{"id":10705,"date":"2023-05-25T16:26:04","date_gmt":"2023-05-25T19:26:04","guid":{"rendered":"http:\/\/&p=10705"},"modified":"2026-08-11T10:58:06","modified_gmt":"2026-08-11T13:58:06","slug":"european-journal-of-endocrinology-volume-189-issue-1-july-2023-pages-g1-g42-https-doi-org-10-1093-ejendo-lvad066","status":"publish","type":"artigos-de-departame","link":"https:\/\/www.endocrino.org.br\/adrenal-e-hipertensao\/artigos-de-departame\/european-journal-of-endocrinology-volume-189-issue-1-july-2023-pages-g1-g42-https-doi-org-10-1093-ejendo-lvad066\/","title":{"rendered":"European Journal of Endocrinology, Volume 189, Issue 1"},"content":{"rendered":"

Recentemente publicadas (junho\/julho 2023), as Diretrizes da Sociedade Europeia de Endocrinologia (ESE) em colabora\u00e7\u00e3o com a Rede Europeia para o Estudo de Tumores Adrenais (ENSAT), renovam as diretrizes anteriores de 2016 sobre o Manejo dos Incidentalomas Adrenais.<\/p>\n

Os Incidentalomas Adrenais s\u00e3o massas adrenais detectadas em exames de imagem realizados por outras raz\u00f5es que n\u00e3o a suspeita de doen\u00e7a adrenal.<\/p>\n

As recomenda\u00e7\u00f5es buscam responder quatro quest\u00f5es principais:<\/p>\n

    \n
  1. Como avaliar o risco de malignidade?<\/li>\n
  2. Como definir e manejar a secre\u00e7\u00e3o aut\u00f4noma de cortisol leve (MACS)?<\/li>\n
  3. Quem deve ser submetido \u00e0 cirurgia e como esta deve ser feita?<\/li>\n
  4. Qual seguimento \u00e9 indicado se o incidentaloma adrenal n\u00e3o for removido cirurgicamente?<\/li>\n<\/ol>\n

    Algumas recomenda\u00e7\u00f5es:<\/strong><\/p>\n

    1) Cada massa adrenal requer avalia\u00e7\u00e3o dedicada. Les\u00f5es homog\u00eaneas com\u00a0< ou = 10 UH<\/u>\u00a0(unidades Hounsfield) na tomografia computadorizada (TC) n\u00e3o contrastada (1\u00ba exame a ser pedido) s\u00e3o\u00a0benignas<\/u>\u00a0e n\u00e3o requerem imagens adicionais independentemente do tamanho.<\/p>\n

    Todas os outros pacientes devem ser discutidos em reuni\u00f5es multidisciplinares, mas apenas\u00a0les\u00f5es > ou = 4 cm n\u00e3o homog\u00eaneas ou com > ou = 20 UH<\/u>\u00a0tem risco maior de malignidade, justificando a escolha da\u00a0remo\u00e7\u00e3o cir\u00fargica<\/u>.<\/p>\n

    2)\u00a0Todos<\/u>\u00a0os pacientes precisam de uma avalia\u00e7\u00e3o cl\u00ednica e end\u00f3crina meticulosa para excluir excesso hormonal e devem dosar o cortisol plasm\u00e1tico ap\u00f3s a supress\u00e3o com 1 mg de dexametasona<\/u>\u00a0\u201covernight\u201d (aplicando o valor de corte para o cortisol plasm\u00e1tico\u00a0<<\/u>\u00a01,8 mcg\/dl). H\u00e1 evid\u00eancias que a maioria dos pacientes sem sinais e sintomas de s\u00edndrome de Cushing manifesta, mas com cortisol p\u00f3s-dexametasona\u00a0><\/u>1,8 mcg\/dl, tem maior morbidade e mortalidade. Para esta condi\u00e7\u00e3o, n\u00f3s propomos o termo secre\u00e7\u00e3o aut\u00f4noma de cortisol leve<\/u> (MACS<\/u>, do ingl\u00eas).<\/p>\n

    A dosagem de\u00a0metanefrinas plasm\u00e1ticas ou urin\u00e1rias<\/u>\u00a0deve ser realizada nos pacientes com les\u00f5es adrenais n\u00e3o t\u00edpicas de adenoma benigno.<\/u><\/p>\n

    A rela\u00e7\u00e3o aldosterona\/renina<\/u> deve ser usada para avaliar pacientes hipertensos ou com hipocalemia<\/u><\/p>\n

    Os androg\u00eanios e precursores da esteroidog\u00eanese <\/u>devem ser dosados na suspeita de carcinoma adrenocortical.<\/u><\/p>\n

    3) Todos os pacientes com MACS devem ser rastreados para comorbidades potencialmente relacionadas ao cortisol (p.ex. hipertens\u00e3o arterial, diabetes mellitus tipo 2, fraturas vertebrais) e adequadamente tratados. Em pacientes com\u00a0MACS e comorbidades relevantes<\/u>, deve-se considerar a\u00a0ressec\u00e7\u00e3o cir\u00fargica<\/u>\u00a0de forma individualizada.<\/p>\n

    5) A indica\u00e7\u00e3o da interven\u00e7\u00e3o cir\u00fargica deve ser guiada pelo risco de malignidade, a presen\u00e7a e a intensidade do excesso hormonal, a idade, as condi\u00e7\u00f5es de sa\u00fade geral e a prefer\u00eancia do paciente.<\/p>\n

    A adrenalectomia minimamente invasiva laparosc\u00f3pica (les\u00f5es at\u00e9 6 cm, sem invas\u00e3o) e a adrenalectomia aberta (sinais de invas\u00e3o local) devem ser realizadas por cirurgi\u00f5es com alto volume de cirurgias adrenais.<\/p>\n

    A cirurgia n\u00e3o <\/u>\u00e9 em geral indicada<\/u> em pacientes assintom\u00e1ticos<\/u> com uma massa adrenal unilateral<\/u> n\u00e3o funcionante<\/u> e caracter\u00edsticas nitidamente benignas<\/u> nos exames de imagem.<\/u><\/p>\n

    6) O seguimento<\/u> de pacientes n\u00e3o submetidos \u00e0 cirurgia adrenal dever\u00e1 ser feito com nova imagem (TC n\u00e3o contrastada ou Resson\u00e2ncia Magn\u00e9tica) ap\u00f3s 6-12 meses<\/u>, sem necessidade de repeti\u00e7\u00e3o se n\u00e3o houver crescimento > 20% no di\u00e2metro m\u00e1ximo.<\/p>\n

    A avalia\u00e7\u00e3o hormonal deve ser repetida se piora das comorbidades ou sinais\/sintomas de disfun\u00e7\u00e3o hormonal.<\/p>\n

    7) Les\u00f5es bilaterais<\/u> devem ser avaliadas individualmente pelos exames de imagem.<\/p>\n

    A investiga\u00e7\u00e3o cl\u00ednica e hormonal deve considerar os diagn\u00f3sticos de hiperplasia macronodular bilateral, adenomas bilaterais (avaliar secre\u00e7\u00e3o aut\u00f4noma de cortisol) hiperplasia adrenal cong\u00eanita (dosar 17-hidroxi-progesterona), les\u00f5es infiltrativas bilaterais como met\u00e1stases, linfoma, doen\u00e7as inflamat\u00f3rias e hemorragia (avaliar insufici\u00eancia adrenal<\/u>).<\/p>\n

    A adrenalectomia bilateral n\u00e3o est\u00e1 indicada na aus\u00eancia de s\u00edndrome de Cushing manifesta.<\/p>\n

    8) Em crian\u00e7as, adolescentes e gestantes<\/u> a Resson\u00e2ncia Magn\u00e9tica<\/u> (RM) \u00e9 o exame de escolha.<\/p>\n

    Nesta popula\u00e7\u00e3o, bem como em adultos < 40 anos, massas adrenais indeterminadas devem ser ressecadas.<\/p>\n

    Em pacientes idosos e fr\u00e1geis, a investiga\u00e7\u00e3o e o manejo devem ser proporcionais ao potencial ganho cl\u00ednico.<\/p>\n

    9) Em pacientes com doen\u00e7a maligna extra-adrenal, deve-se dosar metanefrinas plasm\u00e1ticas ou urin\u00e1rias<\/u>\u00a0para se excluir feocromocitoma.<\/p>\n

    Em les\u00f5es indeterminadas nesta popula\u00e7\u00e3o, pode-se realizar um FDG PET\/CT, ressec\u00e7\u00e3o cir\u00fargica ou bi\u00f3psia,<\/u> se a demonstra\u00e7\u00e3o de malignidade na adrenal alterar a conduta terap\u00eautica.<\/p>\n

    10) Para o futuro, \u00e9 necess\u00e1rio melhor caracteriza\u00e7\u00e3o da MACS<\/u> e o impacto de seu tratamento sobre desfechos cardiovasculares duros, incid\u00eancia de c\u00e2ncer e mortalidade.<\/p>\n

     <\/p>\n

     <\/p>\n

     <\/p>\n","protected":false},"featured_media":9678,"parent":0,"template":"","editoria":[15],"class_list":["post-10705","artigos-de-departame","type-artigos-de-departame","status-publish","has-post-thumbnail","hentry","editoria-adrenal-e-hipertensao"],"acf":[],"yoast_head":"\nEuropean Journal of Endocrinology, Volume 189, Issue 1 - Adrenal e Hipertens\u00e3o<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.endocrino.org.br\/adrenal-e-hipertensao\/artigos-de-departame\/european-journal-of-endocrinology-volume-189-issue-1-july-2023-pages-g1-g42-https-doi-org-10-1093-ejendo-lvad066\/\" \/>\n<meta property=\"og:locale\" content=\"pt_BR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"European Journal of Endocrinology, Volume 189, Issue 1 - Adrenal e Hipertens\u00e3o\" \/>\n<meta property=\"og:description\" content=\"Recentemente publicadas (junho\/julho 2023), as Diretrizes da Sociedade Europeia de Endocrinologia (ESE) em colabora\u00e7\u00e3o com a Rede Europeia para o Estudo de Tumores Adrenais (ENSAT), renovam as diretrizes anteriores de 2016 sobre o Manejo dos Incidentalomas Adrenais. 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