Adrenal

Question 1

An incidental mass on the adrenal gland has a 25% chance of being cancer (primary or met) if it is greater than how much?

Answer 1

> 6cm

(it’s only 2% for tumors

Question 2

Do metastatic lesions to the adrenal glands have a high or low attenuation?

Answer 2

High (they are also highly vascular)

Question 3

Are mets to the adrenal glands usually unilateral or bilateral?

Answer 3

Bilateral

Question 4

What is the most common clinical sx associated with adrenal incidentaloma? How do you test for it?

Answer 4

Cushing syndrome (high cortisol).

Test with overnight dexamethasone suppression test.

Question 5

Usually you do NOT screen for excess aldosterone or androgen when you find an incidentaloma, because these are rare. However, what WOULD prompt you to screen for it?

Answer 5

Aldosterone: Hypertension, hypokalemia

Androgen: Feminization in men, Hirsutism in women

Question 6

When you find an incidentaloma, what 2 tests do you run next?

Answer 6

1. Overnight dexamethasone suppression test

2. Plasma metanephrines

Question 7

What is the best screening test for primary hyperaldosteronism? What is considered a positive test?

Answer 7

• Screen with: Serum aldosterone:renin ratio (not imaging!! Because incidental adrenal lesions are common)
• Positive if: Ratio>20, esp if aldosterone>15

Question 8

How good is CT at picking up adrenal adenomas?

Answer 8

93-100% sensitivity

Question 9

What is the definition of primary and secondary adrenal insufficiency?

Answer 9

Primary: Low cortisol, high ATCH because problem is in the adrenals

Secondary: Low cortisol, low ACTH because problem is in the pituitary

Question 10

Does exogenous use of steroids cause primary or secondary adrenal insufficiency?

Answer 10

Secondary (it makes the pituitary stop secreting ACTH)

Question 11

How long do you have to be on exogenous steroids in order to get insufficiency if you stop them?

Answer 11

3 weeks

Question 12

How should you treat adrenal insufficiency (low BP, orthostatic, low Na, high K) during stress?

Answer 12

IV “stress dose” (10x normal dose, usually ends up to be 100 mg daily) of hydrocortisone. No oral because nausea and vomiting often limit use. No fludrocortisone because at those high doses hydrocortisone covers both.

Question 13

Which type of fluid do you give to correct hyponatremia and hypotension in adrenal insufficiency?

Answer 13

Just normal saline. No hypertonic saline necessary, because restoring volume will suppress ADH which should correct the hyponatremia.