Canadian Urological Association guideline: Diagnosis, management, and followup of the incidentally discovered adrenal mass

Question 1

What is the definition of adrenal incidentalomas?

A. Adrenal masses larger than 2 cm in size that are detected on cross-sectional imaging performed for an unrelated indication.
B. Adrenal masses larger than 1 cm in size that are detected on cross-sectional imaging performed for an unrelated indication.
C. Any adrenal masses detected on cross-sectional imaging performed for an unrelated indication.
D. Adrenal masses larger than 1 cm in size that are detected on cross-sectional imaging performed for a related indication.

Answer 1

B. Adrenal masses larger than 1 cm in size that are detected on cross-sectional imaging performed for an unrelated indication.

Explanation: The definition of adrenal incidentalomas is adrenal masses larger than 1 cm in size that are detected on cross-sectional imaging performed for an unrelated indication. These lesions are common and most of them are benign non-functioning adrenocortical adenomas.

Question 2

What are the three main categories into which adrenal incidentalomas can be broken down?

A. Malignant, benign hyperfunctioning, and benign non-functioning lesions.
B. Malignant, benign, and intermediate lesions.
C. Non-functioning, hyperfunctioning, and metastatic lesions.
D. Benign, malignant, and metastatic lesions.

Answer 2

A. Malignant, benign hyperfunctioning, and benign non-functioning lesions.

Explanation: Adrenal incidentalomas can be broadly categorized into three types: malignant, benign hyperfunctioning, and benign non-functioning lesions. Each category includes several potential etiologies, and the most common type is a benign non-functioning adrenal adenoma.

Question 3

What should the workup for an adrenal incidentaloma include according to Recommendation 1?

A. A comprehensive medical history and physical examination.
B. A focused history and physical examination aimed at identifying signs/symptoms of adrenal hormone excess, adrenal malignancy, and/or extra-adrenal malignancy.
C. An in-depth laboratory testing to identify signs of adrenal hormone excess.
D. Imaging studies to identify the size and location of the adrenal incidentaloma.

Answer 3

B. A focused history and physical examination aimed at identifying signs/symptoms of adrenal hormone excess, adrenal malignancy, and/or extra-adrenal malignancy.

Explanation: The workup for an adrenal incidentaloma should include a focused history and physical examination. The aim of this is to identify signs or symptoms of adrenal hormone excess, adrenal malignancy, and/or extra-adrenal malignancy.

Question 4

When should there be a low threshold for a multidisciplinary review by endocrinologists, surgeons, and radiologists according to Recommendation 2?

A. When the imaging is consistent with a benign lesion.
B. When there is no evidence of hormone hypersecretion.
C. When the tumor has shown no significant growth during follow-up imaging.
D. When the imaging is not consistent with a benign lesion, there is evidence of hormone hypersecretion, the tumor has grown significantly during follow-up imaging, or adrenal surgery is being considered.

Answer 4

D. When the imaging is not consistent with a benign lesion, there is evidence of hormone hypersecretion, the tumor has grown significantly during follow-up imaging, or adrenal surgery is being considered.

Explanation: A multidisciplinary review by endocrinologists, surgeons, and radiologists should be considered when the imaging is not consistent with a benign lesion, there is evidence of hormone hypersecretion, the tumor has grown significantly during follow-up imaging, or adrenal surgery is being considered.

Question 5

What can be confidently diagnosed as benign on non-contrast CT when a mass is homogeneous, well-circumscribed, and measures <10 Hounsfield Units (HU) in attenuation?

A. Adrenocortical carcinoma
B. Lipid-rich adrenal cortical adenomas
C. Pheochromocytomas
D. Lipid-poor adenomas

Answer 5

B. Lipid-rich adrenal cortical adenomas

Explanation: A mass that is homogeneous, well-circumscribed, and measures <10 Hounsfield Units (HU) in attenuation can be confidently diagnosed as benign, overwhelmingly representing lipid-rich adrenal cortical adenomas. This diagnostic confidence is supported by retrospective reviews.

Question 6

Which type of adrenal mass can be confidently diagnosed when the mass shows large areas of macroscopic fat (isoattenuating to retroperitoneal fat and measuring <-10 to -15 HU)?

A. Adrenocortical carcinoma
B. Myelolipoma
C. Pheochromocytoma
D. Adrenal cortical adenoma

Answer 6

B. Myelolipoma

Explanation: Masses with large areas of macroscopic fat (isoattenuating to retroperitoneal fat and measuring <-10 to -15 HU) can be confidently diagnosed as benign myelolipomas.

Question 7

How is the presence of small amounts of macroscopic fat in larger, heterogeneous masses generally interpreted?

A. As a benign feature.
B. As a malignant feature.
C. It does not provide any diagnostic information.
D. It indicates the presence of a pheochromocytoma.

Answer 7

C. It does not provide any diagnostic information.

Explanation: The presence of small amounts of macroscopic fat in larger, heterogeneous masses should not be considered a diagnostically benign feature.

Question 8

What is the sensitivity and specificity of non-contrast CT for benign adenomas at a threshold of <10 HU?

A. Sensitivity 71% and specificity 98%
B. Sensitivity 98% and specificity 71%
C. Sensitivity 50% and specificity 50%
D. Sensitivity 30% and specificity 70%

Answer 8

A. Sensitivity 71% and specificity 98%

Explanation: At a threshold of <10 HU, the sensitivity and specificity of non-contrast CT for benign adenomas is 71% and 98%, respectively.

Question 9

Which type of adrenal incidentaloma is most common?

A. Non-functioning adenoma
B. Ganglioneuroma
C. Myelolipoma
D. Adrenocortical carcinoma

Answer 9

A. Non-functioning adenoma

Explanation: Non-functioning adenomas are the most common type of adrenal incidentaloma, with a prevalence range of 71–84%.

Question 10

Which type of benign functioning adrenal incidentaloma has the highest reported prevalence range?

A. Cortisol secreting adenoma
B. Aldosterone secreting adenoma
C. Pheochromocytoma

Answer 10

A. Cortisol secreting adenoma

Explanation: The reported prevalence range for cortisol secreting adenoma is 1–30%, which is higher than for the other listed types of benign functioning adrenal incidentalomas.

Question 11

How does the prevalence of adrenocortical carcinoma compare to metastases in adrenal incidentalomas?

A. Adrenocortical carcinoma is more common
B. Metastases are more common
C. They have a similar prevalence

Answer 11

C. They have a similar prevalence

Explanation: According to the provided data, the prevalence range of adrenocortical carcinoma is 1.2–12%, and for metastases, it’s 0–21%, indicating a substantial overlap in their prevalence ranges.

Question 12

Which symptoms in the history might suggest the presence of hypercortisolism (Cushing’s syndrome)?

A. Weight gain, central obesity, easy bruising
B. Hypertension, hypokalemia, muscle cramping
C. Headaches, anxiety attacks, sweating
D. Flank pain, vague abdominal discomfort

Answer 12

A. Weight gain, central obesity, easy bruising

Explanation: The history of a patient with hypercortisolism might include weight gain, central obesity, easy bruising, severe hypertension, diabetes, proximal muscle weakness, fatigue, depression, sleep disturbances, menstrual irregularities and virilization (in females), or fragility fractures.

Question 13

Which physical examination findings are associated with aldosteronism?

A. Hypertension, central obesity, supraclavicular fat accumulation
B. Severe hypertension, tachycardia, arrhythmias
C. Hypertension, fluid retention
D. Weight loss, hirsutism, gynecomastia

Answer 13

C. Hypertension, fluid retention

Explanation: In aldosteronism, physical examination may reveal hypertension and fluid retention.

Question 14

What elements of a patient’s history might suggest the presence of a pheochromocytoma?

A. Weight gain, central obesity, easy bruising
B. Hypertension, hypokalemia, muscle cramping
C. Headaches, anxiety attacks, sweating, palpitations
D. Flank pain, vague abdominal discomfort

Answer 14

C. Headaches, anxiety attacks, sweating, palpitations

Explanation: The history of a patient with pheochromocytoma might include headaches, anxiety attacks, sweating, palpitations, or family history of von Hippel-Lindau disease, multiple endocrine neoplasia type 2, familial paraganglioma syndrome, or neurofibromatosis type 1.

Question 15

In the context of a possible adrenocortical carcinoma, what physical examination findings might you expect?

A. Hypertension, central obesity, supraclavicular fat accumulation
B. Severe hypertension, tachycardia, arrhythmias
C. Hypertension, fluid retention
D. Weight loss, hirsutism, gynecomastia

Answer 15

D. Weight loss, hirsutism, gynecomastia

Explanation: In adrenocortical carcinoma, physical examination may reveal weight loss, hirsutism, gynecomastia, and signs of hypercortisolism.

Question 16

What factors in a patient’s history might indicate the presence of metastasis?

A. Weight gain, central obesity, easy bruising
B. Hypertension, hypokalemia, muscle cramping
C. Headaches, anxiety attacks, sweating, palpitations
D. Personal and family history of malignant lesions, weight loss, unexplained fevers

Answer 16

D. Personal and family history of malignant lesions, weight loss, unexplained fevers

Explanation: The history of a patient with metastasis might include a personal and family history of malignant lesions, weight loss, unexplained fevers, lack of adherence to an age-appropriate cancer screening program, and smoking history.

Question 17

Figure 1

Answer 17

Figure 1. Algorithm for the workup of an adrenal incidentaloma. ACC: adrenocortical carcinoma; CT: computed tomography; HTN: hypertension; hypoK: hypokalemia; MRI: magnetic
resonance imaging; PET: positron emission tomography.

Question 18

Answer 18

Figure 2. Management of a functional adrenal lesion. ACTH: adrenocorticotropic hormone MIS: minimally invasive surgery.

Question 19

What is the first-line imaging for the workup of an incidental adrenal mass?

A. Contrast-enhanced CT
B. Non-contrast CT
C. Chemical-shift MRI
D. Positron Emission Tomography (PET)

Answer 19

B. Non-contrast CT

Explanation: Non-contrast CT is the first-line imaging for distinguishing benign lesions from those that require further radiological investigation in patients found to have an incidental adrenal mass.

Question 20

If a mass does not fit the radiological criteria for lipid-rich adenoma or myelolipoma, what additional imaging tests could be considered?

A. Contrast-enhanced washout CT or chemical-shift MRI
B. PET scan
C. Ultrasound
D. X-ray

Answer 20

A. Contrast-enhanced washout CT or chemical-shift MRI

Explanation: If a mass is indeterminate on non-contrast CT, it can be further evaluated with either a contrast-enhanced washout CT or a chemical-shift MRI.

Question 21

In a contrast-enhanced washout CT, a relative washout >40% and an absolute washout >60% support the diagnosis of which type of mass?

A. Malignant mass
B. Benign mass
C. Pheochromocytoma
D. Adrenal cortical carcinoma

Answer 21

B. Benign mass

Explanation: In contrast-enhanced washout CTs, a relative washout >40% and an absolute washout >60% support the diagnosis of a benign mass.

Question 22

What imaging technique exploits the different frequency of protons in water and fat to detect microscopic fat?

A. Non-contrast CT
B. Contrast-enhanced CT
C. Chemical-shift MRI
D. PET scan

Answer 22

C. Chemical-shift MRI

Explanation: Chemical-shift MRI exploits the different frequency of protons in water and fat and is used to detect microscopic fat. It can detect microscopic fat in adrenal adenomas that measure >10 HU on a non-contrast CT and would otherwise be considered lipid-poor.

Question 23

Chemical-shift MRI is most useful for adrenal masses that measure what Hounsfield Units on a non-contrast CT?

A. <10 HU
B. >10 HU
C. 10–30 HU
D. >30 HU

Answer 23

C. 10–30 HU

Explanation: Chemical-shift MRI is most useful for adrenal masses that measure 10–30 HU on a non-contrast CT.

Question 24

In patients with an indeterminate adrenal mass on non-contrast CT, what is the recommended next step in imaging?

A. Washout CT
B. Chemical-shift MRI
C. Both washout CT and chemical-shift MRI
D. No further imaging is necessary

Answer 24

C. Both washout CT and chemical-shift MRI

Explanation: For patients who have an indeterminate adrenal mass on non-contrast CT, second-line imaging with either washout CT or chemical-shift MRI is recommended.

Question 25

When might biopsy be considered in the workup of an incidental adrenal lesion?

A. When the lesion is likely benign
B. When the diagnosis of metastatic disease from an extra-adrenal malignancy would be of value
C. In all cases
D. Never

Answer 25

B. When the diagnosis of metastatic disease from an extra-adrenal malignancy would be of value

Explanation: Biopsy may be considered when the diagnosis of metastatic disease from an extra-adrenal malignancy would be of value. It is not routinely performed due to potential risks.

Question 26

True or False: Adrenal mass biopsy can differentiate an adenoma from an adrenocortical carcinoma (ACC).

A. True
B. False

Answer 26

B. False

Explanation: While biopsy can differentiate metastasis from lipid-poor adenomas and pheochromocytomas, it cannot differentiate an adenoma from an ACC.

Question 27

What should be ensured before proceeding with an adrenal mass biopsy?

A. That the mass is likely malignant
B. That a pheochromocytoma has been excluded
C. That the patient is comfortable with the procedure
D. That the mass is larger than 4 cm

Answer 27

B. That a pheochromocytoma has been excluded

Explanation: Prior to biopsy, it is crucial to ensure that a pheochromocytoma has been excluded. This is because biopsy of a pheochromocytoma can lead to a hypertensive crisis due to the release of catecholamines.

Question 28

Which of the following statements about adrenal mass biopsy is correct according to the given recommendation?

A. Adrenal mass biopsy should be the first step in the workup of an adrenal incidentaloma.
B. Adrenal mass biopsy should be performed routinely for the workup of an adrenal incidentaloma.
C. Adrenal mass biopsy should not be performed routinely for the workup of an adrenal incidentaloma.
D. Adrenal mass biopsy is always required for the workup of an adrenal incidentaloma.

Answer 28

C. Adrenal mass biopsy should not be performed routinely for the workup of an adrenal incidentaloma.

Explanation: Routine biopsy of an adrenal mass is not recommended in the workup of an adrenal incidentaloma. The biopsy should be considered when it would be of value in diagnosing metastatic disease from an extra-adrenal malignancy.

Question 29

What is the most widely accepted screening test to identify cortisol excess in adrenal incidentalomas?

A. 1 milligram (mg) overnight dexamethasone suppression test
B. 24-hour urinary-free cortisol
C. Midnight salivary cortisol
D. Plasma ACTH test

Answer 29

A. 1 milligram (mg) overnight dexamethasone suppression test

Explanation: The 1 mg overnight dexamethasone suppression test is the most widely accepted screening test to identify cortisol excess.

Question 30

True or False: All patients with adrenal incidentalomas should be screened for cortisol excess.

A. True
B. False

Answer 30

A. True

Explanation: The panel supports screening for cortisol excess in all patients with adrenal incidentalomas given that imaging remains imperfect. There likely being a subset of patients with autonomous cortisol secretion but no overt Cushing’s syndrome who could benefit from surgical resection.

Question 31

Which of the following can increase the false-positive rate on the 1 mg dexamethasone suppression test in women?

A. Taking oral contraceptives
B. Having a late dinner
C. Exercising before the test
D. Drinking coffee

Answer 31

A. Taking oral contraceptives

Explanation: Estrogens increase cortisol-binding globulin, resulting in a 50% false-positive rate on the 1 mg dexamethasone suppression test in women taking oral contraceptives.

Question 32

What test is used to assess for cortisol hypersecretion in all adrenal incidentalomas?

A. Plasma-free metanephrines
B. Aldosterone-to-renin ratio
C. 1 mg dexamethasone suppression test
D. DHEAS and testosterone levels

Answer 32

C. 1 mg dexamethasone suppression test

Explanation: The 1 mg dexamethasone suppression test is used to assess for cortisol hypersecretion in all adrenal incidentalomas.

Question 33

In the context of adrenal incidentalomas, what does an aldosterone-to-renin ratio of 20 ng/dL per ng/mL/hr suggest?

A. Cortisol hypersecretion
B. Hyperaldosteronism
C. Catecholamine secretion
D. Androgen secretion

Answer 33

B. Hyperaldosteronism

Explanation: An aldosterone-to-renin ratio of 20 ng/dL per ng/mL/hr has excellent sensitivity and specificity for confirming hyperaldosteronism.

Question 34

Which test is recommended for patients with adrenal incidentalomas where HU ≥10 or HU is not available?

A. Plasma-free metanephrines
B. Aldosterone-to-renin ratio
C. 1 mg dexamethasone suppression test
D. DHEAS and testosterone levels

Answer 34

A. Plasma-free metanephrines

Explanation: For patients with adrenal incidentalomas where HU ≥10 or HU is not available, it is recommended to test plasma-free metanephrines.

Question 35

In suspected cases of adrenocortical carcinoma (ACC) or virilization, which hormones are tested?

A. Cortisol and aldosterone
B. DHEAS and testosterone
C. Catecholamines
D. ACTH

Answer 35

B. DHEAS and testosterone

Explanation: In suspected cases of adrenocortical carcinoma (ACC) or virilization, DHEAS and testosterone levels are tested.

Question 36

What is the recommended screening method for autonomous cortisol secretion in patients with adrenal incidentalomas?

A. Plasma-free metanephrines
B. Aldosterone-to-renin ratio
C. 1 mg dexamethasone suppression test
D. DHEAS and testosterone levels

Answer 36

C. 1 mg dexamethasone suppression test

Explanation: The 1 mg dexamethasone suppression test is the recommended screening method for autonomous cortisol secretion in patients with adrenal incidentalomas.

Question 37

In patients with hypertension and/or hypokalemia, what is the preferred initial test for suspected hyperaldosteronism?

A. Plasma-free metanephrines
B. Aldosterone-to-renin ratio
C. 1 mg dexamethasone suppression test
D. DHEAS and testosterone levels

Answer 37

B. Aldosterone-to-renin ratio

Explanation: The aldosterone-to-renin ratio (ARR) is the preferred initial test for suspected hyperaldosteronism in patients with hypertension and/or hypokalemia.

Question 38

What does an Aldosterone-to-renin ratio (ARR) of >20 ng/dL per ng/mL/hr suggest?

A. Cortisol hypersecretion
B. Hyperaldosteronism
C. Catecholamine secretion
D. Androgen secretion

Answer 38

B. Hyperaldosteronism

Explanation: An aldosterone-to-renin ratio (ARR) of >20 ng/dL per ng/mL/hr is indicative of hyperaldosteronism.

Question 39

What is the role of adrenal vein sampling (AVS) in the management of adrenal incidentalomas?

A. It is used to confirm autonomous cortisol secretion.
B. It is used to confirm the lateralization of aldosterone hypersecretion to the side of the adrenal lesion.
C. It is used to differentiate between lipid-poor adenomas and pheochromocytomas.
D. It is used to confirm the presence of androgen secretion.

Answer 39

B. It is used to confirm the lateralization of aldosterone hypersecretion to the side of the adrenal lesion.

Explanation: Adrenal vein sampling (AVS) is used to confirm the lateralization of aldosterone hypersecretion to the side of the adrenal lesion in cases of hyperaldosteronism.

Question 40

In patients with adrenal incidentalomas and hypertension and/or hypokalemia, what screening is recommended for primary aldosteronism?

A. 1 mg dexamethasone suppression test
B. Aldosterone-to-renin ratio (ARR)
C. Plasma-free metanephrines
D. 24-hour urinary fractionated metanephrines

Answer 40

B. Aldosterone-to-renin ratio (ARR)

Explanation: Patients with adrenal incidentalomas and hypertension and/or hypokalemia should be screened for primary aldosteronism with an aldosterone-to-renin ratio (ARR).

Question 41

What is recommended prior to offering adrenalectomy in patients with primary aldosteronism?

A. 1 mg dexamethasone suppression test
B. Aldosterone-to-renin ratio (ARR)
C. Adrenal vein sampling (AVS)
D. 24-hour urinary fractionated metanephrines

Answer 41

C. Adrenal vein sampling (AVS)

Explanation: Adrenal vein sampling (AVS) is recommended prior to offering adrenalectomy in patients with primary aldosteronism.

Question 42

What screening method is primarily used for pheochromocytoma?

A. 1 mg dexamethasone suppression test
B. Aldosterone-to-renin ratio (ARR)
C. Plasma-free metanephrines
D. 24-hour urinary fractionated metanephrines

Answer 42

C. Plasma-free metanephrines

Explanation: Screening for pheochromocytoma is primarily done by measuring plasma-free metanephrines.

Question 43

Is it necessary to perform biochemical testing for pheochromocytoma in adrenal incidentalomas with unenhanced attenuation of <10 HU?

A. Yes, it is necessary in all cases.
B. No, it can be omitted in these cases.
C. It depends on the size of the mass.
D. It depends on the patient’s symptoms.

Answer 43

B. No, it can be omitted in these cases.

Explanation: Recent evidence suggests that biochemical testing for pheochromocytoma may be unnecessary in adrenal incidentalomas with unenhanced attenuation of <10 HU, which is characteristic of adrenal adenomas.

Question 44

In which patients can screening for pheochromocytoma be omitted?

A. Those with adrenal incidentalomas that display ≥10 HU on non-contrast CT.
B. Those with unequivocal adrenocortical adenomas confirmed on unenhanced CT (HU <10) and no signs or symptoms of adrenergic excess.
C. Those with adrenal incidentalomas that display <10 HU on non-contrast CT.
D. Those with adrenal incidentalomas and signs/symptoms of catecholamine excess.

Answer 44

B. Those with unequivocal adrenocortical adenomas confirmed on unenhanced CT (HU <10) and no signs or symptoms of adrenergic excess.

Explanation: Screening for pheochromocytoma can be omitted in patients who have unequivocal adrenocortical adenomas confirmed on unenhanced CT (HU <10) and no signs or symptoms of adrenergic excess.

Question 45

Which patients should be screened for pheochromocytoma with plasma or 24-hour urinary metanephrines?

A. Those with adrenal incidentalomas that display ≥10 HU on non-contrast CT or who have signs/symptoms of catecholamine excess.
B. Those with unequivocal adrenocortical adenomas confirmed on unenhanced CT (HU <10) and no signs or symptoms of adrenergic excess.
C. Those with adrenal incidentalomas that display <10 HU on non-contrast CT.
D. Those with adrenal incidentalomas and signs/symptoms of catecholamine excess.

Answer 45

A. Those with adrenal incidentalomas that display ≥10 HU on non-contrast CT or who have signs/symptoms of catecholamine excess.

Explanation: Patients with adrenal incidentalomas that display ≥10 HU on non-contrast CT or who have signs/symptoms of catecholamine excess should be screened for pheochromocytoma with plasma or 24-hour urinary metanephrines.

Question 46

In which cases should serum testing for excess androgen be performed?

A. In cases of suspected ACC and/or when clinical signs of virilization are present.
B. In all cases of adrenal incidentalomas.
C. Only when the patient is experiencing symptoms of catecholamine excess.
D. Only when the adrenal incidentaloma displays ≥10 HU on non-contrast CT.

Answer 46

A. In cases of suspected ACC and/or when clinical signs of virilization are present.

Explanation: In cases of suspected ACC and/or when clinical signs of virilization are present, serum testing for excess androgen should be performed.

Question 47

What is the recommended treatment for patients with unilateral cortisol-secreting adrenal lesions and clinical signs/symptoms of Cushing’s syndrome?

A. Medication management.
B. Observation and monitoring.
C. Surgical resection of the hypersecreting adrenal gland.
D. Radiotherapy.

Answer 47

C. Surgical resection of the hypersecreting adrenal gland.

Explanation: Patients with unilateral cortisol-secreting adrenal lesions and clinical signs/symptoms of Cushing’s syndrome should undergo surgical resection of the hypersecreting adrenal gland.

Question 48

What is the optimal management for patients with cortisol-secreting adrenal lesions without symptoms of Cushing’s syndrome, also known as mild autonomous cortisol secretion (MACS)?

A. Adrenalectomy could be an option for select patients, particularly those who are young or have progressive metabolic comorbidities attributable to cortisol excess.
B. These patients should always undergo surgical resection of the adrenal gland.
C. These patients should be managed with medication alone.
D. Observation and monitoring are sufficient for these patients.

Answer 48

A. Adrenalectomy could be an option for select patients, particularly those who are young or have progressive metabolic comorbidities attributable to cortisol excess.

Explanation: Adrenalectomy could be an option for select patients with MACS, particularly those who are young or have progressive metabolic comorbidities attributable to cortisol excess. Patients not managed surgically should undergo annual clinical screening for new or worsening associated comorbidities.

Question 49

What is the recommended treatment for patients with confirmed pheochromocytomas or unilateral aldosterone-producing adrenal adenomas?

A. Medication management.
B. Observation and monitoring.
C. Surgical resection.
D. Radiotherapy.

Answer 49

Patients with confirmed pheochromocytomas or unilateral aldosterone-producing adrenal adenomas should undergo surgical resection.

Question 50

After resection of an aldosterone-secreting adenoma, is postoperative imaging necessary?

A. Yes, it is always necessary.
B. No, it is not necessary.
C. It depends on the specific patient situation.
D. Only if there is a suspicion of recurrence.

Answer 50

B. No, it is not necessary.

Explanation: Following resection of aldosterone-secreting adenomas, postoperative imaging is not necessary. However, a postoperative hormonal workup is required in the short-term to confirm resolution of hyperfunction.

Question 51

What is the recommended treatment for patients with suspected Adrenocortical Carcinomas (ACC)?

A. Chemotherapy.
B. Radiation therapy.
C. Resection.
D. Observation and monitoring.

Answer 51

C. Resection.

Explanation: Resection is recommended for patients with suspected Adrenocortical Carcinomas (ACC).

Question 52

Which surgical approach, open or laparoscopic, has been found to have a lower rate of major postoperative complications for adrenalectomy in cases of Adrenocortical Carcinomas (ACC)?

A. Open approach.
B. Laparoscopic approach.
C. Both have similar rates.
D. The evidence is not clear.

Answer 52

B. Laparoscopic approach.

Explanation: The laparoscopic approach to adrenalectomy for ACC may have a lower rate of major postoperative complications.

Question 53

Is repeat imaging recommended for patients with a characteristic adrenal adenoma (<10 HU on non-contrast CT)?

A. Yes, every six months.
B. Yes, annually.
C. No, it is not recommended.
D. Only if there are changes in clinical symptoms.

Answer 53

C. No, it is not recommended.

Explanation: Repeating imaging is not recommended for patients with a characteristic adrenal adenoma (<10 HU on non-contrast CT) due to the demonstrated safety, the high prevalence of adrenal incidentalomas, and the potential cost to the healthcare system.

Question 54

For patients with non-functioning adrenal lesions that are radiologically benign but >4 cm, what is the recommended follow-up?

A. Repeat imaging in 6–12 months.
B. Immediate surgical intervention.
C. No follow-up is required.
D. Repeat imaging annually.

Answer 54

A. Repeat imaging in 6–12 months.

Explanation: For patients with non-functioning adrenal lesions that are radiologically benign but >4 cm, it is recommended to undergo repeat imaging in 6–12 months.

Question 55

How should indeterminate non-functioning adrenal lesions be managed?
A. Immediate surgical intervention.
B. Repeat imaging in 3–6 months.
C. Both A and B.
D. Shared decision-making between patients and their clinicians, considering options like repeat imaging in 3–6 months or surgical resection.

Answer 55

D. Shared decision-making between patients and their clinicians, considering options like repeat imaging in 3–6 months or surgical resection.

Explanation: In the absence of definitive data to guide the best treatment approach for indeterminate non-functioning adrenal incidentalomas, shared decision-making between patients and their clinicians is recommended. Management options can include repeat imaging in 3–6 months or surgical resection.

Question 56

In cases of bilateral adrenal incidentalomas, how should each lesion be managed?
A. Each lesion should be separately characterized in the same fashion as a unilateral adrenal incidentaloma.
B. Both lesions should be treated as one entity.
C. One lesion should be ignored.
D. Both lesions should be immediately removed without characterization.

Answer 56

A. Each lesion should be separately characterized in the same fashion as a unilateral adrenal incidentaloma.

Explanation: In the setting of bilateral adrenal incidentalomas, each lesion should be separately characterized in the same fashion as a unilateral adrenal incidentaloma, and the same indications for surgery/followup should be followed.

Question 57

What considerations are taken into account when managing adrenal incidentalomas in young adults, children, and pregnant patients?
A. Adrenal lesions in these populations are more likely to be benign, therefore, an evaluation should not be expedited.
B. Adrenal lesions in these populations are more likely to be malignant, therefore, an evaluation should be expedited.
C. Age, pregnancy status, and childhood do not affect the management of adrenal incidentalomas.
D. Radiation safety is not a concern for these populations.

Answer 57

B. Adrenal lesions in these populations are more likely to be malignant, therefore, an evaluation should be expedited.

Explanation: It is generally believed that adrenal lesions in young adults, children, and pregnant patients are more likely to be malignant and, therefore, an evaluation should be expedited. In these individuals, radiation safety is an important consideration.

Question 58

What should be considered in the management of adrenal incidentalomas in patients with a history of an extra-adrenal malignancy?
A. Adrenal biopsy and 18F-FDG-PET can be useful adjuncts when characterization of these lesions will alter clinical management.
B. These patients should always undergo immediate surgical intervention.
C. These patients should never undergo surgical intervention.
D. The history of an extra-adrenal malignancy has no effect on the management of adrenal incidentalomas.

Answer 58

A. Adrenal biopsy and 18F-FDG-PET can be useful adjuncts when characterization of these lesions will alter clinical management.

Explanation: In patients with a history of an extra-adrenal malignancy, adrenal biopsy and 18F-FDG-PET can be useful adjuncts when characterization of these lesions will alter clinical management. Lesions >10 HU are malignant in 70% of patients with a history of extra-adrenal malignancy.

Question 59

In which patients might partial adrenalectomy be considered?
A. Patients with hereditary syndromes at increased likelihood of disease in the contralateral gland.
B. Patients with bilateral pheochromocytomas or aldosterone-producing adenomas.
C. Patients with various pathological processes affecting adrenal gland function.
D. All of the above.

Answer 59

D. All of the above.

Explanation: There may be an emerging role for partial adrenalectomy in patients with hereditary syndromes at increased likelihood of disease in the contralateral gland, bilateral pheochromocytomas or aldosterone-producing adenomas, or those with various pathological processes affecting adrenal gland function to avoid the need for lifelong adrenal replacement therapy.

Question 60

What are the limitations of the current workup of incidental adrenal lesions?
A. It has high sensitivity and specificity in determining whether an incidental adrenal lesion is benign or malignant.
B. It has sensitivity and specificity limitations in determining whether an incidental adrenal lesion is benign or malignant.
C. It has perfect accuracy in determining whether an incidental adrenal lesion is benign or malignant.
D. It cannot detect adrenal lesions at all.

Answer 60

B. It has sensitivity and specificity limitations in determining whether an incidental adrenal lesion is benign or malignant.

Explanation: The current workup of incidental adrenal lesions has sensitivity and specificity limitations in determining whether an incidental adrenal lesion is benign or malignant.

Question 61

What is a promising new method being researched to better risk-stratify patients with incidental adrenal lesions?
A. Urine steroid metabolomics
B. Blood-based genetic testing
C. Advanced imaging techniques
D. Laparoscopic biopsy

Answer 61

A. Urine steroid metabolomics

Explanation: Recent research efforts have focused on the development of urine steroid metabolomics to better risk-stratify patients. Studies have shown that ACC have a distinct pattern of urinary corticosteroid excretion, which can be quantified with this method.

Question 62

According to a 2020 study, what was the sensitivity and specificity of the “triple test” strategy (using urine steroid metabolomics, tumor diameter, and imaging characteristics) to characterize adrenal incidentalomas?
A. Sensitivity of 82.7% and specificity of 95.7%
B. Sensitivity of 90.2% and specificity of 92.4%
C. Sensitivity of 75.5% and specificity of 85.3%
D. Sensitivity of 100% and specificity of 100%

Answer 62

A. Sensitivity of 82.7% and specificity of 95.7%

Explanation: In a 2020 prospective, multicenter study (EURINE-ACT), urine steroid metabolomics were used in conjunction with tumor diameter and imaging characteristics to characterize adrenal incidentalomas, and this “triple test” strategy had a sensitivity of 82.7% and specificity of 95.7%.

Question 63

What is the importance of identifying and managing incidental adrenal masses?
A. They are common, most are benign, but identification and timely management of functional and malignant lesions is crucial.
B. They are rare, most are malignant, but identification and timely management of functional and benign lesions is crucial.
C. They are common, all are benign, and they don’t need any management.
D. They are rare, all are malignant, and they all need immediate surgical intervention.

Answer 63

A. They are common, most are benign, but identification and timely management of functional and malignant lesions is crucial.

Explanation: Incidental adrenal masses are common, and most of these lesions are benign. Nonetheless, identification and timely management of functional and malignant lesions is crucial.