Mantero F, Terzolo M, Arnaldi G, Osella G, Masini A M, Alì A, Giovagnetti M, Opocher G, Angeli A
Department of Internal Medicine, University of Ancona, Italy.
J Clin Endocrinol Metab. 2000 Feb;85(2):637-44. doi: 10.1210/jcem.85.2.6372.
The aim of this study was to perform a national survey on occasionally discovered adrenal masses [adrenal incidentalomas (AI)] under the auspices of the Italian Society of Endocrinology. This multicentric and retrospective evaluation of patients with AI includes 1096 cases collected in 26 centers between 1980 and 1995. Relevant information was obtained by means of a specifically tailored questionnaire. Of the 1096 forms received, 1004 were retained for final analysis. Patients were 420 males and 584 females, aged between 15-86 yr (median, 58 yr). Mass size (computed tomography measurement) ranged from 0.5-25 cm (median, 3.0 cm). Hormonal work-up demonstrated that 85% of the masses were nonhypersecretory, 9.2% were defined as subclinical Cushing's syndrome, 4.2% were pheochromocytomas, and 1.6% were aldosteronomas. Adrenalectomy was performed in 380 patients with removal of 198 cortical adenomas (52%), 47 cortical carcinomas (12%), 42 pheochromocytomas (11%), and other less frequent tumor types. Patients with carcinoma were significantly younger than patients with adenoma (median, 46; range, 17-84; vs. 57, 16-83 yr; P = 0.05). Adenomas were significantly smaller than carcinomas (3.5, 1-15 vs. 7.5, 2.6-25 cm; P < 0.001), and a cut-off at 4.0 cm had the highest sensitivity (93%) in differentiating between benign and malignant tumors. Hormonal work-up of patients with subclinical Cushing's syndrome showed low baseline ACTH in 79%, cortisol unsuppressibility after 1 mg dexamethasone in 73%, above normal urinary free cortisol in 75%, disturbed cortisol rhythm in 43%, and blunted ACTH response to CRH in 55%. Only 43% of patients with pheochromocytoma were hypertensive, and 86% showed elevated urinary catecholamines. All patients with aldosteronoma were hypertensive and had suppressed upright PRA. These results indicate that mass size is the most reliable variable in separating benign from malignant AI. Adrenalectomy should be recommended for AI greater than 4.0 cm because of the increased risk of malignancy, especially in young patients. Endocrine evaluation should be performed in all patients to identify silent states of hormone excess.
本研究的目的是在意大利内分泌学会的支持下，针对偶然发现的肾上腺肿块[肾上腺偶发瘤（AI）]开展一项全国性调查。这项对肾上腺偶发瘤患者的多中心回顾性评估纳入了1980年至1995年间在26个中心收集的1096例病例。通过一份专门定制的问卷获取相关信息。在收到的1096份表格中，1004份被保留用于最终分析。患者包括420名男性和584名女性，年龄在15 - 86岁之间（中位数为58岁）。肿块大小（计算机断层扫描测量）范围为0.5 - 25厘米（中位数为3.0厘米）。激素检查表明，85%的肿块无分泌亢进，9.2%被定义为亚临床库欣综合征，4.2%为嗜铬细胞瘤，1.6%为醛固酮瘤。380例患者接受了肾上腺切除术，切除了198个皮质腺瘤（52%）、47个皮质癌（12%）、42个嗜铬细胞瘤（11%）以及其他较少见的肿瘤类型。癌患者明显比腺瘤患者年轻（中位数为46岁；范围为17 - 84岁；相比之下，腺瘤患者中位数为57岁，范围为16 - 83岁；P = 0.05）。腺瘤明显小于癌（3.5厘米，范围为1 - 15厘米；相比之下，癌为7.5厘米，范围为2.6 - 25厘米；P < 0.001），以4.0厘米为界在区分良性和恶性肿瘤时具有最高的敏感性（93%）。亚临床库欣综合征患者的激素检查显示，79%的患者基础促肾上腺皮质激素水平低，73%的患者在服用1毫克地塞米松后皮质醇不可抑制，75%的患者尿游离皮质醇高于正常，43%的患者皮质醇节律紊乱，55%的患者促肾上腺皮质激素对促肾上腺皮质激素释放激素的反应减弱。只有43%的嗜铬细胞瘤患者患有高血压，86%的患者尿儿茶酚胺升高。所有醛固酮瘤患者均患有高血压且立位血浆肾素活性受抑制。这些结果表明，肿块大小是区分良性和恶性肾上腺偶发瘤最可靠的变量。对于直径大于4.0厘米的肾上腺偶发瘤，由于恶性风险增加，应建议进行肾上腺切除术，尤其是在年轻患者中。所有患者均应进行内分泌评估以识别隐匿性激素分泌过多状态。
