Inzidentalom und subklinische Funktionsstörungen der Nebenniere

Zusammenfassung

Eine autonome Sekretion von Nebennierenhormonen kann einen subklinischen Verlauf nehmen oder durch andere häufige Erkrankungen maskiert werden. Eine weitere diagnostische Herausforderung stellen Patienten mit zufällig entdeckten Raumforderungen der Nebennieren (Inzidentalomen) dar, die durch den universellen Einsatz bildgebender Techniken eine steigende Prävalenz zeigen. Obwohl der Anteil maligner oder hormonaktiver Läsionen insgesamt gering ist sollten alle Patienten mit Nebennieren-Inzidentalom (> 1 cm) einer endokrinen Diagnostik unterzogen werden, um subklinische Verläufe eines Cushing-Syndroms, eines Phäochromozytoms oder eines primären Hyperaldosteronismus zu entdecken. Mittels Kontrastmittel unterstützten CT Aufnahmen kann die Dignität der Läsion beurteilt werden. Zur Untersuchung der hormonellen Aktivität sollten zunächst ein niedrig dosierter Dexamethason-Hemmtest durchgeführt, die Plasma Metanephrine sowie der Aldosteron-Renin-Quotient (bei arterieller Hypertonie) bestimmt werden. Die Therapie des subklinischen Cushing-Syndroms (operativ vs. medikamentöse Therapie) bleibt in Abwesenheit großer randomisierter, prospektiver Studien eine Einzelfallentscheidung. Alle Tumoren mit malignitätsverdächtigen Kriterien (insbesondere wenn > 4 cm Größe) und die subklinischen Phäochromozytome und Aldosteron produzierenden Adenome sollten operiert werden. Bei nicht resezierten Tumoren werden jährliche biochemische Kontrollen für eine Dauer von 5 Jahren empfohlen, insbesondere bei Tumoren > 3 cm. Bei einer Größenzunahme im Follow-up sollte eine Adrenalektomie in Erwägung gezogen werden.

Incidentaloma and subclinical disorders of the adrenal gland

Autonomous secretion of adrenal hormones can follow a subclinical course or even be masked by other frequent diseases. Patients with incidentally discovered adrenal masses (incidentaloma) represent another diagnostic challenge. Their frequency has increased through the growing number of medical imaging procedures. Although the proportion of malignant or hormonally active lesions is low, patients with adrenal incidentalomas (> 1cm) should undergo an endocrine work-up in order to detect subclinical courses of Cushing's syndrome, pheochromocytoma or primary aldosteronism. Enhanced CT is of help in the assessment of the dignity of discovered lesions. In order to evaluate the hormonal activity, it is recommended to perform low dose dexamethason suppression test and to determine the plasma metanephrines and the aldosterone to renin ratio (in hypertensive patients). The therapy of suclinical Cushing's syndrome (operative vs. medicamentous therapy) remains a single-case decision in the absence of randomised prospective studies. All tumors with criterias for malignancy (> 4 cm) and subclinical pheochromocytoma and aldosterone producing adenomas should undergo surgery. In the case of non operated tumors annual bichemical follow-up controls should be performed over a duration of 5 years. In the case of a significant gain of tumor size during follow-up, adrenalectomy should be considered.

Schlüsselwörter

Inzidentalom - subklinisches Cushing-Syndrom - subklinischer Hyperaldosteronismus - subklinisches Phäochromozytom

Key words

incidentaloma - subclinical Cushing’s syndrome - subclinical aldosteronism - subclinical pheochromoyctoma

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