Adrenal

Question 1

How do you distinguish between different adrenal masses on non con imaging?

Answer 1

• HU -20: myeliopoma
• HU < 10: lipid rich adenoma
• HU > 10 -> CT w/ delays

Question 2

What distinguishes malignant adrenal mass from lipid poor adenoma on CT w/ delays

Answer 2

• washout > 60%: lipid poor adenoma

- washout < 30%: likely carcinoma

Question 3

What distinguishes malignant adrenal mass from lipid poor adenoma on MRI?

Answer 3

• lipid poor: adrenal:spleen < 70%, signal loss > 20%
• malignant: adrenal:spleen > 70%, signal loss < 20%
• myelipoma: high signal on T1
• pheo: high signal on T2

Question 4

What syndromes are associated with malignant adrenal masses?

Answer 4

Li Fraumeni, 
Beckwith-Weidman, 
MEN -1 , 
McCune Albright, 
Carney complex

Question 5

What are the signs of adrenal hemorrhage and how is it managed?

Answer 5

signs: anemia + jaundice + mass

Treatment;

- acute;: spontaneous resolution in months (kids)
- chronic: treat w/ steroids if bilateral

Question 6

What is the functional work up for an adrenal incidentaloma?

Answer 6

1. Cortisol hyper secretion
2. Plasma free metanephrine
3. Aldosterone:Renin ratio (if suspect aldosteronoma w/ htn criteria)

Question 7

What syndromes are associated with pheochromocytoma?

Answer 7

Men 2
VHL
NF1, 
Tuberous sclerosis
sturge weber
hereditary paraganglioma (40%)

Question 8

How do you screen for Cushing’s Syndrome?

Answer 8

• low dose dex (1mg): cortisol at night, measure in AM
• late night salivation: (normally low)
• 24hr urinary cortisol

Question 9

How does Cushing’s Disease get diagnosed?

Answer 9

PM ACTH level

• high: Cushing disesease
• low: ACTH independent

Question 10

How do you distinguish source of ACTH in Cushing’s Disease?

Answer 10

High dose dex

- suppressed ACTH: pituitary
- high ACTH: ectopic

Question 11

If a cortisol releasing tumor is unresectable? How is it managed?

Answer 11

• Aminoglutethime: inhibits cholesterol to prenenolone
  
  • impairs aldosterone
• metyrapone: inhibits 11 beta hydrolase
  
  • DOC has mineralocorticoid effects
• ketoconazole: P450 inhibitor, cholesterol side chain cleavage inhabitation
  
  • liver damage
• mifepristone - cortisol and progesterone receptor blockers
• ortho para DDD (mitotane) - used for carcinoma
  
  • cytotoxic effects

Question 12

What are the signs of a pheochromocytoma?

Answer 12

headache, tachycardia, diaphroesis, HTN, flushing, chest pain

Question 13

how are pheos managed?

Answer 13

• alpha blockade
• beta blockade
• hydration
• excision
• Metyrosine: decreases catecholamine synthesis

Question 14

Mutations in what genes have been associated with Pheochromcytomas?

Answer 14

RET
VHL
mitochondrial succinate dehydrogenase

Question 15

what are the indications for partial adrenalectomy?

Answer 15

solitary
bilateral disease
familial syndrome