Malignant and functional adrenal gland tumors

Question 1

what are the major functional adrenal tumors?

Answer 1

adrenal cancers 
cushing syndrome 
pheochromocytoma 
aldosteronoma 
incidentaloma

Question 2

what makes adrenal cancer different from the other adrenal syndromes in terms of presentation?

Answer 2

different hormonal syndromes combined with each other

Question 3

what are concerning CT findings for adrenal cancer?

Answer 3

• irregular shape
• large size
• intralesional calcification
• unilateral location
• high CT attenuation values
• invasion into vessels

Question 4

what lab studies are done for suspected adrenal cancer?

Answer 4

• cortisol
• metanephrines / catecholamines
• serum androgens / estrogens

Question 5

what are the treatment options for adrenal cancer?

Answer 5

• surgery
• palliative
• treat metabolic syndromes

Question 6

adrenal tumors can be approached laparoscopically if less than what size?

Answer 6

6 cm

Question 7

what is the potassium level in cushing syndrome?

Answer 7

hypokalemia

Question 8

diagnosis of cushings syndrome

Answer 8

• check cortisol - if positive then check ACTH
• low ACTH means adrenal gland source (independent)
• ACTH normal / high - ectopic or pituitary source (dependent)

Question 9

adrenal tumor

cortisol
ACTH
dexamethasone test

Answer 9

• high cortisol
• low ACTH
• no suppression with low dose or high dose dexamethasone

Question 10

treatment for adrenal cancer

Answer 10

surgery

Question 11

pheochromocytoma: clinical features

Answer 11

• hypertension

- orthostatic hypotension

Question 12

what are some associated conditions of pheochromocytoma?

Answer 12

• von recklinghausen neurofibromatosis
• von hippel lindau disease
• tuberous sclerosis
• MEN 2A and 2B syndrome

Question 13

what is the best imaging modality for pheochromocytoma?

Answer 13

CT

Question 14

what is the preoperative preparation for pheochromocytoma?

Answer 14

• alpha blockade first
• phenoxybenzamine
• possibly beta blockade

Question 15

definition: primary hyperaldosteronism

Answer 15

failure to suppress aldosterone secretion by intravascular volume expansion is the fundamental basis for establishing the diagnosis

Question 16

definition: conn syndrome

Answer 16

elevated BP due to an identifiable cause (renal disease, medication, renal artery stenosis, pheochromocytoma)

Question 17

what is the potassium level in primary hyperaldosteronism?

Answer 17

hypokalemia

majority of patients are normokalemic

Question 18

conn syndrome: clinical features

Answer 18

• muscle weakness
• polydipsia
• polyuria
• nocturia
• muscle cramps
• headache

Question 19

what is the three tier diagnosis strategy for primary hyperaldosteronism?

Answer 19

• initial screening
• confirmation of diagnosis
• determination of subtype of primary hyperaldosteronism

Question 20

what is the treatment for aldosterone producing adenoma?

Answer 20

surgery

Question 21

what is the treatment for bilateral idiopathic hyperaldosteronism?

Answer 21

medical therapy - aldosterone antagonists

Question 22

what is the screening test for primary aldosteronism? what are the confirmatory tests?

Answer 22

aldosterone-to-renin ratio

• 24 hr urine aldosterone
• saline suppression test (give salt, then aldosterone is still high and renin is low post-test)

Question 23

what does renal vein sampling do? when is it warranted?

Answer 23

compared aldosterone levels to determine laterality of adrenal lesion

use when CT scan findings are equivocal or if both glands are abnormal

Question 24

what is the treatment for primary hyperaldosteronism?

Answer 24

• APA (aldosterone producing adenoma) - surgery
• IHA (idiopathic hyperaldosteronism) - subtotal adrenectomy (poor results)
• medical treatment (RECOMMENDED) - spironolactone (aldosterone receptor antagonist)

Question 25

what is an adrenal incidentaloma? what questions should be asked upon finding one?

Answer 25

unsuspected adrenal mass on imaging

• is it functional?
• malignant potential?
• does pt have a primary cancer and could it be metastatic?

Question 26

what should you always check for prior to needle biopsy for a adrenal incidentaloma?

Answer 26

pheochromocytoma