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Adrenal > all things adrenal > Flashcards

all things adrenal Flashcards

1
Q

Adrenal carcinoma presents in which decades of life typically?

A

first and fifth decades

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2
Q

Most common presentation of functional adrenal carcinoma?

A

cushings syndrome and virilization; often with rapid progression

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3
Q

Presentation of pheochromocytoma:

A

diaphoresis, tachycardia, hypertension

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4
Q

Most common cause of Cushing’s syndrome?

A

exogenous steroids; second most common cause is Cushing’s disease (pituitary tumor)

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5
Q

Which patients should be considered for laparoscopic retroperitoneal adrenalectomy preferentially over the transabdominal approach?

A

previous abdominal surgeries and bilateral adrenal lesions

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6
Q

True or False. Large fluid volumes should be used to maintain intravascular volume during and after surgery for patients with pheochromocytomas.

A

True

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7
Q

Management of cardiac arrhythmias during surgery for pheochromocytomas:

A

short acting beta blockage such as esmolol or lidocaine

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8
Q

Management of intraoperative hypertension for pheochromocytomas:

A

sodium nitroprusside drip; can add magnesium

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9
Q

Initial lab test of choice for pheochromocytomas:

A

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

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10
Q

Initial lab work up of adrenal incidentaloma:

A

24 hr urine metanephrines, free cortisol levels, evening salivary cortisol levels, plasma aldersterone to renin ratio

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11
Q

First test for work up of cushing syndrome:

A

24 hour urine cortisol

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12
Q

Which test determines whether the tumor is ACTH dependent or independent?

A

low dose dexamethasone suppression test

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13
Q

Which test determines the source of the ACTH production of the tumor?

A

high dose dexamethasone suppression test

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14
Q

What test is used to diagnose pheochromocytoma when a tumor is not visualized on CT or MRI?

A

MIBG

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15
Q

Test to confirm Conn syndrome (aldosteronoma):

A

plasma aldosterone to renin ratio: >25

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16
Q

Electrolyte findings in Conn syndrome:

A

hypokalemia, hypernatremia, low urinary sodium, high urinary potassium, metabolic alkalosis

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17
Q

MRI findings of adrenal cortical adenoma

A

loss of signal on opposed-phase chemical shift imaging

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18
Q

true or false. an adrenal lesion with <10 hounsfield units on CT has a high likelihood of being benign

A

true. carcinomas usually have >20 HU

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19
Q

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)

A

mitotane

20
Q

screening tests for hypercortisolism

A

24 hr urine cortisol and low dose dexamethasone test

21
Q

if either 24 hr urine cortisol or low dose dexamethasone test are elevated, what is the next test to get?

A

serum ACTH; if ACTH is low this indicates an adrenal source; if ACTH is high this inidicates an extraadrenal source

22
Q

what test is ordered to determine the type of extraadrenal source of elevated cortisol and ACTH?

A

high dose dexamethasone test

23
Q

suppression of high dose dexamethasone test indicates:

A

pituitary source

24
Q

no suppression of high dose dexamethasone test indicates:

A

an ectopic ACTH producing lesion

25
Q

first line antihypertensive agent for intraoperative control of HTN for pheochromocytoma

A

nitroprusside

other options are phentoalmine, nicardipine, labetolol, esmolol

26
Q

laparoscopic adrenalectomy is relatively contraindicated at what size?

A

> 6-8cm

27
Q

true or false. the initial screening test for a pheochromocytoma should be serum metanephrines

A

false. 24 hr urine metanephrines to screen; serum metanephrines to confirm

28
Q

indications for mitotane after adrenal cancer resection:

A

R1 resection
vascular or capsular invasion
intraoperative tumor spillage
high grade disease

29
Q

surveillance regimen for disease recurrence for adrenocortical cancer after resection:

A

CT or MRI chest/ab/pelvis every 3 months for 2 years and then every 4-6 months for 5 years

30
Q

preoperative medical management of HTN for pheochromocytoma:

A

phenoxybenzamine followed by carvedilol

31
Q

preoperative medical management of HTN for aldosteronoma:

A

spironolactone (aldosterone antagonist/K sparing diuretic), ACE-I, ARB and/or calcium channel blocker

32
Q

postop management after resection of an aldosteronoma:

A

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

33
Q

where does the right adrenal vein empty?

A

directly into IVC

34
Q

where does the left adrenal vein empty?

A

merges with inferior phrenic and enters left renal vein prior to emptying into the IVC

35
Q

biochemical tests for adrenal incidentaloma:

A

urine metanephrines, free cortisol levels, evening salivary cortisol and plasma aldosterone to renin ratio

36
Q

arterial blood supply of the adrenal gland:

A

superior adrenal artery (off inferior phrenic)
middle adrenal artery (off aorta)
inferior adrenal artery (off renal artery)

37
Q

true or false. large fluid volumes should be given during and immediately after surgery to patients with pheochromocytomas

A

true. to maintain adequate intravascular volume

38
Q

pheochromocytomas are derived from what cell type

A

chromaffin cells of adrenal medulla and sympathetic ganglia

39
Q

classic presenting symptoms of pheochromocytomas

A

headache, diaphoresis, palpitations

40
Q

rule of 10s for pheochromocytoma

A

10% are malignant, familial, and extraadrenal

41
Q

most ideal approach for adrenal surgery for patients with bilateral lesions or previous abdominal surgery

A

posterior retroperitoneal lap adrenelectomy

42
Q

most common primary tumor to metastasize to adrenal gland

A

lung

43
Q

Workup of adrenal incidentaloma:

A

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

44
Q

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%.

A

True.

45
Q

Features on imaging concerning for malignancy of the adrenal gland:

A

> 20 HU, calcifications, heterogenous, >4cm , unilateral

46
Q

Most important predictor of survival in adrenal carcinoma

A

adequacy of resection

Adrenal (1 decks)

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