Sonographie von Nebennierentumoren - wann ist die Punktion indiziert?

 

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Zusammenfassung

In der Diagnostik von NN-Tumoren (NN-Tu) ist die Sonographie hoch sensitiv und konkurriert mit anderen bildgebenden Verfahren. Nur ein geringerer Teil dieser Tumoren ist hormonaktiv. Unter den gutartigen NN-Tu sind die Adenome am häufigsten zu finden (- 8 % in Sektionsstatistiken, 0,5 - 4 % in CT). Phäochromozytome sind seltener (4,8 % in uFNP-Sammelstatistik). Unter den malignen NN-Tu sind Metastasen (32,5 %) deutlich häufiger als primäre Karzinome (19,8 %). Die NN sind der vierthäufigste Metastasierungsort bei Primärtumoren wie Bronchialkarzinom, malignes Melanom, Mamma-, Magen- und Nierenzellkarzinom. Seltener sind Lymphominfiltrate in NN-Tu zu finden (3,4 %). Inzidentalome sind zufällig entdeckte NN-Tu ohne jede Klinik, Malignome sind darunter höchst selten (< 0,2 %). Bei Tumoren kleiner 2 cm wurden keine Malignome beobachtet und selten eine Hormonaktivität. Zu empfehlen ist beim zufällig entdeckten NN-Tumor: minimales Laborprogramm mit 24-h-Katecholamine i. U., Dexamethason-Test, Elektrolyte i. S., US-follow-up bei NN-Tu kleiner 3 cm und weitere Abklärung mit FNP oder OP oberhalb 3 cm. Die uFNP der NN besitzt eine hohe Sensitivität (90 - 95 %). Die rechte NN ist transhepatisch besser zugänglich. Komplikationen sind selten (Pneumothorax, Blutung, Schmerzen, ca. 3 %). Gewarnt wird vor der Punktion des Phäochromozytoms (2 - 4 % maligne) wegen der Gefahr einer hypertensiven Krise. Publiziert sind hierzu nur Kasuistiken. Andererseits wird berichtet über zahlreiche Fälle komplikationslos punktierter Phäochromzytome. Bei den heute zur Verfügung stehenden hervorragenden, bildgebenden Verfahren und der komplikationsarmen Möglichkeiten der minimalinvasiven Adrenalektomie ist eine Indikation zur Feinnadelpunktion (uFNP) nur eingeschränkt gegeben bei: 1. Verdacht auf Metastase mit therapeutischer Konsequenz. 2. Verdacht auf Lymphom 3. bei unklarem Tu 3 - 5 cm, hormoninaktiv und ohne Tumorzeichen 4. OP-Verweigerer. 5. Unklarer NN-Tumor an sich stellt nur eine relative Indikation dar. Zu empfehlen ist folgendes Vorgehen bei zufällig entdeckten NN-Tumoren: < 3 cm und hormoninaktiv → US-Kontrolle; > 5 cm + Tumorverdacht → OP; 3 - 5 cm uFNP oder OP.

Abstract

The normal adrenal glands can be detected by high-resolution-sonography in a high percentage of cases. Sonography is also highly sensitive in the diagnosis of tumours of the adrenal glands. Only some of those tumours are hormonally active. Amongst the benign tumours, adenomas are the most frequent (up to 8 %). Pheochromocytomas are less frequent (4.8 % in uFNB statistics). Amongst the malignant tumours, metastases are more frequent than primary carcinomas (32.5 % vs. 19,8 % in uFNB-statistics). The adrenal glands are the fourth most common location of metastases. Bronchiogenic carcinomas, malignant melanomas, carcinomas of the breast and stomach as well as renal carcinomas metastasise into the adrenals most often. Much less frequent are infiltrates of lymphomas in adrenal glands tumours (3.4 %). Incidentalomas are accidentally detected tumours of the adrenal glands without clinical symptoms. Malignant tumours only represent a very small part of incidentalomas (0.2 %). They seldom show hormonal activity. In the case of an accidentally detected tumour, we propose a minimal laboratory profile (24-h-urinary-catecholamines, dexamethasone-test, electrolyte metabolism). The uFNB of the adrenal glands has a high sensitivity (90 - 95 %). Complications are rare (pneumothorax, bleeding, pain; approximately 3 %). Biopsy of pheohromocytomas (2 - 4 % malignant) is dangerous because of the risk of provoking a hypertensive crisis. Case studies have been published about this problem. On the other hand, numerous cases of uncomplicated biopsies have also been published. Considering the excellent imaging methods and laparoscopic surgery methods on hand, the indication of FNP is restricted to the following cases: 1. the presence of a metastasis leading to therapeutical consequences; 2. suspected lymphoma 3. undefined lesion (3 - 5 cm), hormonally inactive, without typical signs of a tumour 4. patients refusing surgery. 5. uFNB in case of tumours of undefined dignity is only justified in specific cases. Recommendations for this procedure in accidentally detected tumours of the adrenal glands: < 3 cm and hormonally inactive → US-follow up, > 5 cm + suspected tumour → surgery, 3 - 5 cm uFNB after laboratory diagnostics.

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PD Dr. Dieter Nürnberg

Medizinische Klinik B, Ruppiner Kliniken GmbH

Fehrbelliner Str. 38

16816 Neuruppin

Phone: ++ 49/33 91/39 32 10

Fax: ++ 49/33 91/39 32 02

Email: d.nuernberg@ruppiner-kliniken.de