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Endocrine Jun 2017To determine the accuracy of biochemical tests for the diagnosis of pheochromocytoma and paraganglioma. (Review)
Review
Accuracy of recommended sampling and assay methods for the determination of plasma-free and urinary fractionated metanephrines in the diagnosis of pheochromocytoma and paraganglioma: a systematic review.
PURPOSE
To determine the accuracy of biochemical tests for the diagnosis of pheochromocytoma and paraganglioma.
METHODS
A search of the PubMed database was conducted for English-language articles published between October 1958 and December 2016 on the biochemical diagnosis of pheochromocytoma and paraganglioma using immunoassay methods or high-performance liquid chromatography with coulometric/electrochemical or tandem mass spectrometric detection for measurement of fractionated metanephrines in 24-h urine collections or plasma-free metanephrines obtained under seated or supine blood sampling conditions.
RESULTS
Application of the Standards for Reporting of Diagnostic Studies Accuracy Group criteria yielded 23 suitable articles. Summary receiver operating characteristic analysis revealed sensitivities/specificities of 94/93% and 91/93% for measurement of plasma-free metanephrines and urinary fractionated metanephrines using high-performance liquid chromatography or immunoassay methods, respectively. Partial areas under the curve were 0.947 vs. 0.911. Irrespective of the analytical method, sensitivity was significantly higher for supine compared with seated sampling, 95 vs. 89% (p < 0.02), while specificity was significantly higher for supine sampling compared with 24-h urine, 95 vs. 90% (p < 0.03). Partial areas under the curve were 0.942, 0.913, and 0.932 for supine sampling, seated sampling, and urine. Test accuracy increased linearly from 90 to 93% for 24-h urine at prevalence rates of 0.0-1.0, decreased linearly from 94 to 89% for seated sampling and was constant at 95% for supine conditions.
CONCLUSIONS
Current tests for the biochemical diagnosis of pheochromocytoma and paraganglioma show excellent diagnostic accuracy. Supine sampling conditions and measurement of plasma-free metanephrines using high-performance liquid chromatography with coulometric/electrochemical or tandem mass spectrometric detection provides the highest accuracy at all prevalence rates.
Topics: Adrenal Gland Neoplasms; Chromatography, High Pressure Liquid; Humans; Metanephrine; Paraganglioma; Pheochromocytoma; Sensitivity and Specificity; Specimen Handling; Tandem Mass Spectrometry
PubMed: 28405881
DOI: 10.1007/s12020-017-1300-y -
NIH Consensus and State-of-the-science...To provide health care providers, patients, and the general public with a responsible assessment of currently available data regarding the management of clinically... (Review)
Review
OBJECTIVE
To provide health care providers, patients, and the general public with a responsible assessment of currently available data regarding the management of clinically inapparent adrenal masses ("incidentalomas").
PARTICIPANTS
A non-Federal, nonadvocate, 12-member panel representing the fields of medicine, surgery, endocrinology, pathology, biostatistics, epidemiology, radiology, oncology, and the public. In addition, experts in these same fields presented data to the panel and to a conference audience of approximately 300.
EVIDENCE
Presentations by experts; a systematic review of the medical literature provided by the Agency for Healthcare Research and Quality; and an extensive bibliography of incidentaloma research papers, prepared by the National Library of Medicine. Scientific evidence was given precedence over clinical anecdotal experience.
CONFERENCE PROCESS
Answering predefined questions, the panel drafted a statement based on the scientific evidence presented in open forum and the scientific literature. The draft statement was read in its entirety on the final day of the conference and circulated to the experts and the audience for comment. The panel then met in executive session to consider these comments and released a revised statement at the end of the conference. The statement was made available on the World Wide Web at http://consensus.nih.gov immediately after the conference. This statement is an independent report of the panel and is not a policy statement of the NIH or the Federal Government.
CONCLUSIONS
The management of clinically inapparent adrenal masses is complicated by limited studies of incidence, prevalence, and natural history, including the psychologic impact on the patient who is informed of the diagnosis. Improvements in the resolution of abdominal imaging techniques combined with increased use of abdominal imaging suggest that the prevalence of clinically inapparent adrenal masses will continue to escalate. The low prevalence of adrenal cortical carcinomas and the relatively low incidence of progression to hyperfunction call into question the advisability of the current practice of intense, long-term clinical followup of this common condition. All patients with an incidentaloma should have a 1-mg dexamethasone suppression test and a measurement of plasma-free metanephrines. Patients with hypertension should also undergo measurement of serum potassium and plasma aldosterone concentration/plasma renin activity ratio. A homogeneous mass with a low attenuation value (less than 10 HU) on CT scan is likely a benign adenoma. Surgery should be considered in all patients with functional adrenal cortical tumors that are clinically apparent. All patients with biochemical evidence of pheochromocytoma should undergo surgery. Data are insufficient to indicate the superiority of a surgical or nonsurgical approach to manage patients with subclinical hyperfunctioning adrenal cortical adenomas. Recommendations for surgery based upon tumor size are derived from studies not standardized for inclusion criteria, length of followup, or methods of estimating the risk of carcinoma. Nevertheless, patients with tumors greater than 6 cm usually are treated surgically, while those with tumors less than 4 cm are generally monitored. In patients with tumors between 4 and 6 cm, criteria in addition to size should be considered in making the decision to monitor or proceed to adrenalectomy. The literature on adrenal incidentaloma has proliferated in the last several years. Unfortunately, the lack of controlled studies makes formulating diagnostic and treatment strategies difficult. Because of the complexity of the problem, the management of patients with adrenal incidentalomas will be optimized by a multidisciplinary team approach involving physicians with expertise in endocrinology, radiology, surgery, and pathology. The paucity of evidence-based data highlights the need for well-designed prospective studies. Either open or laparoscopic adrenalectomy is an acceptable procedure for resection of an adrenal mass. The choice of procedure will depend upon the likelihood of an invasive adrenal cortical carcinoma, technical issues, and the experience of the surgical team. In patients with tumors that remain stable on two imaging studies carried out at least 6 months apart and do not exhibit hormonal hypersecretion over 4 years, further followup may not be warranted.
Topics: Adrenal Gland Neoplasms; Adrenalectomy; Aftercare; Aldosterone; Biopsy, Needle; Dexamethasone; Disease Progression; Evidence-Based Medicine; Glucocorticoids; Humans; Hypertension; Incidence; Incidental Findings; Laparoscopy; Magnetic Resonance Imaging; Metanephrine; Patient Selection; Potassium; Practice Guidelines as Topic; Prevalence; Renin; Risk Factors; Tomography, X-Ray Computed; Treatment Outcome
PubMed: 14768652
DOI: No ID Found -
BMC Endocrine Disorders Jun 2004BACKGROUND: Fractionated plasma metanephrine measurements are commonly used in biochemical testing in search of pheochromocytoma. METHODS: We aimed to critically...
A systematic review of the literature examining the diagnostic efficacy of measurement of fractionated plasma free metanephrines in the biochemical diagnosis of pheochromocytoma.
BACKGROUND: Fractionated plasma metanephrine measurements are commonly used in biochemical testing in search of pheochromocytoma. METHODS: We aimed to critically appraise the diagnostic efficacy of fractionated plasma free metanephrine measurements in detecting pheochromocytoma. Nine electronic databases, meeting abstracts, and the Science Citation Index were searched and supplemented with previously unpublished data. Methodologic and reporting quality was independently assessed by two endocrinologists using a checklist developed by the Standards for Reporting of Diagnostic Studies Accuracy Group and data were independently abstracted. RESULTS: Limitations in methodologic quality were noted in all studies. In all subjects (including those with genetic predisposition): the sensitivities for detection of pheochromocytoma were 96%-100% (95% CI ranged from 82% to 100%), whereas the specificities were 85%-100% (95% CI ranged from 78% to 100%). Statistical heterogeneity was noted upon pooling positive likelihood ratios when those with predisposition to disease were included (p < 0.001). However, upon pooling the positive or negative likelihood ratios for patients with sporadic pheochromocytoma (n = 191) or those at risk for sporadic pheochromocytoma (n = 718), no statistical heterogeneity was noted (p = 0.4). For sporadic subjects, the pooled positive likelihood ratio was 5.77 (95% CI = 4.90, 6.81) and the pooled negative likelihood ratio was 0.02 (95% CI = 0.01, 0.07). CONCLUSION: Negative plasma fractionated free metanephrine measurements are effective in ruling out pheochromocytoma. However, a positive test result only moderately increases suspicion of disease, particularly when screening for sporadic pheochromocytoma.
PubMed: 15225350
DOI: 10.1186/1472-6823-4-2