In this guide to working up adrenal masses, endocrinologist Chienying Liu, MD, clears away the confusion on screening and interpretation of results. She provides usable flowcharts and tables showing appropriate tests to order as well as guidelines on testing protocols that optimize accuracy, plus tips on medications and conditions that can muddy results or cause false positives.
uh Welcome everybody and thank you for coming into this webinar. So I'm going to talk about woke up in a genome ass um This is not another common uh problem, but you will definitely see at least a couple of cases in your lifetime. So uh first of all I want to show you what ct of the adrenal glands look like, what a normal adrenal glands look like. Okay, so you see the uh the adrenal glands those are normal. This is a cross sectional plane so that inverted y inverted the or triangular shape in some people call it. Uh And this corn rural view. You can see this right adrenal right here, normal adrenal. And then you can see this adrenal mass coming up of the left adrenal gland. I just want to briefly review the anatomy and also steroids, organic pathways of the adrenal gland as you remember. And you can see uh the adrenal gland is composed of various layers here. You have the capsule and the cortex where various adrenal steroids are sympathized and medulla where the cattle colonies are sympathized. You can see in the cortex there are three layers. Um And al dash is treated in the infirmary Lohse cortisol is secreted in the physical lara and in regions are sympathized in the particular Larrys. And then um cata colonies sympathized in the body. So the steroids will become as well as the cat colonies will become important in terms of chemical evaluation tumors arising from the cortex and mostly adenoma can be functional or nonfunctional and really adrenal cortical carcinoma, tumors arising from the majella. Our video cuomo said thomas. Yeah. So when assessing when adrenal mass, it is important to assess for Molina potential and functionality, imaging fino type and characteristics become very important in the assessment of adrenal mass. In addition to biochemical evaluation, this was history and fiscal biopsy is really rarely needed so broadly. Um Adrenal mass can be grouped based on functionality. We're not they are malignant and adenoma is a benign region that can be functional secreting corridor industrial rarely androgynous or non functional. Um And ch congenital adrenal hyperplasia uh usually present with bilateral general masses and can be functional because of enzymatic deficiency leading to accumulation of precursors. Massive macro modular disease is associated with apparent between receptors that can lead to cushion syndrome. Pio Commerce Saitama is usually benign but 10% or more can be movement and you can see the non functional vision here. Adenoma, milo lipo, Maciste, ganglion aroma hemangioma. They're usually denied and non functional primary adrenal cancer extremely rare and can secret virtually any adrenal steroids. He can also be nonfunctional uh atrocities. Uh many cancers can metastasize to the adrenal gland being foam, adrenaline. Diplomas are very, very rare if biopsies ever needed to be in this situation. To diagnose lymphoma and to diagnose atrocities otherwise is rarely needed. And imaging features and biochemical workout can be clean, provide information. Now these lesions are frequently denied appearing. I'm imaging cT or MRI. Whereas these lesions, even though field can be benign, most of them are benign and ganglia in your own mind, hemangioma are benign. They can they can appear suspicious on imaging. So it's very difficult to sort out based on imaging. 100%. And this is what about chemical work up? Will be helpful. So let's review imaging characteristics because they are important in the evaluation of the genome. Ass ct characterization of general mass relies very much on hans field unit. So hans begin essentially is a attenuation value of the vision. It's essentially is a density measurement by C. T. So you can see water has zero Huntsville unit fat minus 100 air minus 1000 adenoma usually have higher into a cytoplasmic back. Therefore it has lower monthly unit compared to theo coma, saitama, adrenal, cortical carcinoma or um atrocities The cut off of 10 on non contrast ct very important on non contrast ct has been accepted by many of us to identify an adenoma. You can see they're highly this cut off is highly specific for an adenoma. So if you have a lesion that has 1000 unit or lower is very much an adenoma, you will miss a few cases. The case is that your missus probably small field home aside Hamas um uh and and other etiology. But again the majority of cases will be denied adenoma lesion. Brandon 10 Hunts Vienna can be seen in about 10 or 40% of looking for adenomas. And this is where radiologist we do wash out. They will look at the contrast on delayed C. T. And and uh and this is based on the findings that adenoma must enhance rapidly but also have rapid wash out of I. V. Contrast compared to non adenomas. And here are the studies and criterias um that you know some radiologists will use. Uh this is not for you to remember. This is just F. Y. I. Caveats are close to 30% of feel. Diplomacy thomas may be misclassified as an adenoma purely Just look at it based on the person washout. Because some fields up to 30% of fields can wash out. Uh And why shall may not be reliable in identifying a political adenoma? Especially if hans unit is very high on non contrast cities. For example in the high thirties or high forties you may miss a malignancy if you rely on washout. Um So what about my characterization? Uh Chemical shift on my is another way to identify an adenoma. There's lots of physics here I can fully understand but suffice to say that fathom water have different resonance frequencies and so adenoma typically has in face Out of phase signal drop off on the T1. You can see this is in phase out of phase. There's a signal drop off. Okay, so this is just another way of saying that there is back in the tumor but you can also see that signal drop off is kind of objective, right? Um It's just so the darker than this than in face. Um Many of us actually do prefer C. T. Two M. I. For the initial evaluation and assessment of adrenal consequence of Roma. So this light summarizes the ideologies of adrenal incident of Hamas and also biochemical work up when she consider the numbers here indicate the prevalence of various types of adrenal masses that you can see. Um And so for field based on this study, I like the study by cat word at all from 2000 and nine because this study excluded all the patients with non malignancy, so it's truly an incidental. So based on the study, theo common saitama has a prevalence of 3.1% of all Adrenal incident lomas. Other studies have demonstrated up to 5%. Um and primary industrialism 0.6%, up to 2%, hyper capitalism or subtle chorizo access 6.4% is the most common abnormality. You know during the incident to a Muslim. You have other etiologies that are not common, so fulfill you in general, you want to screen in all adrenal masses. The exceptions are if the vision look like a simple cyst or a clearly milo like coma or a clearly adenoma. On imaging, you can skip worker for fear Hamas, saitama. And this other test that you want to get your mental difference uh and or platform and reference in terms of AL dash on you want to screen for all nationalism. Primary nationalism. If the person has hypertension and this is regardless of hypo khalid Miya or not. And this are the test that you want to get and I want to come back why potassium is informed. Mhm. For quarters of access, another name for that is autonomous course of situation. We're talking about subtle cortisol ophthalmology. This is uh this is the most common abnormalities that you can see in the work of adrenal incident to lomas, rarely christmas syndrome. Okay. Um and the test will be one malignant medicine. and if it is abnormal, you can get additional testing facility here and I'll come back to each individual um tumor type and for the other uh adrenaline theologies for ch uh adrenal steroids that you want to get. And for A. C. C. It literally can decrease all kinds of steroids. And so these are the common steroids that we typically get again clinically appropriate. You can get additional testing. Um uh The other day we have a patient with dope secreting tumor. So you want to get a dope in that situation. Um Obviously this is not gonna be primary care. We can definitely help out with work out of these masses. Let's look at fia chroma saitama specifically. So uh two more secretion of catacombs means essentially determines the symptoms. So you can see the presentation can be variable because it depends on how frequent and how much the cat colonies are she created. So the classic symptoms we know about our episodic spells of headaches, sweating palpitations. Some patients present with paroxysmal hypertension. Some patients present with sustained hypertension with or without proximal blood pressure elevations. And some patients have completely normal blood pressure. But there is a massive amount of reserve of catacomb means waiting to be provoked to be released. And so, um, you know, some can present in crisis because of this uh, this huge amount of catacomb reserve, they presented crisis. They presented multi organ failure when there's a sudden release of massive amount of category means other symptoms are cardiomyopathy, arrhythmias, intestinal uh, ischemia and areas because cattle colonies are not secreted in constant fashion. And so measurement of cat economies will miss the diagnosed with glaucoma saitama. And the advancement in diagnostic testing came from the understanding that there is continuous inter to mineral metabolism of the cattle colonies to melton efforts. Melton ephron annual minimum effort. And there's similar metabolism in a normal ganglia as well as the madura. So there is continuous secretion of this metabolized into the circulation and therefore the metabolites will be your diagnostic test. And in january tumor size is strongly possibly correlated with the plasma concentration of men efforts. So you can measure the metabolites of catacomb means plasma. Made reference or urine uh fractionated magnificence. And here are the two studies comparing the sensitivity of of both both NIH and Male clinic. If you look at plasma magnificence, highly sensitive, highly sensitive. Okay. Um and essentially if the test is negative, you pretty much ruled out all common sight on the only lesions that you'll miss are the small fields uh very small, usually smaller than once a year in terms of the urine. Uh, NIH and Mayo clinic studies are slightly different as you can see for the NIH study. They looked at your in making efforts and that's where the the recommendation came from. Because it has also equally highly sensitive, 97% less, much less specific. Whereas male clinic in their studies, they found the metal difference and cata colonies in the urine actually, uh uh we're more specific compared to the the compared to the plasma. And this is especially true in older patients. Okay. But in terms of recommendations and woke up either one is really fine. Especially based on Nike study. If you have a low suspicion for a tumor to F Yokohama saitama and the patient is older. You could potentially do the urine study based on male clinic studies. All right. So let's take a look at how we do this, you know, a diagnostic test. And appropriately so for plasma men efforts. The recommended optimal testing condition is to have patience on the supply position for 30 minutes. This is recommended by endocrine society 2014 guidelines. And I don't know which lab actually can do this in the United States. But there's several studies have demonstrated that if you have them sit at the chair, not the waiting room chair, you really want them to sit without standing up for 15 minutes. The sensitivity and specificity will be just as good. Okay, so this is what we tell our patients fasting in the morning to see the at the lateral table for 15 minutes. And this can minimize the sympathetic stimulation when you stand up. Okay. The average feel size in a symptomatic patient is intrigued by centimeter and so a level that is at least 3-4 times elevated or consider uh diagnostic. And so the calabria is um there there can be mild about chemical abnormalities in small fields. And this is the situation where it can be difficult to tease out. Are the test results mildly positive because false positive or are they do too small? Your homosexual moms and imaging evaluation can be potentially helpful in this situation. There is whole list of medications that can cause physiologic increase in catacomb. Me who are affecting we uptake or metabolism of cata Comics listed here and they should be discontinued. It possible if you look at a sympathy sympathy emblematic asians, these agents can increase catacomb institution and various antidepressants including my secret uh antidepressant uh serotonin re uptake inhibitor selective or non selective uh cocaine. They inhibit the uptake of catacomb needs from the uh synaptic cleft. Therefore there's increase catacomb means um and increased plasma made reference as well. Mono amine oxidase uh inhibitors block the conversion of more epidemic and epinephrine to non active uh metabolites. Um And so uh you know this can again cause false elevation in the catacombs means as was mentioned difference. Anti psychotics uh dopamine agonist and some of the psychotropic drugs can cause catacombs release and there's alcohol abuse. Medical stressors, medical illnesses can cause catacomb release. And so we want to be careful um You know if patients apnea particularly you can give you a false positive result. Yeah So this is a summary slide that up 3-45% of Katrina incidental lomas can be field homicide Hamas and patients may be completely asymptomatic but that doesn't mean I don't want to treat because there's a huge reserve of category names in the tremor and they can they can present in crisis. um and resulting in death. And you want to work up in all patients with um even including patients with normal Tennessee because C. T. Mm I can really cannot really differentiate, feel chroma saitama from metastases or dreaming for carcinoma. Many of them have high function in a there are vascular and they have a genius. And this is where chemical workout will be very important. The exceptions for you not to do with your work up is if the vision is clearly a simple adrenal cyst or a uh milo like coma were clearly an adenoma. Which on C. T. U. B. Husky. And that 100 and less and homogeneous. Okay, the lower the country and the more likely the vision is an adenoma, not a homosexual. Mhm. You always want to treat with an alpha blocker priority surgery. And this is including patients are completely asymptomatic. Just because. Remember, there's a huge reserves of category means that can be secreted release doing surgery. All right, let's move into primary abolitionism. So vocations with adrenal incident aroma screening for primary audition is um is recommended if they have hypertension. The prevalence of primary doctrine is um in this situation is up to 2%. And I want to take this opportunity to review other indications from endocrine society. Clinical practice guidelines. Uh to review other indications for screening for primary doctrine is um patients on medication, three or four entire potential medications, patients with hypertension and hypotension colonial, either spontaneous or on diabetics. Keep in mind that most patients with primary and optimism are normal. Kalinic Patients with hypertension and sleep apnea. In one study, they found prevalence of primary nationalism was as high as 34%,, patients with hypertension. And first degree relative with primary or doctrine is um, patient with hypertension and family history of stroke and hypertension. At a young age, they started a situation that we will be thinking about familial primary reductionism. So why screening for climate? All documents? All right. Um, Well, doctrine has been demonstrated to have negative cardiovascular facts. And one third of patients with primary or nationalism can be actually surgically corrected and so you don't want to miss this opportunity to happen. The patient takes fewer medications. However, there are various screening because testing for primary optimism can be very cumbersome, tedious and costly. Saddle was cast. Case detection. Case confirmation and adrenaline sense maybe medications right? Um, and not to mention the straight cut off values can be very difficult to establish. So, you do want to pick a number that gives you a good chance to establish the diagnosis, and that can potentially be to a surgical cure or have patient treatment medically appropriate. All right. So talk about his detection. So the recommended protocol is because adoption is affected by timing of the day and the posture. So you want to do it correctly. Uh, It should be done in the morning. The patient should be out of bed at least two hours, walking around at least for two hours and then they should be seated for five or 15 minutes. And you want to measure concurrently plasma adoption concentration in plasma screen in activity. And you calculate the ratio. So the cut off ratio is between 20 to 40 as positive case detection have been used in various studies. And so this is what we are looking at. However, um we do have to use common sense. Right. If you just relying on the ratio, it can be misleading. For example, uh uh, the production level three is completely normal. Not even elevated, But if you have a plot marine activity, that is 0.01 the racially 300. But this person obviously does not have primary documents. So you want to make sure abduction is at least elevated. Um and 10 is pretty much Uh, what we use for the cut off now, you know, I would say a couple of years ago, maybe three or five years ago we have advocated for 15 being a cut off. However, one study demonstrated that about 16% of patients with primary, our optimism can have elder level less than 15. So 10 is pretty much the cut off that we use now and you want to make sure the plas marine activity is suppressed and one is a cut off threshold and just keep in mind that, you know, this is the cut off and we may end up doing more evaluations. Um, but this is not to miss uh, many patients with the possibility of primary and optimism. Obviously, the higher the additional level, the higher likelihood of this patient having primary are dashing muslim. All right. Um, there are medications that can affect the test results that may need to be stopped if there's a strong suspicion for primary on nationalism and I want to relieve this. I think it's always fun to be some basic theology. So this has been an NGO taste introduction system that if you remember from medical school or residency. Um, so the kidney is here, the adrenal and so the gesture go mellow apparatus produces rena and in the liver It converts plasma angiotensin it into Angiotensin one and the angiotensin converting enzyme that converts into a tencent one angiotensin two, which has a basal constrictive properties uh leading to elevate blood pressure is also essentially vascular vascular toxicity. It also endure 10cent 2. Also stimulate a dream of going to secret held Austria and the Al dash woman exerts its effects with uh sodium retention and potassium loss in the kidney. So when you have an adenoma, Dawson secreting adenoma, what's going to happen is you're going to have um increased renal filtration, increased sodium retention and increased renal filtration. And you're going to have decreased plasm of union activity. Uh huh. Um So with medications, let's take a look at a few medications. So if you have a direct rina inhibitors, you're going to block this and therefore Plaza marina when measure is going to be elevated and then L doctrine is going to be lower. If you have AIDS inhibitor, similarly, Plaza marina and activity is going to be elevated and then allegations gonna be decreased. Similarly a RV elevated plasma being an activity or L DASH cam, where is the beta blocker? It blocks the step here and therefore you're going to have lower Plaza marina activity as well as how doctors levels. So this table summarizes how medications would change held a strong and plaza marina activity levels. We saw beta blockers decreased platform, arena and L. Doctorow including does the same thing and says do the same thing as well A. S. And they are be increased plasma union activity, decreased testosterone. The dye hydro paradigm calcium channel blocker like no mask has some effect but not huge and minimum affecting our National diuretics increase both hypo Kalina, decreased progesterone, hyper Kalina, increase your testosterone so load decreased our National in normal individuals and salt restriction increase increase on a national level. And so let's go back to this. So so you can see the directions of the albuterol and plasma medium levels with this medications. And so if the suspicion for primary industrialism is very high and the numbers do not make sense, We'll have to stop some of these medications. And so the scenarios I'm talking about is when you have plasma arena activity above one, especially those people on H. A. R. V. or uh production concentration less than 10. This is the situation that you want to consider to start the medications and this durations are recommended by the endocrine society. Spironolactone. Colonel Miller. Right, try interim for at least for 4 to 6 weeks, four weeks minimum. And potassium wasting directly. Four weeks other medications. Two weeks uh will be sufficient. Yeah, confirmatory tests. I just want to show you it's tedious even to endocrinologist. Yeah. The the two confirmatory tests are very popular in the United States. They're actually for at least four and so are so low you do three days of oral solo. We're talking about six g of sodium or 15 tablets of sodium chloride. And you want to make sure sodium is elevating era. So you want to do a urine sodium as well. And the idea is going to give an assault in normal individuals, your adoption should be suppressed. Okay, Similarly with normal saving. Again, we can help with this you uh, if there's a suspicion for your patients who have primary factionalism. However, you may be able to actually make the diagnosis of primary or doctrines and we don't confirmatory testing. So when to skip, come from a tweet us in their situations. So this is the guidelines from 2016. Remember how high pakhalina would decrease their doctrine, right? So if you have spontaneous hippo Collini um and you get your L doctrine back that is elevated. Of course the Plaza initiative, you know, undetectable or less than one, then you don't need further confirmatory test. Okay, Because there's no situation that can lead to this kind of clinical profile. Hype. Okay, linear again, has to be spontaneous. Okay. Not on diabetics. So the guidelines were published in 2016 and this was actually verified by a study in Japan uh in 2019. So this is a retrospective studies looking at the role of al dashing and potassium sparing confirmatory test for primary and nationalism. So they looked at 327 cases detection positive hypertension, hypertensive patients, they all have plans marine activity less than one. And they were able to confirm primary reductionism. They use capital Polio Challenge test. 252 patients were confirmed to have primary protectionism. Then they look at potassium level and national level. So if you have L dash in level that is greater than 20 but not As high as greater than three. When you have spontaneous hip pocketing, 3.4 or lower, 100% of them. A 100% of them were diagnosed or confirmed to apply introductions. Now, if you have very high elevation level, grand in 30, regardless of potassium level, 100% of the patients will confirm to find real nationalism. So you can actually make the diagnosis in the office again, this is the situation where you do want to get a potassium level concurrently with abduction and possible interactivity. Alright, so summary you want to obtain abduction and plasma mean activity came seven participants part of it and rest of the electrolytes. You want to make sure the patient is seeded for 5-15 minutes after waking up for at least two hours. And if you have elbow level that is more than 10 plasma or even suppress. Regardless of medications you can pursue with confirmatory testing because that means a inhibitor was born electron have not exerted effects enough to raise the plasma women activity to one. Yeah. Um, for confirmatory testing, um you may be able to skip if you have elder that is greater than 20. We spontaneous typically mia or elder that is very elevated within 30 regardless of potassium level. But again, keeping my the plasma meaning activity should be all suppressed as we work. All right, let's moving onto autonomous quarters of secretion. Um This is a topic. Um, It's really abnormal. Hp A hypothalamic pituitary adrenal access testing with subtle cortisol hyper secretion. Um And so so we're not talking about obvious between christians patients where patients will definitively benefit from a dream elected. I find this topic a little bit more difficult to talk just because there's really no consensus in defining this condition. Okay. All right. Let's move on. Suffice to say that one militant mrs on suppression test is the most sensitive test for this for autonomous quarters of secretion that can be settled. And so what you do is you want to give accepted song at 11 mg? Uh, at 11. I'm sorry. This is a P. M. This is the type of here at 11 p.m. Then you obtain quarters or between 8 to 9 o'clock in the morning. You also want to get a medicine level and the reason you want to get a text medicine level because some of us, um, some patients are metabolized exercises quite rapidly so the decks may not reach a level high enough to suppress the result. And even though this is the best has high sensitivity is not very specific because false positivity is not uncommon. You can see false positivity in patients with obesity, sleep apnea, any stressors, illnesses, uh and women or contraceptives or contraceptives, increased cortisol binding globulin. So total quarters or will be major elevated and there will be false positive results and will be non suppressed. So you want to avoid this test in women taking oral contraceptives. So let's take a look at possible results. So the cut up 1.8 or lower is considered normal and you're done. You stop here. However, if cortisol is very elevated Above five is considered you know elevated um and based on the guidelines from the european um society um they they wanted us to consider autonomous quarter situation when you have a level that is greater than five. And they recommend additional testing and I definitely agree we definitely want to do A. C. T. H. Because you know hyper cortisol is um could be due to a c th dependent process not adrenal. So they see th will be elevated, not suppressed. You can look into celebrate cortisol level to see the consistent with elevated cortisol. Um you can do 24 years and three quarters all to assess for the degree of a hyper quarters of the time. They also recommend to consider repeating dexamethasone suppression test in 3 to 12 months. And I would add D. H. A. Self faith because in adrenal christians in adrenal hyper capitalism. Dhe a self it is usually very long or suppressed. What about if it is just mild abnormality? So the society guidelines recommend consider this between 1.95 possible autonomous cortisol hyper secretion. Um And they recommend additional testing measuring huth again, you could potentially repeat uh depression testing for 12 months as well. And I would add dHS something as well that could be potentially harmful. All right. So um So what do you do with abnormal testing results? This slide is a little bit busy, but this is from the guidelines, Your european society guidelines uh adrenal incident Aloma. So what do you do? Right. Um We really don't have good data to recommend conclusively what to do when you have abnormalities like this. Again, we're not talking about a dream of christian. This is subtle adrenal access or autonomous autonomous quarters of secretion. We also don't have enough data to support that these patients will benefit definitively from surgery. Mhm. Um So let me uh just walk you through the slide here. So you do one moment. Tax you look at the different levels. It's normal. You're done. Then when it's mildly abnormal you want to consider possible autonomous quarters of secretion. Then they recommend look at look for any mobility's potentially related to autonomous course of secretion. And those are the mobility's hypertension, glucose intolerance, type two, diabetes, obesity, diesel academia, osteoporosis. Those are so common in our society nowadays. Right. Um And so if you have one of those probabilities when you have mild abnormality, surgery will be rarely needed. Even they also you know because they smiled. Uh And they are very common conditions will be this would require searching, will require multidisciplinary discussion. Okay. But they do recommend follow up testing when you have a test result that is a little bit more abnormal. Return fire. Then you want to consider this autonomous cortisol secretion. And if they have any of the cool mobility's surgery could be potentially consider more frequently. Um or you can consider the key testing. So this are the guidelines firm that european society. Um Again I find this topic very difficult just because lack of consensus and this can be difficult in primary care settings as well. We discussed even in our Katrina conference with surgeons, with my colleagues in endocrinology. So we will definitely help you out if you have any of these patients like this. All right. So we went through the top three adrenal pathologies, feel homicidal, primary Aldo and cortisol access. Um And I want to just summarize um know sort of um work out how do you you know take care of those three pathologies. So my proposed work out for an adrenal mass. The first passes you wanted to fasting apps uh fasting platform and reference. Make sure they are seated um And also abdominal basically seated as well. But they need to be walking around for at least two hours. And you can throw in a. M. A. C. Th course on dhc solving. Um You could, sorry uh We see you chris gibb plasma magnificence if the mass is clearly adenoma assist or a mile or like toma mm You with skip this if the person has no hypertension. Okay? And then after the passing labs then you can do the dex suppression. Then you want to obtain both quarters of index Memphis and novels. Again we can help and work up the adrenal mass for you. No problem. Just give us a call or your patient to us. Um All right so let's come to the last category of other etiologies. They are not common adrenal. Um The gentle do not hyperplasia can present with bilateral renal message. They're usually um milo like Hamas and there um and we can do a testing for you. The common steroids ordered are 17 or H. P. D. H. A. Self a testosterone, interesting dialogue about the store steroids as appropriate between a quarter concussion oma is very rare. 1.9% of all adrenal incident to lomas. Um They're different steroids you can order. This is just some of them. Okay you have to look at their com com presentation Genome which has seen is very rare. As you as you see here in patients without any nor malignancy, less than 1%. I want to. This is my last slide of this presentation. Wanted to emphasize that for larger gino masses suspicious for angina, cortical carcinoma or large boko saitama. Please feel free to reach out for immediate triage. Uh This is my email. You can reach out to any of the physician liaisons as well. We will get your patient in and try out to them and work it out appropriate. So this is uh endocrine service team. I'm based at the endocrine clinic here at harnesses. Um There are many of us, so there's no pictures here, but you can google it, there's link you can get to know us and I also work with endocrine surgeons very closely. We worked very closely together And if you're patient car surgery they will go to this clinic and I do work at this clinic one session a week and here is our contact info.
