUT SUBCLINICAL HYPERSECRETION BY THE TUMOUR

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SUB CLINICAL CUSHINGS – SEEN IN 2 CASES – NORMAL CORTISOL LEVELS PRE OP– DEVELOPED ADDISIONS’ CRISIS IN THE

IMMEDIATE POST OP PERIOD FOLLOWING ADRENALECTOMY DUE TO SUPRESSION OF THE NORMAL REMAINING GLAND BY THE TUMOUR

– NP – 59 SCINTISCAN IDEAL FOR DETECTION [ Kloos R.T. Grodd M.D

et al, Endocrin Rev 1995]CORTISOL HYPERSECRETION

NOT

ALWAYS SO OBVIOUS !

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*USG MORE FREQUENTLY USED IN 10 DIAGNOSIS DUE TO WIDESPREAD USED OF THE SAME (AS OPPOSED TO CT, MRI)*CONTRARY TO FINDINGS IN WESTERN LITERATURE WHERIN UPTO 8 % OF ALL AUTOPSIES REVEAL ADRENAL TUMOURS

NO OF CASES %

US ABDOMEN 51 88

CT ABDOMEN 6 10

MR I ABDOMEN 1 2

INVESTIGATIONS

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• CT SCAN DISPARITY IN SIZE BETWEEN CT AND OPERATIVE FINDINGS

[O.H Clarke, D.Linos, 1997]

• RELEVANT FINDING SINCE SIZE IS CRUCIAL IN PLANNING TREATMENT MODALITY

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SCATTER DIAGRAM DEPICTING SIZE AND AGE DISTRIBUTION FOR

INCIDENTALOMAS

00.5

11.5

22.5

33.5

44.5

55.5

66.5

77.5

88.5

99.510

0 10 20 30 40 50 60 70 80

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COMPARISON OF SIZE BY CT & OPERATIVE FINDINGS (AMONG

OPERATED CASES ONLY)SIZE ON

CTACTUAL SIZE

[PEROPERATIVE] TOTAL

<3CM 3-5CM >5CM< 3 CM 0 2 0 23-5 CM 0 9 12 21>5 CM 0 0 12 12TOTAL 0 11 24 35

DISCREPANCY IN SIZE IN TUMOURS BETWEEN 3-5 CM AS DETECTED ON CT SCAN [P<0.001]

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TYPES OF INCIDENTALOMAS DETECTED IN GOVT GENERAL HOSPITAL CHENNAI BETWEEN 1991-

2000 [N – 58]

DIAGNOSIS N %1 ADENOMA 36 602 CORTICAL CARCINOMA 9 163 PHEOCHROMOCYTOMA 7 134 MYELOLIPOMA 1 25 METASTATIC TUMOUR 1 26 CYST 1 27 GANGLIONEUROMA 1 28 TUBERCULOMA 2 3

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BIOCHEMICAL BEHAVIOUR• ALL ANDROGEN SECRETING

TUMOURS WERE FOUND TO BE MALIGNANTBENIGN VS MALIGNANT NATURE OF

TUMOURS • METASTASTASIS LOCAL INVASION,

LN SPREAD ONLY UNEQUIVOCAL INDICATIONS OF MALIGNANCY.

SIZE AND MALIGNANCY• ALL MALIGNANT TUMOURS WERE >

THAN 5 CM

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TREATMENT N %

ADRENALECTOMY 33 57

FOLLOWUP 23 40

INITIAL FOLLOW UP & SUBSEQUENT ADRENALECTOMY

2 3

TREATMENT OF INCIDENTALOMAS IN GOVT. GENERAL HOSPITAL CHENNAI

BETWEEN 1991-2000

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INDICATION MORTALITY UP TO SIX WEEKS

AFTER SURGERY

MORTALITY SIX WEEKS AFTER

SURGERY

BENIGNN=23 CASES

1* 4.3% NIL NIL

MALIGNANT N=12 CASES

2 17% 6 59%

OUTCOME OF SURGERY

* DEATH DUE TO PRE EXISITING CARDIAC ILLNESS

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OUTCOME OF SURGERY1. MALIGNANT CORTICAL CARCINOMA

ASSOCIATED WITH >80% MORTALITY IN OUR 3 YEARS OF FOLLOWUP

2. MORTALITY IN BENIGN CASES – 1 CASE OF PHEO WITH CO-EXISTING CARDIAC ILLNESS

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RESULTS• TOTAL NO. OF CASES - 58• MOST COMMON METHOD FOR DETECTION

- USG ABDOMEN (80%)• MOST COMMON HPE - CORTICAL

ADENOMA• NO. OF CASES TREATED BY

ADRENALECTOMY – 35 [9 WITH 3-5 CM SIZE]

• MORTALITY FOR ADRENALECTOMY WITH SIZE 3-5 CM WITH NO PRE EXISTING MEDICAL ILLNESS – NONE

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POINTS IN FAVOUR OF SURGERY IN INCIDENTALOMAS BETWEEN 3-6 CM

• UNWILLINGNESS OF PATIENTFOR 6 MONTHLY FOLLOW UP

• COST OF REPEATED CT SCAN VS SURGERY

• AGE < 50 YRS• BEST OPTION IN OUR SETUP IN THE

ABSENCE OF MEDICAL ILLNESS THAT WOULD COMPLICATE SURGERY AND ANESTHESIA

CAN INCIDENTALOMAS BE SAFELY OBSERVED????

NO!!!!

SURGERY SAFE ESP AFTER LAP ADRENALECTOMYD.A. LINOS ET AL, GREECE,WJS,SEP 1996

YES !!!!

INCIDENTALOMS < 4CM CAN BE SAFELY OBSERVEDM.KEVIN BARRY ET AL, MAYO CLINIC ROCHESTER, WJS, 1998

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• WHAT IS THE EFFECT OF UNTREATED INCIDENTALOMA ON QUALITY ADJUSTED LIFE EXPECTANCY?

• HOW DO OUTCOMES DIFFER BETWEEN VARIOUS DIAGNOSTIC-THERAPEUTIC STRATEGIES, OVERALL AND FOR DIFFERENT PATIENT SUB GROUPS?

• WHAT IS THE CLINICAL SIGNIFICANCE OF COST EFFECTIVE CALCULATIONS?

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EVIDENCE BASED GUIDELINE OFFERING BEST BALANCE BETWEEN GAIN IN QUALITY

ADJUSTED LIFE YEARS [QALY] AND COST1] * > 6 cm or presence of hypertension or hypokalemia– Full hormonal analysis followed by Adrenalectomy if suggestive of CA or Pheo

*If hormone analysis negative – FNAC & ignore if benign

2] *< 5 cm detected by MRI and features of benign, non pheo tumour – Ignore

*Features of CA – FNAC & Adrenalectomy

3]OTHERS – Adrenal medullary hormone analysis and urine VMA followed by adrenalectomy if positive

Job Kevit et al, Endocrine and Metab clinics of NA, Mar 2000

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STATISTICS FROM DIFFERENT SERIESSTUDY Total

nAV

AGEAV

SIZEPHEO CA PSC

Barzonet al,Italy

202 55 3.6 cm

9 23 20

Herrera et al, Mayo

clinic, USA

342 62 2.5 cm

5 4 2

Proye et al, France

103 15 5 0

Linos et al, Greece

57 49 5.9 cm

4 2 5

NDR et al India

58 41 3.6 cm

7 9 2

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RISK OF MALIGNANCY IN SIZE > 5 CM

AUTHOR NO OF CASES

SIZE> 5 CM < 5 CM

TANG & GRAY 16 13 3

SULLIVAN 27 26 1

DORAIRAJAN 9 9 0

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• US SCAN WAS THE MOST COMMON INVESTIGATION IN 10 DETECTION

• NON FUNCTIONING CORTICAL ADENOMA COMMONEST CAUSE FOR AN INCIDENTALOMA

• OPEN ADRENALECTOMY SAFE IN 3-5 CMTUMOURS, IN THE ABSENCE OF CO-EXISTING MEDICAL ILLNESS IN OUR SETUP???

• ROLE OF CT SCAN IN EVALUATION OF SIZE OF ADRENAL TUMOURS UNDEPENDABLE

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