B5.034 Prework 1 Adrenal Mass

Question 1

3 layers of the adrenal gland

Answer 1

capsule
cortex
medulla

Question 2

3 layers of the adrenal cortex

Answer 2

zona glomerulosa
zona fasciculata
zona reticularis

Question 3

what is an adrenal incidentaloma?

Answer 3

an adrenal mass > 1 cm discovered serendipitously

4-6% prevalence, increases with age

Question 4

what are the possible identifications of incidentalomas?

Answer 4

most are clinically non-hypersecreting benign tumors
5% autonomous cortisol production
5% are pheos
1% aldosterone producing adenomas
4% adrenal carcinomas
2.5% metastatic cancer

Question 5

symptoms of pheo

Answer 5

basic triad: headache, sweating, palpitations
about half have sustained hypertension
most of the rest have paroxysmal spells
5% have neither

Question 6

basic overview of pheos

Answer 6

tumor that produces excess catecholamines
equal sex incidence
increasing incidence with age
less than 0.1% of all patients with hypertension

Question 7

rule of 10 for pheos

Answer 7

10% bilateral
10% extraadrenal (paragangliomas)
10% above the diaphragm
10% familial (really close to 30%)
10% malignant

Question 8

lab diagnosis of pheo

Answer 8

elevated plasma fractionated metanephrines
elevated urinary fractionated catecholamines, metanephrines, and VMA
presence of adrenal mass on CT or MRI

Question 9

special technique to image pheos

Answer 9

MIBG scan
pentetreotide
PET scan

Question 10

treatment of pheo

Answer 10

pre-operative preparation with alpha blockers
beta blockers to prevent reflex tachycardia
surgical removal
volume replacement after surgery

Question 11

what is the function of alpha blockers in pheo treatment

Answer 11

decrease chances of labile HTN

can increased chances of orthostatic HTN and reflex tachy, however (thus adding B blockers)

Question 12

histo of a pheo

Answer 12

lots of Golgi in cells producing NE and epi

dark around nucleus

Question 13

patient presentation with Cushings

Answer 13

fat pads
moon face
red cheeks
bruisability
thin skin
poor muscle development
poor wound healing
striae
pendulous adomen
acne
opportunistic infections

Question 14

what is cushings disease

Answer 14

large spectrum of manifestations due to excessive glucocorticoid exposure either from the adrenal gland or exogenous

Question 15

clinical findings in Cushings

Answer 15

truncal obesity
IGT/diabetes in 20-60%
hypertension in 70-80%
hyperlipidemia
coagulopathy
osteoporosis in 30-50%
depression in 50-80%
hypogonadism
central hypothyroidism
decreases growth in children

Question 16

diagnosis options in cushings

Answer 16

24 hr urinary cortisol more than 3x the upper limit
1 mg dexamethasone at 11 PM to 12 AM and measurement of serum cortisol at 8 AM, should be less than 1.8
late evening salivary cortisol

Question 17

action of dexamethosone

Answer 17

substitutes for endogenous cortisol in suppressing ACTH release

Question 18

pituitary MRI in the context of cushings

Answer 18

discrete adenoma will be visible in 35-65% of patients
10% of population 20-40 have incidental tumors of the pituitary with no symptoms
15% of patients with ectopic ACTH have abnormal results on MRI

Question 19

when do you refer to surgery for cushings

Answer 19

unequivocal pituitary neoplasm on MRI >6mm in a patient without ectopic ACTH features

Question 20

options for sources of cushings

Answer 20

pituitary: microadenomas, adenoma, hyperplasia
carcinoid tumor (usually lung)
adrenal: cortical adenoma, carcinoma, hyperplasia

Question 21

what is inferior petrosal sinus sampling

Answer 21

bilateral simultaneous inferior petrosal sinus and peripheral venous sampling for ACTH levels before and after CRH stimulation
compare the ratios of ACTH in the petrosal sinuses to ACTH in the periphery after CRH
>3 = Cushings
ratio more even, carcinoma of the lung a possibility

Question 22

treatment for cushings

Answer 22

curative treatment is transphenoidal surgery to remove the pituitary adenoma
when surgery is not an option, some meds can be given

Question 23

ketoconazole mechanism

Answer 23

nonselective inhibitor of adrenal and gonadal steroids

blocks multiple enzymes in the cortisol pathway

Question 24

ketoconazole adverse effects

Answer 24

headaches, sedation, nausea

potential hepatotoxicity

Question 25

how do you treat cushings when all other options fail?

Answer 25

bilateral adrenalectomy

Question 26

different causes of hypertension

Answer 26

primary hyperaldosteronism
secondary hyperaldosteronism
pheochromocytoma
essential hypertension

Question 27

what is primary aldosterone excess?

Answer 27

high aldosterone, low renin
5-13% of patients with hypertension
20% of patients with resistant hypertension

Question 28

causes of primary aldosterone excess

Answer 28

adrenocortical adenoma (Conn's syndrome) most common
bilateral idiopathic hyperaldosteronism (IHA) due to micro or macronodular hyperplasia, 20-30%

Question 29

secondary hyperaldosteronism

Answer 29

high aldosterone, high renin

usually due to renovascular hypertension, diuretic use, renin secretin tumors, or severe LV failure

Question 30

clinical features of hyperaldosteronism

Answer 30

hypertension
hypokalemia > polyuria, nocturia, muscle cramps, occasional severe muscle weakness, paresthesia, tetany
more common in middle aged women

Question 31

how to screen for hyperaldosteronism

Answer 31

plasma aldosterone: renin ratio in AM, can be on most hypertensive meds
ratio > 20 and plasma aldosterone >15 with suppressed renin
confirmatory test with oral salt loading or saline infusion
24 hour urine for aldosterone and sodium

Question 32

describe a 24 hours urine study for aldosterone

Answer 32

24 hour urine for aldosterone and sodium
individual should be on a high salt diet
sodium excretion should be around 200
this amount of sodium should suppress aldosterone, so if aldosterone >12, there’s an issue

Question 33

adrenal imaging results in hyperaldosteronism

Answer 33

if a solitary, unilateral adenoma >1 cm in a patient <40 y, proceed with laparoscopic resection

Question 34

adrenal vein sampling indications

Answer 34

if CT is normal or nodules are <1 cm, bilateral, or patient is >40 yrs, adrenal vein sampling is the gold standard to determine is localized to one adrenal gland

Question 35

treatment of hyperaldosteronism

Answer 35

decrease BOTH bp and aldosterone levels
laparoscopic resection will cure in 30-60% of unilateral adenomas
if surgery refused or bilateral hyperplasia, BP meds should include aldosterone receptor antagonists

Question 36

aldosterone receptor antagonists

Answer 36

spironolactone

eplerenone

Question 37

tumor marker for adrenocortical carcinoma

Answer 37

serum DHEA

Question 38

potential effects of adrenocortical carcinoma

Answer 38

mass effect symptoms

symptoms related to excess glucocorticoid, mineralocorticoid, androgen or estrogen secretion

Question 39

some typical causes for bilateral masses

Answer 39

generally not endocrine
metastatic disease
lymphoma
infection
hemorrhage

Question 40

examples of endocrine bilateral adrenal masses

Answer 40

ACTH dependent cushings
bilateral pheo
bilateral primary hyperaldosteronism