EXAM #2: TUMORS OF THE ADRENAL GLAND

Question 1

What do you need to remember about adrenal cancer?

Answer 1

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

Question 2

What are the concerning features of an adrenal tumor for malignancy?

Answer 2

1) Irregular
2) Large (greater than 4cm)
3) Calcification
4) Unilateral
5) High CT attenuation (greater than 20 HU)
6) Extension into local structures

Question 3

What labs should be checked when you suspect an adrenal cancer?

Answer 3

1) Cortisol
2) Catecholamine metabolites
3) Androgens

Question 4

How is adrenal cancer treated?

Answer 4

1) Surgery if possible

2) Palliation and symptomatic relief if not

Question 5

What size of adrenal cancer can be approached laproscopically?

Answer 5

Less than 6cm

*Otherwise flank, midline, or thoracoabdominal

Question 6

What causes 99% of Cushing Syndrome?

Answer 6

Iatrogenic Cushing’s

Question 7

What is the approach to diagnosing Cushing Syndrome?

Answer 7

1) Cortisol lab
2) Follow-up high cortisol with ACTH
3) Dexamethasone suppression
4) Imaging

Question 8

What is the expected finding in Cushing Disease with a dexamethasone suppression test?

Answer 8

Cortisol will be LOW if pituitary is the source

Question 9

What imaging is recommended for diagnosing Cushing Disease/ Syndrome?

Answer 9

CT unless Cushing Disease is suspected, then MRI

Question 10

If an adrenal source is causing Cushing Syndrome, what is the treatment of choice?

Answer 10

Surgery

*Make sure you give a stress dose of steroids

Question 11

What syndromes are associated with Pheochromocytoma?

Answer 11

1) Von Recklinghouse NF
2) Von Hippel Lindau
3) Tuberosclerosis
4) MEN 2a/ 2b

Question 12

What lab test should you order in possible pheochromocytoma?

Answer 12

Metanephrine

Question 13

What imaging modality is used to diagnose a pheochromocytoma?

Answer 13

CT

Question 14

Where is the “Organ of Zuckerkandl?”

Answer 14

Bifurcation of the aorta

*Can be location of ectopic adrenal medulla tissue

Question 15

How do you do pre-operative preparation for surgical excision of a pheochromocytoma?

Answer 15

Alpha-blocker, esp. Phenoxybenzamine

*Note that Beta blockers are NOT always needed but can be started pre-op

Question 16

What is the most common approach to excision of a pheochromocytoma?

Answer 16

Laproscopic

Question 17

What do you need to be prepared for after removing a pheochromocytoma?

Answer 17

Hypotension

Question 18

If you find a pheochromocytoma during a different surgical procedure, what should you do?

Answer 18

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

Question 19

If Conn Sydrome is leading to HTN, what is this called?

Answer 19

Secondary HTN

Question 20

What electrolyte abnormality is associated with Conn Syndrome?

Answer 20

Hypokalemia, though most patients are normokalemic

Question 21

What is the difference between Alodsterone Producing Adenoma (APA) and IPA?

Answer 21

APA= unilateral; treat with surgery

IPA= bilateral idiopathic, treated medically

Question 22

How do you diagnose Conn Syndrome or hyperaldosterone syndrome?

Answer 22

1) Urine aldosterone

2) Saline suppression test

Question 23

What imaging modality is preferred for diagnosing primary hyperaldosterone syndrome?

Answer 23

CT

Question 24

If CT is equivocal, what is the next procedure that is performed for diagnosis?

Answer 24

Fluoroscope guided renal vein sampling

Question 25

How is APA treated?

Answer 25

Laproscopy surgery

Question 26

How is IPA treated?

Answer 26

Aldosterone receptor antagonist i.e. spironolactone

Question 27

What is an “incidentaloma?”

Answer 27

Unsuspected adrenal mass seen on imaging

Question 28

What are the three questions to ask yourself when you find and incidentaloma?

Answer 28

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?

Question 29

After an H and P, what is the next thing you would do?

Answer 29

Pull a lab panel for the different adrenal tumors

Question 30

What do you need to remember about biopsying adrenal masses?

Answer 30

ALWAYS check for pheochromocytoma first

Question 31

What imaging cutoffs are used to evaluate an adrenal tumor?

Answer 31

Less than 4cm is rarely metastatic

Greater than 6cm is more likely malignant