all things adrenal Flashcards
Adrenal carcinoma presents in which decades of life typically?
first and fifth decades
Most common presentation of functional adrenal carcinoma?
cushings syndrome and virilization; often with rapid progression
Presentation of pheochromocytoma:
diaphoresis, tachycardia, hypertension
Most common cause of Cushing’s syndrome?
exogenous steroids; second most common cause is Cushing’s disease (pituitary tumor)
Which patients should be considered for laparoscopic retroperitoneal adrenalectomy preferentially over the transabdominal approach?
previous abdominal surgeries and bilateral adrenal lesions
True or False. Large fluid volumes should be used to maintain intravascular volume during and after surgery for patients with pheochromocytomas.
True
Management of cardiac arrhythmias during surgery for pheochromocytomas:
short acting beta blockage such as esmolol or lidocaine
Management of intraoperative hypertension for pheochromocytomas:
sodium nitroprusside drip; can add magnesium
Initial lab test of choice for pheochromocytomas:
plasma free metanephrines; if positive this is followed by 24 hour urine metanephrines to confirm; in equivocal cases a clonidine suppression test may be performed
Initial lab work up of adrenal incidentaloma:
24 hr urine metanephrines, free cortisol levels, evening salivary cortisol levels, plasma aldersterone to renin ratio
First test for work up of cushing syndrome:
24 hour urine cortisol
Which test determines whether the tumor is ACTH dependent or independent?
low dose dexamethasone suppression test
Which test determines the source of the ACTH production of the tumor?
high dose dexamethasone suppression test
What test is used to diagnose pheochromocytoma when a tumor is not visualized on CT or MRI?
MIBG
Test to confirm Conn syndrome (aldosteronoma):
plasma aldosterone to renin ratio: >25
Electrolyte findings in Conn syndrome:
hypokalemia, hypernatremia, low urinary sodium, high urinary potassium, metabolic alkalosis
MRI findings of adrenal cortical adenoma
loss of signal on opposed-phase chemical shift imaging
true or false. an adrenal lesion with <10 hounsfield units on CT has a high likelihood of being benign
true. carcinomas usually have >20 HU
what drug improves overall survival after resection for stage 1-3 adrenocortical carcinoma and is recommended for patients at high risk for recurrence (e.g. tumor spillage)
mitotane
screening tests for hypercortisolism
24 hr urine cortisol and low dose dexamethasone test
if either 24 hr urine cortisol or low dose dexamethasone test are elevated, what is the next test to get?
serum ACTH; if ACTH is low this indicates an adrenal source; if ACTH is high this inidicates an extraadrenal source
what test is ordered to determine the type of extraadrenal source of elevated cortisol and ACTH?
high dose dexamethasone test
suppression of high dose dexamethasone test indicates:
pituitary source
no suppression of high dose dexamethasone test indicates:
an ectopic ACTH producing lesion
first line antihypertensive agent for intraoperative control of HTN for pheochromocytoma
nitroprusside
other options are phentoalmine, nicardipine, labetolol, esmolol
laparoscopic adrenalectomy is relatively contraindicated at what size?
> 6-8cm
true or false. the initial screening test for a pheochromocytoma should be serum metanephrines
false. 24 hr urine metanephrines to screen; serum metanephrines to confirm
indications for mitotane after adrenal cancer resection:
R1 resection
vascular or capsular invasion
intraoperative tumor spillage
high grade disease
surveillance regimen for disease recurrence for adrenocortical cancer after resection:
CT or MRI chest/ab/pelvis every 3 months for 2 years and then every 4-6 months for 5 years
preoperative medical management of HTN for pheochromocytoma:
phenoxybenzamine followed by carvedilol
preoperative medical management of HTN for aldosteronoma:
spironolactone (aldosterone antagonist/K sparing diuretic), ACE-I, ARB and/or calcium channel blocker
postop management after resection of an aldosteronoma:
stop ACE-I; stop spironolactone; gradually wean Ca channel blocker; eat high salt diet to avoid rebound hyperkalemia; repeat BP and chemistry 1 week after surgery
where does the right adrenal vein empty?
directly into IVC
where does the left adrenal vein empty?
merges with inferior phrenic and enters left renal vein prior to emptying into the IVC
biochemical tests for adrenal incidentaloma:
urine metanephrines, free cortisol levels, evening salivary cortisol and plasma aldosterone to renin ratio
arterial blood supply of the adrenal gland:
superior adrenal artery (off inferior phrenic)
middle adrenal artery (off aorta)
inferior adrenal artery (off renal artery)
true or false. large fluid volumes should be given during and immediately after surgery to patients with pheochromocytomas
true. to maintain adequate intravascular volume
pheochromocytomas are derived from what cell type
chromaffin cells of adrenal medulla and sympathetic ganglia
classic presenting symptoms of pheochromocytomas
headache, diaphoresis, palpitations
rule of 10s for pheochromocytoma
10% are malignant, familial, and extraadrenal
most ideal approach for adrenal surgery for patients with bilateral lesions or previous abdominal surgery
posterior retroperitoneal lap adrenelectomy
most common primary tumor to metastasize to adrenal gland
lung
Workup of adrenal incidentaloma:
plasma metanephrines to screen for pheochromocytoma
low dose dexamethasone suppression test to assess for Cushing syndrome
if hypertensive also check renin: aldosterone ratio to rule out aldosteronoma
True or False. If an adrenal lesion measures less than 10 Hounsfield units on CT, the likelihood that it is a benign adenoma is nearly 100%.
True.
Features on imaging concerning for malignancy of the adrenal gland:
> 20 HU, calcifications, heterogenous, >4cm , unilateral
Most important predictor of survival in adrenal carcinoma
adequacy of resection
