Kloos R T, Gross M D, Francis I R, Korobkin M, Shapiro B
Division of Endocrinology and Metabolism, University of Michigan, Ann Arbor, USA.
Endocr Rev. 1995 Aug;16(4):460-84. doi: 10.1210/edrv-16-4-460.
Independently, endocrinology, radiology, and nuclear medicine can not optimally differentiate the etiology of the incidental adrenal mass. Rather, the insight necessary for this task must be contributed by all three disciplines. Incidentally discovered adrenal masses are being detected at an increasing rate. This trend is expected to continue based on the incidence of adrenal masses in autopsy series and the increasing use of high resolution abdominal imaging techniques. CT and MRI are able to definitely characterize only a minority of these lesions (simple cyst, myelolipoma, obvious local malignant invasion). Biochemical screening for hormone excess is essential regardless of a nonsuggestive complete history and physical examination. An argument may be made for not further pursuing nonhypersecreting lesions with the typical features of a benign adenoma on CT scan and an attenuation value of 0 HU or less. Adrenocortical scintigraphy is recommended in all patients with normal biochemical screening tests, especially those with CT attenuation values greater than 0 HU. In this setting, we believe that the functional and anatomical information provided by NP-59 and [75Se]selenomethylnorcholesterol scintigraphy allows one to noninvasively, accurately, and less expensively (Table 9) categorize adrenal masses as benign nonhypersecretory adenomas (the vast majority) vs. a possibly malignant lesion (the minority). In the presence of normal biochemistry, a concordant NP-59 imaging pattern is diagnostic of a nonhypersecretory benign adrenal adenoma and requires no immediate therapeutic intervention. Conversely, patients with discordant patterns of NP-59 scintigraphy have lesions that carry a significant risk for malignancy, and the pursuit of a tissue diagnosis is indicated, usually by means of FNA. Normal adrenocortical tissue on cytological studies in this setting may represent inadvertent sampling of adjacent normal adrenocortical tissues or the presence of a well differentiated adrenocortical carcinoma. In patients with lesions larger than 2 cm in whom NP-59 scintigraphy is nonlateralizing, the possibility of a periadrenal or pseudoadrenal mass is likely and should prompt review, or perhaps even repeat, of high resolution adrenal imaging (occasionally angiography may be helpful). In lesions shown to be 2 cm or less in size with a nonlateralizing NP-59-scan, there is a possibility of a periadrenal or pseudoadrenal mass; however, once this is excluded it must be recognized that benign and malignant lesions, because of the limitations of scintigraphy, cannot always be clearly distinguished by this method when masses are small.(ABSTRACT TRUNCATED AT 400 WORDS)
内分泌学、放射学和核医学单独都无法最佳地鉴别肾上腺意外瘤的病因。相反，这项任务所需的见解必须由这三个学科共同提供。肾上腺意外瘤的检出率正在上升。基于尸检系列中肾上腺瘤的发病率以及高分辨率腹部成像技术的日益广泛应用，预计这一趋势将持续下去。CT和MRI仅能明确表征少数这类病变（单纯囊肿、髓样脂肪瘤、明显的局部恶性侵犯）。无论完整病史和体格检查是否提示异常，进行激素过量的生化筛查都是必不可少的。对于CT扫描显示具有典型良性腺瘤特征且衰减值为0 HU或更低的非分泌性病变，可不进一步追查。对于生化筛查正常的所有患者，尤其是CT衰减值大于0 HU的患者，建议进行肾上腺皮质闪烁显像。在这种情况下，我们认为NP - 59和[75Se]硒甲基胆固醇闪烁显像所提供的功能和解剖学信息，能够让人们以无创、准确且成本较低的方式（表9）将肾上腺肿块分为良性非分泌性腺瘤（绝大多数）和可能的恶性病变（少数）。生化指标正常时，NP - 59显像模式一致可诊断为非分泌性良性肾上腺腺瘤，无需立即进行治疗干预。相反，NP - 59闪烁显像模式不一致的患者，其病变具有显著的恶性风险，通常需要通过细针穿刺抽吸活检（FNA）来获取组织诊断。在这种情况下，细胞学检查显示正常肾上腺皮质组织可能代表意外获取的相邻正常肾上腺皮质组织，或者存在高分化肾上腺皮质癌。对于NP - 59闪烁显像无侧别倾向且病变大于2 cm的患者，肾上腺周围或假肾上腺肿块的可能性较大，应促使重新审视甚至重复进行高分辨率肾上腺成像（偶尔血管造影可能会有所帮助）。对于NP - 59扫描无侧别倾向且大小显示为2 cm或更小的病变，存在肾上腺周围或假肾上腺肿块的可能性；然而，一旦排除这种情况，必须认识到由于闪烁显像的局限性，当肿块较小时，良性和恶性病变并不总能通过这种方法清楚区分。（摘要截选至400字）
