What is the current view on sampling adrenals?
I was told that it is “contraindicated” particularly when Pheo neoplasia suspected. So I usually follow this non-sampling adrenal advice, particularly if I suspect Pheo. (Im trained in Europe with ESAVS and Asia,as well as following and sourcing this forum, too; in case there are different views in different countries??).
What is the current view on sampling adrenals?
I was told that it is “contraindicated” particularly when Pheo neoplasia suspected. So I usually follow this non-sampling adrenal advice, particularly if I suspect Pheo. (Im trained in Europe with ESAVS and Asia,as well as following and sourcing this forum, too; in case there are different views in different countries??).
I recently had a case with bilateral adrenal mass (1.5cm trnsv right adrenal, 2.6cm trnsv left adrenal, heterogeneous echogenicity, inflammatory surrounding pattern, irregular capsule, neovascularization). I suspected Pheo at least in the left gland which was bigger (there was systemic hypertension with no other obvious underlying reason). Referring vet sent the case for 24h care for stabilising hypertension. In there, they decided sampling the adrenal. NOw we have a confirmed diagnosis but the patient went blind and is laterally recumbent…from a suspected hypertensive crisis. As far as I know, patient was ambulatory and “doing well” before hand. I will investigate more (may be the current sate of patient is not linked to the FNA in itself) but my question is only regarding the sampling YESvsNO…not just in this case…but in general, as in this place they report they do this routinely…so may be Im missing something)
Our decision was based on owner not considering adrenalectomy. and even if they were up to adrenalectomy…Is surgery safer than FNA? as in…if the mass is unilateral (not this case) and is more than 2cm…would you FNA or just remove? and if it is Pheo…is removal safer than FNA?
And what about suspected lesions in liver, spleen or pancreas (this case apparently had 2 nodules in pancreas that were sampled and turned out to be pheo, too)? Should they be sampled? the risk would be the same as sampling the adrenal itself…right?
Just to clarify…I am not intending to put any blame on any of us…Im just testing what the rest do with adrenals to see if Im being too conservative…or there are new tendencies…
I appreciate any advice.
Comments
I use a 25g soft slide
I use a 25g soft slide instead of jab and be sur eto have a solid cytologist comfortable with reading these. I have sampled probably 50 in my lifetime and have gotten an adrenaline surge once that self resolved. I always coag these first and BP and monitor HR priopr to and after sampling.
With the urine catecholamine available from marshfield labs now here in the usa i sample very few. If its invasive into the phrenic or the cvc then its pheo or carcinoma. Urine catecholanmine is normal then its carcinoma. So you can deduce your way into the aggressive pathology dx but when differentiating the adenoma from myelolipoma and hyperplasia and ensuring benign I think thats where fna is useful academically but not sure it changes anything clinically. Puts a name on it essentially.
Thanks, this is helpful.
I
Thanks, this is helpful.
I didn’t know about the urine catecholamine. I’ll investigate if that’s an option here.
What about sampling suspicious lesions in other tissues? I guess you wouldn’t question that and will go ahead…?
Information from VIN about
Information from VIN about functional testing.
Functional Tests:
1) Metanephrines (i.e. MN, NMN) are breakdown metabolites of epinephrine and norepinephrine. Testing for metanephrines in cases of suspected pheochromocytoma is gaining in popularity. Measurement of plasma free metanephrines or fractionated urine metanephrines is the test of choice in people.21 Currently, no consensus has been reached for dogs as to whether plasma or urine metanephrines testing is preferable.22
In dogs, plasma free NMN can be significantly higher in dogs with pheochromocytoma compared to dogs with adrenocortical tumors, non-adrenal disease, and healthy dogs.3,22 Plasma free NMN has excellent sensitivity and specificity for the diagnosis of pheochromocytoma in dogs.3 Plasma samples require special handling, however.3,22
Urinary metanephrines have been investigated in dogs. Dogs with hyperadrenocorticism may have increased concentrations of NMN but urinary NMN >4 times normal is suggestive of a pheochromocytoma.2 Ideally, urine is collected in the home environment because stress associated with travel to the hospital can increase catecholamine and metanephrine excretion.23 Additionally, special handing is necessary (e.g. addition of acid to stabilize the metanephrines, refrigerated, protected from light, etc.).2,22,23
Treatment with phenoxybenzamine, steroids, and tricyclic antidepressants can falsely increase MN and NMN in people.21 Additionally, impaired renal function can impair excretion of metanephrines.
2) Inhibin is a hormone involved in reproductive physiology. Adrenal glands serve as extra-gonadal sources of inhibin. Adrenocortical tumors and pituitary-dependent hyperadrenocorticism are associated with increased serum inhibin levels but pheochromocytomas are not.24 Undetectable levels of serum inhibin in a neutered dog with an adrenal mass is supportive of a pheochromocytoma.24
Have the owner bring a urine sample collected at home because the stress of the hospital visit can affect the urine catecholamine levels.
Awesome thank you Randy
Awesome thank you Randy