Adrenal

Question 1

Most common mets to adrenal come from where?

Answer 1

Lungs, kidney, breast, GI tract, melanoma

Question 2

At what size does does risk for cancer increase?

Answer 2

more then 4-5 cm

Question 3

Contrast washout for benign adenoma

Answer 3

take up contrast fast and washout fast

Question 4

contrast washout for cancer

Answer 4

take up contrast fast and washout slow

Question 5

normal cortisol level after dexamethasone test

Answer 5

should be suppressed to less than 1.8 ug/dL

Question 6

value for hypercortisolism on dexamethasone test

Answer 6

> 5 ug/dL

Question 7

abnormal/indetermine value for subclinical hypercortisolism on dexamethasone test

Answer 7

1.8-5 ug/dL

Question 8

how do you confirm hypercortisolism

Answer 8

ACTH level and 24 hour urinary cortisol level (of midnight solitary cortisone level)

elevated urinary cortisol level and a low of suppressed ACTH supports hypercortisolism

Question 9

what aldosterone : renin ratio is dx of Conn’s

Answer 9

> 20

Question 10

what test to confirm Conn’s after aldosterone:renin ratio?

Answer 10

aldosterone suppression testing

saline infusion test or 24 hour urinary aldosterone test while patient is on high salt diet

Question 11

how long does patient need to be off spironolactone before testing for Conn’s?

Answer 11

6 weeks

Question 12

who to get adrenal vein sampling in?

Answer 12

bilateral adrenal nodules
unilateral nodule less than 1 cm
normal appearing glands
age older than 45 years old to see if unilateral hyper secretion amenable to surgery

Question 13

if plasma free metanephrines mildly elevated what test to get next?

Answer 13

24 hour urine catecholamines and fractionated metanephrines

Question 14

How to screen for sex hormone secreting tumor

Answer 14

plasma DHEA sulfate level, elevated levels concerning for adrenocortical carcinoma

also check 17-estradiol is feminization in men or post menopausal women

Question 15

who can you not do laparoscopic adrenalectomy?

Answer 15

large suspected ACC greater than 6-7 cm

Question 16

what are the approaches to lap adrenalectomy?

Answer 16

trans abdominal lateral or retroperitoneoscopic

Question 17

when to avoid the retroperitoneoscopic approach?

Answer 17

larger tumors greater than 4-5 cm and obese patients with BMI greater than 35

Question 18

pre op prep for pheo

Answer 18

alpha blockage with phenoxybenzamine or doxazosin then beta blocker if needed

high sodium diet and liberal fluid diet to prepare for catecholamine induced intravascular depletion

Question 19

post op for pheo

Answer 19

stop alpha blocker

continue other HTN only if needed for essential HTN or chronically on beta blocker

Question 20

hyperaldosterone pre op tx

Answer 20

spironolactone and potassium supplementation

post op spironolactone stopped

Question 21

follow up for pheo after surgery

Answer 21

annual biochemical testing

Question 22

follow up for Cushing’s after surgery

Answer 22

glucocorticoid therapy post op that is weaned once HPAA recovered

Question 23

Follow up if surgery not done

Answer 23

CT every 3-6 months then annually for 1-2 years
biochemical testing annually for up to 5 years

excise if lesion has grown or shows signs of hypersecretion

after 5 years if no other symptoms can stop follow up