Links
Archives
Wednesday, October 26, 2005
Management of the Clinically Inapparent Adrenal Mass
NIH consensus
Among unselected patients and those with nonendocrinologic complaints, clinically inapparent adrenal masses are most often nonfunctioning tumors (approximately 70 percent).
The available data suggest that nearly all lesions smaller than 4 cm are benign.
Masses greater than or equal to 3 cm are more likely to develop hyperfunction compared to smaller tumors. The interpretation of these followup studies is affected by variable length of followup and variable followup strategies.Most studies indicate that the transformation rate of small (less than 3 cm) nonfunctioning nodules to functional tumors is low.
Followup of patients with nonfunctioning adrenal masses suggests that 5 to 25 percent of masses increase in size by at least 1 cm.
Usually, large clinically inapparent adrenal masses (greater than 6 cm) are treated surgically. Approximately 25 percent of masses greater than 6 cm in diameter are adrenal cortical carcinomas.
A homogeneous mass with a smooth border and an attenuation value of less than 10 HU on an unenhanced CT study strongly suggests the diagnosis of a benign adrenal adenoma.
Although chemical shift MRI is commonly performed, it does not provide additional information beyond that which is already available on unenhanced CT.
CT-guided fine needle aspiration may be helpful in the diagnostic evaluation of patients with a history of cancer (particularly lung, breast, and kidney), with no other signs of metastases, and a heterogenous adrenal mass with a high attenuation value (greater than 20 HU). (Usually not recommended in Japan Since histopathological diagnosis upon smaller specimen may be challenging)
Exceptions of requirement for hormonal evaluation will include patients with imaging characteristics of myelolipoma or an adrenal cyst.
Patients with "silent" pheochromocytomas are at risk for a hypertensive crisis and should undergo adrenalectomy.
If a patient with a unilateral incidentaloma is found on history or physical examination to have the signs and symptoms suggestive of glucocorticoid, mineralocorticoid, adrenal sex hormone, or catecholamine excess that is confirmed biochemically, adrenalectomy is often considered
Matsunami Hospital Department of Endocrinology
体内のどこかに癌のある方にみつかった、副腎偶発腫瘍の場合、その4分の3はその癌が副腎に転移したものという統計結果があります
Among unselected patients and those with nonendocrinologic complaints, clinically inapparent adrenal masses are most often nonfunctioning tumors (approximately 70 percent).
The available data suggest that nearly all lesions smaller than 4 cm are benign.
Masses greater than or equal to 3 cm are more likely to develop hyperfunction compared to smaller tumors. The interpretation of these followup studies is affected by variable length of followup and variable followup strategies.Most studies indicate that the transformation rate of small (less than 3 cm) nonfunctioning nodules to functional tumors is low.
Followup of patients with nonfunctioning adrenal masses suggests that 5 to 25 percent of masses increase in size by at least 1 cm.
Usually, large clinically inapparent adrenal masses (greater than 6 cm) are treated surgically. Approximately 25 percent of masses greater than 6 cm in diameter are adrenal cortical carcinomas.
A homogeneous mass with a smooth border and an attenuation value of less than 10 HU on an unenhanced CT study strongly suggests the diagnosis of a benign adrenal adenoma.
Although chemical shift MRI is commonly performed, it does not provide additional information beyond that which is already available on unenhanced CT.
CT-guided fine needle aspiration may be helpful in the diagnostic evaluation of patients with a history of cancer (particularly lung, breast, and kidney), with no other signs of metastases, and a heterogenous adrenal mass with a high attenuation value (greater than 20 HU). (Usually not recommended in Japan Since histopathological diagnosis upon smaller specimen may be challenging)
Exceptions of requirement for hormonal evaluation will include patients with imaging characteristics of myelolipoma or an adrenal cyst.
Patients with "silent" pheochromocytomas are at risk for a hypertensive crisis and should undergo adrenalectomy.
If a patient with a unilateral incidentaloma is found on history or physical examination to have the signs and symptoms suggestive of glucocorticoid, mineralocorticoid, adrenal sex hormone, or catecholamine excess that is confirmed biochemically, adrenalectomy is often considered
Matsunami Hospital Department of Endocrinology
体内のどこかに癌のある方にみつかった、副腎偶発腫瘍の場合、その4分の3はその癌が副腎に転移したものという統計結果があります
Monday, October 24, 2005
Preoperative Cardiac Risk Assessment
Preoperative evaluation of patients with, or at risk of, coronary artery disease undergoing non-cardiac surgery
British Journal of Anaesthesia, 2002, Vol. 89, No. 5 747-759
Abstract
The increasing number of patients with coronary artery disease undergoing major non-cardiac surgery justifies guidelines concerning preoperative evaluation, stress testing, coronary angiography, and revascularization. A review of the recent literature shows that stress testing should be limited to patients with suspicion of a myocardium at risk of ischaemia, and coronary angiography to situations where revascularization can improve long-term survival. Recent data have shown that any event in the coronary circulation, be it new ischaemia, infarction, or revascularization, induces a high-risk period of 6 weeks, and an intermediate-risk period of 3 months. A 3-month minimum delay is therefore indicated before performing non-cardiac surgery after myocardial infarction or revascularization. However, this delay may be too long if an urgent surgical procedure is requested, as for instance with rapidly spreading tumours, impending aneurysm rupture, infections requiring drainage, or bone fractures. It is then appropriate to use perioperative beta-block, which reduces the cardiac complication rate in patients with, or at risk of, coronary artery disease. The objective of this review is to offer a comprehensive algorithm to help clinicians in the preoperative assessment of patients undergoing non-cardiac surgery.
Eagle's Cardiac Risk Assessment
# See Also
1. Preoperative Cardiovascular Evaluation
# Major Cardiovascular Risks: Unstable Coronary Syndromes
1. Recent Myocardial Infarction (Within 30 days)
2. Unstable Angina or severe Angina (Angina Class 3-4)
3. Decompensated Congestive Heart Failure
4. Severe valvular disease
5. Significant arrhythmia
1. High grade Atrioventricular Block
2. Symptomatic ventricular arrhythmia
3. Uncontrolled rate in supraventricular arrhythmia
# Intermediate Cardiovascular Risks
1. Mild Angina Pectoris (Angina Class 1-2)
2. Prior Myocardial Infarction (by history or EKG)
3. Compensated or prior Congestive Heart Failure
4. Renal Insufficiency (Serum Creatinine >2 mg/dl)
5. Diabetes Mellitus
# Minor Cardiovascular Risks
1. Advanced age
2. Abnormal Electrocardiogram
1. Left Ventricular Hypertrophy
2. Left Bundle Branch Block
3. ST segment abnormalities
4. T Wave abnormalities
3. Heart rhythm other than sinus rhythm (e.g. Atrial Fib)
4. Low functional capacity (<4 METS)
5. History of Cerebrovascular Accident
6. Uncontrolled Hypertension (diastolic BP >110 mmHg)
Performance of three preoperative risk indices; CABDEAL, EuroSCORE and Cleveland models in a prospective coronary bypass database
Conclusions: The CABDEAL model was initially developed for the prediction of major morbidity. Thus, it is not surprising that this model evinced the highest predictive value for increased morbidity in this database. Both the Cleveland and the EuroSCORE models were better predictive of mortality. These results have implications for the selection of risk indices for different purposes. The simple additive CABDEAL model can be used as a hand-held model for preoperative estimation of patients' risk of postoperative morbidity, while the EuroSCORE and Cleveland models are to be preferred for the prediction of mortality in a large patient sample.
PREOPERATIVE ASSESSMENT Chapter 22
High risk: cardiac risk often > 5%
Aortic repair (aneurysmal, dissection)
Noncarotid major vascular (infrainguinal and intraabdominal)
Peripheral vascular surgery
Anticipated prolonged surgical procedures with large fluid shifts and/or blood loss
Major emergency procedures, particularly in the elderly
Intermediate risk: cardiac risk generally < 5%
Major intraabdominal (nonvascular)
Intrathoracic (nonendoscopic)
Major orthopedic
Carotid endarterectomy
Major head and neck
Radical prostatectomy
Low risk: cardiac risk generally < 1%
Opthalmologic (excluding prolonged retinal)
Minor head and neck
Minor prostate (such as cystoscopy or TURP)
Biopsies and superficial procedures
ACC-AHA Preoperative Cardiac Risk Assessment
ACC/AHA Guideline Update for Perioperative Cardiovascular Evaluation for Noncardiac Surgery
Class I: Patients With Suspected or Known CAD
1. Evidence for high risk of adverse outcome based on noninvasive test results.
2. Angina unresponsive to adequate medical therapy.
3. Unstable angina, particularly when facing intermediate-risk* or high-risk* noncardiac surgery.
4. Equivocal noninvasive test results in patients at high-clinical risk† undergoing high-risk* surgery.
Class IIa
1. Multiple markers of intermediate clinical risk † and planned vascular surgery (noninvasive testing should be considered first).
2. Moderate to large ischemia on noninvasive testing but without high-risk features and lower LVEF.
3. Nondiagnostic noninvasive test results in patients of intermediate clinical risk† undergoing high-risk* noncardiac surgery.
4. Urgent noncardiac surgery while convalescing from acute MI.
Class IIb
1. Perioperative MI.
2. Medically stabilized class III or IV angina and planned low-risk or minor* surgery.
Class III
1. Low-risk* noncardiac surgery with known CAD and no high-risk results on noninvasive testing.
2. Asymptomatic after coronary revascularization with excellent exercise capacity (greater than or equal to 7 METs).
3. Mild stable angina with good left ventricular function and no high-risk noninvasive test results.
4. Noncandidate for coronary revascularization owing to concomitant medical illness, severe left ventricular dysfunction (e.g., LVEF less than 0.20), or refusal to consider revascularization.
5. Candidate for liver, lung, or renal transplant more than 40 years old as part of evaluation for transplantation, unless noninvasive testing reveals high risk for adverse outcome.
British Journal of Anaesthesia, 2002, Vol. 89, No. 5 747-759
Abstract
The increasing number of patients with coronary artery disease undergoing major non-cardiac surgery justifies guidelines concerning preoperative evaluation, stress testing, coronary angiography, and revascularization. A review of the recent literature shows that stress testing should be limited to patients with suspicion of a myocardium at risk of ischaemia, and coronary angiography to situations where revascularization can improve long-term survival. Recent data have shown that any event in the coronary circulation, be it new ischaemia, infarction, or revascularization, induces a high-risk period of 6 weeks, and an intermediate-risk period of 3 months. A 3-month minimum delay is therefore indicated before performing non-cardiac surgery after myocardial infarction or revascularization. However, this delay may be too long if an urgent surgical procedure is requested, as for instance with rapidly spreading tumours, impending aneurysm rupture, infections requiring drainage, or bone fractures. It is then appropriate to use perioperative beta-block, which reduces the cardiac complication rate in patients with, or at risk of, coronary artery disease. The objective of this review is to offer a comprehensive algorithm to help clinicians in the preoperative assessment of patients undergoing non-cardiac surgery.
Eagle's Cardiac Risk Assessment
# See Also
1. Preoperative Cardiovascular Evaluation
# Major Cardiovascular Risks: Unstable Coronary Syndromes
1. Recent Myocardial Infarction (Within 30 days)
2. Unstable Angina or severe Angina (Angina Class 3-4)
3. Decompensated Congestive Heart Failure
4. Severe valvular disease
5. Significant arrhythmia
1. High grade Atrioventricular Block
2. Symptomatic ventricular arrhythmia
3. Uncontrolled rate in supraventricular arrhythmia
# Intermediate Cardiovascular Risks
1. Mild Angina Pectoris (Angina Class 1-2)
2. Prior Myocardial Infarction (by history or EKG)
3. Compensated or prior Congestive Heart Failure
4. Renal Insufficiency (Serum Creatinine >2 mg/dl)
5. Diabetes Mellitus
# Minor Cardiovascular Risks
1. Advanced age
2. Abnormal Electrocardiogram
1. Left Ventricular Hypertrophy
2. Left Bundle Branch Block
3. ST segment abnormalities
4. T Wave abnormalities
3. Heart rhythm other than sinus rhythm (e.g. Atrial Fib)
4. Low functional capacity (<4 METS)
5. History of Cerebrovascular Accident
6. Uncontrolled Hypertension (diastolic BP >110 mmHg)
Performance of three preoperative risk indices; CABDEAL, EuroSCORE and Cleveland models in a prospective coronary bypass database
Conclusions: The CABDEAL model was initially developed for the prediction of major morbidity. Thus, it is not surprising that this model evinced the highest predictive value for increased morbidity in this database. Both the Cleveland and the EuroSCORE models were better predictive of mortality. These results have implications for the selection of risk indices for different purposes. The simple additive CABDEAL model can be used as a hand-held model for preoperative estimation of patients' risk of postoperative morbidity, while the EuroSCORE and Cleveland models are to be preferred for the prediction of mortality in a large patient sample.
PREOPERATIVE ASSESSMENT Chapter 22
High risk: cardiac risk often > 5%
Aortic repair (aneurysmal, dissection)
Noncarotid major vascular (infrainguinal and intraabdominal)
Peripheral vascular surgery
Anticipated prolonged surgical procedures with large fluid shifts and/or blood loss
Major emergency procedures, particularly in the elderly
Intermediate risk: cardiac risk generally < 5%
Major intraabdominal (nonvascular)
Intrathoracic (nonendoscopic)
Major orthopedic
Carotid endarterectomy
Major head and neck
Radical prostatectomy
Low risk: cardiac risk generally < 1%
Opthalmologic (excluding prolonged retinal)
Minor head and neck
Minor prostate (such as cystoscopy or TURP)
Biopsies and superficial procedures
ACC-AHA Preoperative Cardiac Risk Assessment
ACC/AHA Guideline Update for Perioperative Cardiovascular Evaluation for Noncardiac Surgery
Class I: Patients With Suspected or Known CAD
1. Evidence for high risk of adverse outcome based on noninvasive test results.
2. Angina unresponsive to adequate medical therapy.
3. Unstable angina, particularly when facing intermediate-risk* or high-risk* noncardiac surgery.
4. Equivocal noninvasive test results in patients at high-clinical risk† undergoing high-risk* surgery.
Class IIa
1. Multiple markers of intermediate clinical risk † and planned vascular surgery (noninvasive testing should be considered first).
2. Moderate to large ischemia on noninvasive testing but without high-risk features and lower LVEF.
3. Nondiagnostic noninvasive test results in patients of intermediate clinical risk† undergoing high-risk* noncardiac surgery.
4. Urgent noncardiac surgery while convalescing from acute MI.
Class IIb
1. Perioperative MI.
2. Medically stabilized class III or IV angina and planned low-risk or minor* surgery.
Class III
1. Low-risk* noncardiac surgery with known CAD and no high-risk results on noninvasive testing.
2. Asymptomatic after coronary revascularization with excellent exercise capacity (greater than or equal to 7 METs).
3. Mild stable angina with good left ventricular function and no high-risk noninvasive test results.
4. Noncandidate for coronary revascularization owing to concomitant medical illness, severe left ventricular dysfunction (e.g., LVEF less than 0.20), or refusal to consider revascularization.
5. Candidate for liver, lung, or renal transplant more than 40 years old as part of evaluation for transplantation, unless noninvasive testing reveals high risk for adverse outcome.
Sunday, October 09, 2005
AstraZeneca Oncology Breast Cancer Atlas
