EXAM #2: TUMORS OF THE ADRENAL GLAND Flashcards
What do you need to remember about adrenal cancer?
1) Majority are metastatic at the time of diagnosis
2) B/c of invasion, multiple adrenal syndromes can be combined i.e. a mix of presentations
What are the concerning features of an adrenal tumor for malignancy?
1) Irregular
2) Large (greater than 4cm)
3) Calcification
4) Unilateral
5) High CT attenuation (greater than 20 HU)
6) Extension into local structures
What labs should be checked when you suspect an adrenal cancer?
1) Cortisol
2) Catecholamine metabolites
3) Androgens
How is adrenal cancer treated?
1) Surgery if possible
2) Palliation and symptomatic relief if not
What size of adrenal cancer can be approached laproscopically?
Less than 6cm
*Otherwise flank, midline, or thoracoabdominal
What causes 99% of Cushing Syndrome?
Iatrogenic Cushing’s
What is the approach to diagnosing Cushing Syndrome?
1) Cortisol lab
2) Follow-up high cortisol with ACTH
3) Dexamethasone suppression
4) Imaging
What is the expected finding in Cushing Disease with a dexamethasone suppression test?
Cortisol will be LOW if pituitary is the source
What imaging is recommended for diagnosing Cushing Disease/ Syndrome?
CT unless Cushing Disease is suspected, then MRI
If an adrenal source is causing Cushing Syndrome, what is the treatment of choice?
Surgery
*Make sure you give a stress dose of steroids
What syndromes are associated with Pheochromocytoma?
1) Von Recklinghouse NF
2) Von Hippel Lindau
3) Tuberosclerosis
4) MEN 2a/ 2b
What lab test should you order in possible pheochromocytoma?
Metanephrine
What imaging modality is used to diagnose a pheochromocytoma?
CT
Where is the “Organ of Zuckerkandl?”
Bifurcation of the aorta
*Can be location of ectopic adrenal medulla tissue
How do you do pre-operative preparation for surgical excision of a pheochromocytoma?
Alpha-blocker, esp. Phenoxybenzamine
*Note that Beta blockers are NOT always needed but can be started pre-op
What is the most common approach to excision of a pheochromocytoma?
Laproscopic
What do you need to be prepared for after removing a pheochromocytoma?
Hypotension
If you find a pheochromocytoma during a different surgical procedure, what should you do?
1) Complete procedure rapidly
2) Do NOT manipulate tumor
3) Nitroprusside
4) Start alpha and beta blockade s/p
*Perform the procedure electively afterward–can’t do the same day
If Conn Sydrome is leading to HTN, what is this called?
Secondary HTN
What electrolyte abnormality is associated with Conn Syndrome?
Hypokalemia, though most patients are normokalemic
What is the difference between Alodsterone Producing Adenoma (APA) and IPA?
APA= unilateral; treat with surgery
IPA= bilateral idiopathic, treated medically
How do you diagnose Conn Syndrome or hyperaldosterone syndrome?
1) Urine aldosterone
2) Saline suppression test
What imaging modality is preferred for diagnosing primary hyperaldosterone syndrome?
CT
If CT is equivocal, what is the next procedure that is performed for diagnosis?
Fluoroscope guided renal vein sampling
How is APA treated?
Laproscopy surgery
How is IPA treated?
Aldosterone receptor antagonist i.e. spironolactone
What is an “incidentaloma?”
Unsuspected adrenal mass seen on imaging
What are the three questions to ask yourself when you find and incidentaloma?
1) Is it functional?
2) What is the malignant potential
3) Does the patient have a primary tumor that this could be a met from?
After an H and P, what is the next thing you would do?
Pull a lab panel for the different adrenal tumors
What do you need to remember about biopsying adrenal masses?
ALWAYS check for pheochromocytoma first
What imaging cutoffs are used to evaluate an adrenal tumor?
Less than 4cm is rarely metastatic
Greater than 6cm is more likely malignant
