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European Journal of (2008) 158 699–704 ISSN 0804-4643

CLINICAL STUDY Natural course of small adrenal lesions in multiple endocrine neoplasia type 1: an endoscopic ultrasound imaging study S Schaefer1, M Shipotko1,5, S Meyer1, D Ivan1, K J Klose3, J Waldmann2, P Langer2 and P H Kann1,4 1Division of Endocrinology and Diabetology, Philipp’s University, D-35033 Marburg, Germany (EU), 2Surgery and 3Radiology, Philipp’s University, 35033 Marburg, Germany (EU), 4Institute for Clinical Research and Development, 55116 Mainz, Germany (EU) and 5I M Sechenov Moscow Medical Academy, 11999 Moscow, Russia (Correspondence should be addressed to P H Kann; Email: [email protected]) S Schaefer and M Shipotko contributed equally to this work

Abstract Objective: Adrenal lesion is one of the features of multiple endocrine neoplasia type 1 (MEN1). This study aimed to assess prevalence, natural course and clinical relevance of small adrenal lesions without clinical symptoms, endocrine activity, or mechanical problems and thus without clear indication for surgical therapy by endoscopic ultrasound (EUS). Design and methods: Forty-nine patients with familial MEN1 were studied. Twenty-seven of these with adrenal lesions were detected by EUS and at least two performed EUS examinations were included into a subgroup where changes in adrenal morphology were studied by measuring changes in the largest diameter of the dominant adrenal tumour. Results: EUS detected adrenal lesions in 36 (73%) patients: 6 (12%) plump adrenals, 17 (35%) nodular hyperplasia, 12 (24%) and 1 (2%) . Bilateral adrenal lesions were detected in 17 patients and unilateral in 19 patients. A change in the largest tumour diameter was found to be for nodular hyperplasia K0.02G1.41% per month (range K2.56 to 4.58%) and for adenomas K0.61G1.95% per month (range K6.25 to 1.15%). One patient had an adrenal cyst with significant growth. There was no evidence of or metastatic disease during the study. Conclusions: The prevalence of adrenal lesions in MEN1 is higher than that reported earlier. Except one cystic lesion, no significant change in the tumour size was observed over a mean observation period of more than 2 years. In a typical situation, small adrenal lesions in MEN1 seem to be constant in their morphology.

European Journal of Endocrinology 158 699–704

Introduction pancreatic neuroendocrine tumours down to a diameter of 1–2 mm (8, 9). The high sensitivity of EUS Multiple endocrine neoplasia type 1 (MEN1) is a genetic in the detection of adrenal lesions has been reported disorder with neoplasia of the , recently (7). parathyroid, endocrine and other endocrine The purpose of this study was to determine prevalence, tissues (1). Adrenal lesions are also associated with and especially natural course and thus clinical relevance MEN1. However, the prevalence, natural course and of asymptomatic, small adrenal lesions (!3cm) in clinical management of adrenal lesions in MEN1 have MEN1 patients by EUS imaging. not yet been clearly defined. In the literature, the prevalence of adrenal involve- ment ranges from 9 to 55% (2–7). Most of the lesions were described as non-functional. The first reports Design and methods about adrenal lesions in MEN1 refer to autopsy studies or to incidental findings at laparotomy. Later The study was conducted according to the Declaration in the diagnostics of adrenal lesions in MEN1, of Helsinki, and the study protocol was reviewed and radiological methods and abdominal ultrasound were approved by the local ethical committee. Informed used (2–6). In this study, endoscopic ultrasound (EUS) of written consent was obtained from each subject. the pancreas, paragastric/paraduodenal lymph nodes Forty-nine patients with familial MEN1 (24 female/25 and the adrenals was performed. This method is male, 46G14 years) were studied. Twenty-seven of these now considered to be an established diagnostic patients with at least two performed EUS examinations approach in MEN1. EUS enables us to visualise small and asymptomatic adrenal lesions !3 cm according

q 2008 Society of the European Journal of Endocrinology DOI: 10.1530/EJE-07-0635 Online version via www.eje-online.org

Downloaded from Bioscientifica.com at 10/01/2021 12:06:34AM via free access 700 S Schaefer, M Shipotko and others EUROPEAN JOURNAL OF ENDOCRINOLOGY (2008) 158 to EUS criteria without endocrine activity were included aldosterone concentrations O15 ng/dl the aldosterone into a subgroup (15 male/12 female, 46G14 years), to renin ratio was determined. A ratio O5was where changes in adrenal morphology were studied considered pathological (hyperaldosteronism). Aldos- prospectively. The mean observation time of this terone in serum was determined by RIA (Multi Kristall subgroup was 27G9 months (range 3–43 months). Gamma Counter LB 2111, Berthold Technologies During follow-up, EUS was performed 3.6G1.0 times GmbH & Co.KG, Bad Wildbad, Germany) and renin in (range 2–5 times). plasma was determined by chemiluminescence immu- The adrenal lesions were classified according to EUS noassay (Liaison Direct Renin, DiaSorin S.p.A., Salu- criteria as: plump adrenal; nodular hyperplasia; ade- ggia, Italy). A pathological excretion of catecholamines noma; cyst. or metabolites (adrenaline, noradrenaline, , Plump adrenals were diagnosed by subjective vanillylmandelic acid, homovanillic acid, metanephr- impression of the examiner when thickening of the ine, normetanephrine) in urine was diagnosed accor- adrenal was striking. Nodular hyperplasia was defined ding to the reference ranges given by the manufacturer. as nodular transformation of the adrenals without In case of pathological excretion of catecholamines in clear capsular borders of the nodules. was urine, a clonidine test was performed. Elevated basal defined as a nodular lesion with a visible capsule and/or plasma catecholamines (according to the reference a difference in echogeneity of the lesion to the ranges given by the manufacturer) and a suppression surrounding adrenal tissue. Cyst was diagnosed if an !50% after administration of 300 mg clonidine orally echo-free lesion was detected. were considered pathological (). The natural course of adrenal manifestation in the Catecholamines in urine and plasma were determined subgroup of 15 males and 12 females was assessed by by high-performance liquid chromatography using a following the largest diameter of the dominant lesion as reverse-phase technique (Autosampler Waters, Waters determined by EUS. Plump adrenals were not included GesmbH, Wien, Austria). into this analysis. These investigations were performed at the University Dominant lesion was defined: in the case of a single Hospital of Marburg in the majority of patients, but tumour, this lesion; in the case of nodular hyperplasia, some patients were seen at other institutions. Therefore, the largest diameter of the largest nodule; in the case of intervals and methods of analysis and bilateral lesions, the largest lesion by regarding cyst and endocrine function testing could not be standardised. adenoma before nodular hyperplasia. Before inclusion in the study, one patient had The slope of the regression line (change from baseline undergone unilateral nephrectomy and adrenalectomy (%)/time (months)) of each single lesion referring to all because of renal (no. 41), one patient unilateral measurements available for each particular lesion was adrenalectomy because of an incidentaloma 4.5 cm taken as the change in largest tumour diameter. in diameter (no. 39) and another patient bilateral EUS, which included imaging of the adrenal, adrenalectomy because of adrenocorticotrophin pancreas, and the surrounding structures was per- (ACTH)-independent Cushing’s syndrome (no. 42). No formed by one single experienced investigator (PHK) regrowth of any suspicious tissue after adrenalectomy following a routine procedure (8, 9) using a Pentax was noted during follow-up, and these data did not FG 32 UA endosonoscope with a longitudinal 7.5 MHz enter statistical analysis. One further patient (no. 31) sector array in combination with a Hitachi EUB 525 showed ACTH-independent Cushing’s syndrome due to ultrasound computer. Pre-medication was performed bilateral nodular hyperplasia and underwent bilateral with 30 mg pentazocine, 10–30 mg diazepam, and adrenalectomy after the first EUS investigation. This 0.25–0.5 mg atropine. The examination time was particular patient was not available for follow-up. w45 min. In addition, as part of their clinical assessment, 19 patients underwent computed tomography (CT) during the study. Adrenal lesions as assessed by CT and descri- Results bed in the CT report were compared with EUS findings. Hormone analysis and endocrine function testing EUS detected adrenal lesions in 36 (73%) patients: were performed to exclude endocrine activity. A urinary 6 (12%) plump adrenals; 17 (35%) adrenal nodular cortisol excretion value O403 mg/24 h or a serum hyperplasia; 12 (24%) adrenal adenomas; 1 (2%) cortisol concentration O30 mg/l in the morning adrenal . following the administration of 2 mg dexamethasone Bilateral adrenal lesions were detected in 17 patients orally the preceding evening (low dose dexamethasone and unilateral lesions in 19 patients. suppression test) were considered pathological (hyper- The change in the diameter of the largest tumour cortisolism). The cortisol in serum and urine was was found to be: for adrenal nodular hyperplasia, determined by chemiluminescence immunoassay K0.02G1.41% per month (range K2.56 to 4.58%) (UniCel DxI 800, Access Immunoassay System, Beck- (Fig. 1) and for adenomas, K0.61G1.95% per month mann Coulter GmbH, Krefeld, Germany). In case of (range K6.25 to 1.15%) (Fig. 2).

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One patient had an adrenal cyst with significant growth during the last year of examination (month 0, 2.8 cm; month 7, 2.9 cm; month 10, 3.0 cm; month 22, 3.7 cm). Therefore, laparoscopic adrenalectomy was performed in this patient. Thus, except one cystic lesion no significant change in the diameter of the adrenal lesions in our cohort of patients with MEN1 was observed. In all patients, there was no evidence for carcinoma or metastatic disease during the study. CT reported no plump adrenals (3 detected by EUS), 6 adrenal nodular hyperplasia (12 detected by EUS) and 3 adrenal adenomas (4 detected by EUS).

Figure 2 Follow-up of ten adrenal adenomas in MEN1 obtained by endoscopic ultrasound (EUS) imaging. Discussion

In general, adrenal lesions in MEN1 are reported to (61%) MEN1 patients. This study showed that there be rarer than parathyroid or pancreatic endocrine was no significant change in the diameter of small lesions. According to previous studies, the prevalence of asymptomatic adrenal lesions in patients with MEN1, adrenal changes in MEN1 ranges from 9 to 55% (2–7). which confirms the results of previous studies over a However, in most of these studies, radiological methods time period of 15 years using different, however, less (CT, magnetic resonance imaging) were performed to precise, imaging methods (7, 14). assess the adrenal involvement in MEN1. These In our study, in almost all patients, mutations in the methods do not seem to be completely precise. EUS MEN1 gene have been detected (Table 2). In three (6%) enables the detection and localisation of adrenal lesions patients, no mutation could be demonstrated, corre- that cannot be detected by CT (7), as was also docu- sponding well to previously reported data (10–14). mented for pancreatic lesions in MEN1 (9). According to These individuals may have mutations in promoter or our results, the sensitivity of CT when compared with UTRs, which remains to be investigated. In a recently EUS in the detection of adrenal lesions in MEN1 was published study, a genotype–phenotype correlation found to be low. However, CT was performed as part between different mutations and the incidence of non- of the clinical routine by different investigators, but functioning pancreatic tumours and EUS by one single investigator with special attention could be established (15). However, this correlation to the adrenal lesions. Therefore, these data are was lacking for adrenal lesions. probably biased. No carcinoma or metastatic disease was detected in In this study, EUS detected adrenal lesions in 36 our cohort during the study period. However, Skogseid (73%) patients. Hence, we find adrenal involvement et al. reported a series of 17 MEN1 patients with adrenal in MEN1 to be more common than that reported involvement, three of whom (18%) had adrenocortical previously (Table 1). However, plump adrenals are subjective impressions when performing EUS and have (ACC) that exhibited adrenocortical hor- to be considered carefully. Nevertheless, according to mone excess (2). According to Langer et al. (6), 22% of our data, ‘objective’ adrenal involvement (adrenal patients with adrenal involvement in MEN1 developed adenoma, nodular hyperplasia, cyst) occurred in 30 ACC. Consequently, the malignant potential of adrenal

Table 1 Frequency of adrenal tumours in multiple endocrine neoplasia type 1 (MEN1) patients (literature data).

MEN1 patients

Study Total With adrenal tumours

Skogseid (1995) 43 17 (40%) Burgess (1996) 33 12 (36%) Carty (1998) 34 3 (9%) Giraud (1998) 62 15 (24%) Langer (2002) 67 18 (26%) Barzon (2001) 20 7 (35%) Waldmann (2007) 38 21 (55%) O Vierimaa (2007) 82 29 (35%) Figure 1 Follow-up of 16 nodules in nodular adrenal hyperplasia in Present study 49 36 (73%) MEN1 obtained by endoscopic ultrasound (EUS) imaging.

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Table 2 Patient number, age at date of last endoscopic ultrasound (EUS) (years), sex (M, male; F, female), clinical characteristics (pHPT, primary hyperparathyroidism; PIT, pituitary others and Shipotko M Schaefer, S adenoma; NEP, neuroendocrine pancreatic tumour), morphology of the adrenals (n/v, not visible), genetic diagnosis (n/d, no mutation detected; n/a, data not available).

Age Sex MEN1 characteristics Left adrenal Right adrenal Genetics

1 22 M pHPT, NEP (inactive) Adenoma Nodular hyperplasia 67 Ins AGCCC 2 47 M pHPT, NEP (inactive) Adenoma Nodular hyperplasia 67 Ins AGCCC 3 28 M pHPT, NEP (inactive) Nodular hyperplasia Normal E116X Ex 2 4 21 F pHPT, NEP () Adenoma Plump L168P Ex 3 5 42 F pHPT, PIT (), NEP (, ) Adenoma Normal F448X Ex 9 6 51 F pHPT, NEP (gastrinoma) Plump Plump 427 del 6bp 1390 (GTCCCA) 7 43 F pHPT Normal Plump n/a 8 60 M pHPT, NEP (inactive), bronchial Nodular hyperplasia Nodular hyperplasia E116X Ex 2 9 60 F pHPT, NEP (inactive) Nodular hyperplasia n/v 1652–1653 ins G, E530X Ex 10 10 55 M pHPT, PIT (prolactinoma), NEP (inactive) Adenoma Normal E116X Ex 2 11 70 M pHPT, NEP (PPoma) Nodular hyperplasia Nodular hyperplasia n/a 12 53 M pHPT, NEP (gastrinoma) Nodular hyperplasia n/v E530X Ex 10 13 60 F pHPT, PIT (prolactinoma) Nodular hyperplasia Nodular hyperplasia n/a 14 41 F NEP (inactive) Cyst Normal L168P Ex 3 15 25 F pHPT, PIT (inactive), NEP (inactive) Normal Plump K119X Ex 2 16 37 F pHPT, PIT (prolactinoma), NEP (insulinoma), bronchial carcinoid Adenoma Normal K120X Ex 2 17 65 F PHPT, gastral carcinoid Normal n/v Y90X 18 50 M pHPT, NEP (gastrinoma) Nodular hyperplasia Normal 466 14bp del 19 54 F pHPT, PIT (prolactinoma), NEP (gastrinoma) Adenoma Plump E116X Ex 2 20 49 M pHPT, NEP (gastrinoma) Adenoma Normal 514 ins C 21 68 M pHPT, PIT (prolactinoma), NEP (inactive) Adenoma Normal n/d 22 42 F pHPT, NEP (inactive) Plump Normal S155F Ex 3 23 69 M PIT (inactive), NEP (inactive) Normal Normal n/a 24 48 M pHPT Nodular hyperplasia Normal n/a 25 38 M NEP (inactive) Normal Normal L168P Ex 3 26 53 F pHPT, PIT (prolactinoma), NEP (inactive) Normal n/v Intron 4 G/A 27 45 M pHPT, PIT (prolactinoma), NEP (gastrinoma) Nodular hyperplasia Normal 545 28 28 F pHPT, NEP (probably insulinoma) Normal Normal E26K 29 48 M pHPT, PIT (inactive), NEP (inactive), thymus carcinoid Adenoma Adenoma n/d 30 58 F pHPT, PIT () Nodular hyperplasia Plump n/a 31 47 F Nodular hyperplasia Nodular hyperplasia n/a (2008) ENDOCRINOLOGY OF JOURNAL EUROPEAN 32 36 M pHPT, PIT (carcinoma), NEP (inactive) Normal Normal n/a 33 54 M pHPT, NEP (gastrinoma, insulinoma) Nodular hyperplasia n/v Q554X 34 31 M pHPT, PIT (prolactinoma), NEP (inactive) Nodular hyperplasia Nodular hyperplasia nt 894 G/A 35 46 F pHPT, PIT (n/a), NEP (inactive) Nodular hyperplasia Nodular hyperplasia R436Y Downloaded fromBioscientifica.com at10/01/202112:06:34AM 36 39 M pHPT, PIT (prolactinoma), NEP (gastrinoma) Normal Normal C488G/stop 37 47 M pHPT, NEP (inactive) Normal Normal T193I 38 35 F pHPT, NEP (gastrinoma) Adenoma Normal n/d 39 33 F pHPT, NEP (inactive) Adrenalectomy Plump T193I 40 38 M pHPT, PIT (inactive), NEP (inactive) Adenoma Plump K285X 41 65 F pHPT, PIT (inactive), NEP (inactive) Adenoma Nephrectomy and adrenalectomy n/a 42 60 F pHPT, NEP (gastrinoma) Adrenalectomy Adrenalectomy splice Intron 4 C894 G/A 43 41 F pHPT, NEP (inactive) Adenoma Adenoma P529X Ex 10 44 26 F NEP (inactive) Normal Normal E26K 45 73 M pHPT, NEP (inactive) Plump Plump n/a 46 48 M PIT (prolactinoma), NEP (VIPoma) Normal n/v L168P Ex 3 47 21 F Normal Normal S155F Ex 3 48 20 F Normal Normal S155F Ex 3 49 55 M pHPT, PIT (prolactinoma), NEP (gastrinoma) Nodular hyperplasia Nodular hyperplasia L168P Ex 3 158 via freeaccess EUROPEAN JOURNAL OF ENDOCRINOLOGY (2008) 158 Endoscopic ultrasound of adrenal lesions in MEN1 703 changes in MEN1 can be striking. 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