Flashcards in Assessment of incidental adrenal mass Deck (12):
1
Most common tumor in adults
Adrenal masses
2
Etiology
41% adenomas
14% metastasis
10% adrenocortical Ca
3
Differential
Common-> non-secreting adrenal adenoma
Uncommon->
Cushing's
Phaeochromocytoma
Primary hyperaldosteronism
Adrenal cyst, myelolipomas, hemangiomas, ganglioneuroma
Granulomatous infiltration
Adrenocortical Ca
Adrenal mets
Adrenal malignant melanoma
4
Clinical assessment
Clinical signs of hormone overproduction
Cushings
Phaeochromocytoma
Primary hyperaldosteronism
Mass effect->abdominal pain
5
Features of primary hyperaldosteronism
Hypertension
Muscle cramps/weakness
Cardiac arrythmias
Hypokalemia induced nephrogenic diabetes insipidus
6
Initial Investigations
Electrolytes: hypokalaemia may suggest hyperaldosteronism; hypokalaemia may be present in Cushing's syndrome.
Fasting lipid profile: hyperlipidaemia may be present in Cushing's syndrome.
Fasting blood glucose: hyperglycaemia may be present in Cushing's syndrome or phaeochromocytoma.
FBC: leukocytosis with neutrophilia may occur in Cushing's syndrome.
Screening test for Cushing's syndrome with late night salivary cortisol or overnight (1 mg) dexamethasone suppression test (OST).
Screening for phaeochromocytoma with fractionated plasma metanephrines.
Patients with HTN should also have plasma renin/aldosterone ratio measured to assess for hyperaldosteronism.
7
If screening for hormone activity positive, further testing
For Cushing's syndrome, 24-hour urine free cortisol and early morning (9 am) serum corticotropin (ACTH).
For phaeochromocytoma, 24-hour urine total metanephrines and fractionated catecholamines.
For hyperaldosteronism, plasma aldosterone concentration on an unrestricted salt diet, 24-hour urinary aldosterone excretion, and saline infusion test (saline suppression test
8
Imaging
CT with contrast and MRI
FDG-PET
9
Features of benign on imaging
Homogenous
10
Features of malignancy on imaging
Irregular shape
Calcification
Tumor necrosis
>4cm
>20HU on unenhanced CT
Delay in contrast medium washout
Metastatic->bilateral
11
Manegemtn
Surgical
Imaging evaluation at 6-12 months
Biochemical testing annually
12