all things adrenal

Question 1

Adrenal carcinoma presents in which decades of life typically?

Answer 1

first and fifth decades

Question 2

Most common presentation of functional adrenal carcinoma?

Answer 2

cushings syndrome and virilization; often with rapid progression

Question 3

Presentation of pheochromocytoma:

Answer 3

diaphoresis, tachycardia, hypertension

Question 4

Most common cause of Cushing’s syndrome?

Answer 4

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

Question 5

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

Answer 5

previous abdominal surgeries and bilateral adrenal lesions

Question 6

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

Answer 6

True

Question 7

Management of cardiac arrhythmias during surgery for pheochromocytomas:

Answer 7

short acting beta blockage such as esmolol or lidocaine

Question 8

Management of intraoperative hypertension for pheochromocytomas:

Answer 8

sodium nitroprusside drip; can add magnesium

Question 9

Initial lab test of choice for pheochromocytomas:

Answer 9

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

Question 10

Initial lab work up of adrenal incidentaloma:

Answer 10

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

Question 11

First test for work up of cushing syndrome:

Answer 11

24 hour urine cortisol

Question 12

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

Answer 12

low dose dexamethasone suppression test

Question 13

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

Answer 13

high dose dexamethasone suppression test

Question 14

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

Answer 14

MIBG

Question 15

Test to confirm Conn syndrome (aldosteronoma):

Answer 15

plasma aldosterone to renin ratio: >25

Question 16

Electrolyte findings in Conn syndrome:

Answer 16

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

Question 17

MRI findings of adrenal cortical adenoma

Answer 17

loss of signal on opposed-phase chemical shift imaging

Question 18

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

Answer 18

true. carcinomas usually have >20 HU

Question 19

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)

Answer 19

mitotane

Question 20

screening tests for hypercortisolism

Answer 20

24 hr urine cortisol and low dose dexamethasone test

Question 21

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

Answer 21

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

Question 22

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

Answer 22

high dose dexamethasone test

Question 23

suppression of high dose dexamethasone test indicates:

Answer 23

pituitary source

Question 24

no suppression of high dose dexamethasone test indicates:

Answer 24

an ectopic ACTH producing lesion

Question 25

first line antihypertensive agent for intraoperative control of HTN for pheochromocytoma

Answer 25

nitroprusside other options are phentoalmine, nicardipine, labetolol, esmolol

Question 26

laparoscopic adrenalectomy is relatively contraindicated at what size?

Answer 26

>6-8cm

Question 27

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

Answer 27

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

Question 28

indications for mitotane after adrenal cancer resection:

Answer 28

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

Question 29

surveillance regimen for disease recurrence for adrenocortical cancer after resection:

Answer 29

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

Question 30

preoperative medical management of HTN for pheochromocytoma:

Answer 30

phenoxybenzamine followed by carvedilol

Question 31

preoperative medical management of HTN for aldosteronoma:

Answer 31

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

Question 32

postop management after resection of an aldosteronoma:

Answer 32

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

Question 33

where does the right adrenal vein empty?

Answer 33

directly into IVC

Question 34

where does the left adrenal vein empty?

Answer 34

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

Question 35

biochemical tests for adrenal incidentaloma:

Answer 35

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

Question 36

arterial blood supply of the adrenal gland:

Answer 36

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

Question 37

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

Answer 37

true. to maintain adequate intravascular volume

Question 38

pheochromocytomas are derived from what cell type

Answer 38

chromaffin cells of adrenal medulla and sympathetic ganglia

Question 39

classic presenting symptoms of pheochromocytomas

Answer 39

headache, diaphoresis, palpitations

Question 40

rule of 10s for pheochromocytoma

Answer 40

10% are malignant, familial, and extraadrenal

Question 41

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

Answer 41

posterior retroperitoneal lap adrenelectomy

Question 42

most common primary tumor to metastasize to adrenal gland

Answer 42

lung

Question 43

Workup of adrenal incidentaloma:

Answer 43

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

Question 44

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%.

Answer 44

True.

Question 45

Features on imaging concerning for malignancy of the adrenal gland:

Answer 45

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

Question 46

Most important predictor of survival in adrenal carcinoma

Answer 46

adequacy of resection