Casefiles 11: adrenal mass, disk herniation, PAD Flashcards
ddx of “adrenal incidentaloma”
most are?
benign functioning and nonfunctioning adrenal adenomas, adrenocortical carcinoma, and metastatic tumors
nonfunctioning adenomas, accounting for 55% to 94% of all cases.
Functioning adrenal tumors
pheochromocytoma, aldosterone-producing adenoma, and cortisol-producing adenoma
s/s of ? should be actively sought in the history and on physical examination of adrenal incidentaloma pt
excess catecholamines, aldosterone, cortisol, and androgens
history of hypertension, headaches, palpitations, profuse sweating, abdominal pain, anxiety, and prior history of malignancy
features suggestive of Cushing syndrome
The functional assessment consists of three main diseases
pheochromocytoma (metanephrine and catecholamine levels, low ACTH or DHEAS)
Conn’s syndrome
hypercortisolism (overnight 1-mg dexamethasone suppression test (DST))
What can be measured to evaluate for an aldosterone-producing adenoma (Conn syndrome) where ? is suggestive of hyperaldosteronism
Plasma aldosterone and renin activity
an aldosterone-renin ratio greater than 30
confimatory: Saline salt loading test or captopril challenge
After determining whether an adrenal mass is functioning or nonfunctioning, anatomic assessment is performed, preferably with ?
What is used for the evaluation of an adrenal mass in a patient with a known extra-adrenal cancer because of its ability to separate benign from metastatic lesions?
CT or MRI
PET scan
Imaging characteristics suggestive of adrenocortical carcinoma include ?
irregular margins, inhomogeneous density, scattered areas of decreased attenuation, local invasion
large size and enlargement over time, majority are 6 cm or greater
CT characteristics that are highly specific for adrenal adenomas are ?
Hounsfield units less than 10 during noncontrast CT and early contrast washout during a CT with intravenous contrast (defined as more than 60% contrast clearance at 10-15 minutes after contrast injection)
One/both of these CT features has extremely high negative predictive value for malignancy, and incidentalomas with these findings can be managed with observation only
Surgery is recommended for what adrenal masses?
all functioning tumors, nonfunctioning tumors 4 cm or greater, tumors that enlarge (growth of more than 0.8-1.0 cm during a 3- to 12-month period), tumors with imaging characteristics suspicious for carcinoma, or solitary adrenal metastases
The adrenal gland is a frequent site of metastasis which include ?
breast, kidney, colon, stomach, melanoma, and most commonly lung cancer
Management of patients with nonfunctioning adrenal incidentalomas smaller than 4 cm
follow-up imaging at 3 and 15 months.
A change in size greater than 1 cm may prompt adrenalectomy.
then annual H&Ps
Pheochromocytoma is a tumor that arises from the ?
“10% tumor” because ?
chromaffin cells of the adrenal medulla and secretes catecholamines.
10% are bilateral, extra-adrenal, multiple, malignant, and over 10% familial
how to localize pheos
CT or MRI
usually appears bright on a T2-weighted MRI
An iodine-131 metaiodobenzylguanidine (MIBG) scan may be obtained for confirmation or evaluation of non localized pheo
PET scan if others fail
other screening if dx pheo
CXR for mets (most common site)
EKG and ECHO: chronic catecholamine excess may cause cardiomyopathy
what should be given 1 to 2 weeks before surgery to remove pheo?
α-adrenergic–blocking agent: allows for relaxation of the constricted vascular tree and correction of the reduced plasma volume which prevents hypotension that often occurs following tumor removal
-β-adrenergic–blocking agent may be added to oppose the reflex tachycardia associated with α-blockade, but never start first due to potential precipitation of a HTN crisis related to unopposed α-receptor stimulation.
the preferred α-adrenergic antagonist is ?
phenoxybenzamine
also, α-Methyl-p-tyrosine, which is often used in combination with phenoxybenzamine, competitively inhibits tyrosine hydroxylase, the rate-limiting enzyme in catecholamine synthesis
Intraoperative medical management of pheos is critical because of the danger of ?
large fluctuations in blood pressure, heart rate, and fluids
monitor BP with art line, monitor volume with CVC and foley, IV nitroprusside for HTN control, esmolol for tachycardia
Acute hypotension may occur following excision of a pheochromocytoma related to sudden diffuse vasodilatation, so tx with ?
fluid administration, if that fails continuous IV norepinephrine
motor weaknesses associated with the affected nerve roots can also be detected with herniated disks (L4: ?; L5: ?)
anterior tibialis
extensor hallicus longus
Disc herniation at what level is most common?
L5-S1 level with S1 nerve root compression is most common (40%-50%)
then L4-L5 level herniation with L5 nerve root compression occurs in 40%
L3-L4 disc herniation with L4 nerve root compression occurs in 3% to 10%
cauda equina syndrome
Compression of the sacral nerve bundle, which forms the end of the spinal cord. Common symptoms: bladder and bowel dysfunctions, pain and/or weakness in the legs. Important to pick it up early to avoid nerve entrapment that ends up producing long-term dysfunctions
back pain red-flag symptoms
older than 50, presence of systemic symptoms such as fever, night sweats, weight loss, hx of malignancy, night pain, immune suppressed status, hx of IV drug use, failure to respond to initial treatments, prolonged corticosteroid use, diagnosis of osteoporosis, and trauma
L2 nerve root:
muscle group?
sensory dermatome?
DTR?
hip flexor
anterior medial thigh
no DTR