Adrenal

Question 1

Incidentaloma- concerning imaging findings?

Answer 1

• > 4 cm
• > 10 Hounsfield units
• Lipid poor
• < 50 % contrast washout in 10 minutes
• Unilateral
• Heterogenous

Question 2

Incidentaloma- most common pathology?

Answer 2

Non functional adenoma (90%)

Question 3

Incidentaloma- most common functional tumor?

Answer 3

Hypercortisolism (6 %)
Pheo (3 %)
Aldo (< 1 %)

Question 4

Aldosteronoma- screening test and cutoffs?

Answer 4

Aldosterone to Renin ratio > 30
Aldosterone level >20

Usually with aldosterone > 20

Question 5

Aldosteronoma confirmatory tests?

Answer 5

• 72 hour salt loading test
• Measure 24 hour urinary aldo after loading
• Saline load test
• Measure aldosterone after 2 L NS bolus over 4 hours

Question 6

Adrenal venous sampling- catheter placement confirmation?

Answer 6

Adrenal vein to IVC cortisol ratio > 3 (greater than 5 if stimulated)

Question 7

Adrenal venous sampling- confirmation of lesion laterality?

Answer 7

• Ratio of > 4
• Ratio of < 3 suggests bilateral disease

Ratio of aldo:cortisol on each side to each other adjusts for depth

Question 8

Cushing syndrome- etiology?

Answer 8

ACTH dependent (60-70 %)
Ectopic ACTH (20 %)
Adrenal (15-20%)

Question 9

Cushing syndrome- diagnostic algorithm?

Answer 9

1. Overnight low dose dexa
2. AM cortisol and ACTH
3. 24 hour urinary cortisol

Question 10

Adrenal metastasis- epidemiology?

Answer 10

• 4th most common site
• Only site in up to 85 %
• Functional lesion must be ruled out
• FNA 90 % sensitive

Question 11

Pheochromocytoma- genetic associations?

Answer 11

• MEN 2
• VHL
• NF 1
• SDH deficiency

Question 12

Hyperaldosteronism etiology?

Answer 12

Bilateral hyperplasia (40%)
Adrenal adenoma/unilateral hyperplasia (60%)

Question 13

AVS diagnostic algorithm?

Answer 13

1. Confirm adrenal vein catheterization (adrenal vein to IVC cortisol ratio, >3:1, or >10:1 if using cosyntropin stimulation)
   2. Measure adrenal vein and IVC aldosterone and cortisol levels
   3. Calculate cortisol-corrected PAC ratios (Divide aldosterone by cortisol for each side individually)
   4. Divide the higher cortisol corrected PAC by the lower
   □ > 4 : 1 unilateral, contralateral adrenal usually suppressed to below IVC levels
   < 3:1 suggests bilateral hyperplasia

Question 14

ACC benign vs malignant?

Answer 14

Weiss criteria on pathology

Question 15

Pheo benign vs malignant?

Answer 15

PASS score on pathology