Adrenal incidentalomas

Multiple Select

What two questions do you need to answer regarding the mass on the L adrenal gland?

• Is it benign or malignant?

• Is it producing hormones?

• What is the size of the mass?

• What are the symptoms of the patient?

Multiple Choice

What are the characteristics of Adrenocortical adenomas, Myelolipomas, and Adrenocortical carcinoma (ACC) based on their location, benignity, hormones produced, and percentage?

• Adrenocortical adenomas: Cortex, Benign, 15% functional: Cortisol or aldosterone, Non 89.7% Cortisol 6.4% Aldo 0.6%

• Myelolipomas: Cortex, Benign, No hormones, No percentage

• Adrenocortical carcinoma (ACC): Cortex, Malignant, 60% functional: Cortisol or androgens, 1.9%

• Pheochromocytoma: Medulla, 10% malignant, Catecholamines, 3.1%

Multiple Choice

Mark, a 45-year-old man, sought medical attention due to recurrent episodes of severe headaches, sweating, and palpitations that occurred unpredictably over the past six months. During one of these episodes, his blood pressure was found to be significantly elevated. Mark's primary care physician referred him to the endocrinology clinic suspecting a possible adrenal disorder. What lab values and tests would help to confirm a diagnosis of pheochromocytoma?

• White blood cell count, hemoglobin, and platelet count
• Plasma cortisol, plasma aldosterone, and plasma renin activity

• Thyroid-stimulating hormone, free thyroxine, and triiodothyronine levels
• Serum metanephrines & Vanillylmandelic acid (VMA), Urine VMA, and abdominal CT scan

Multiple Choice

What are the characteristics of "lipid rich" and "lipid poor" lesions in terms of Hounsfield units?

• Lipid rich lesions have > 10 HU

• Lipid poor lesions have < 10 HU

• Lipid rich lesions are darker on CT

• Lipid poor lesions are lighter on CT

Open Ended

What do you do next?

Multiple Choice

What are the primary secretory products of the adrenal cortex and medulla?

• Aldosterone

• Cortisol

• Catecholamines

• All of the above

Multiple Choice

What testing do you order for Ms. J who is taking levothyroxine for hypothyroidism?

• Cortisol

• DHEAS

• (+/- ACTH)

• +/- dex suppression test

Multiple Choice

Emma, a 30-year-old woman, was admitted to the internal medicine ward with a two-month history of progressive weakness, fatigue, and unintentional weight loss. She reported episodes of dizziness upon standing. On examination, her blood pressure was significantly lower than expected. Laboratory tests revealed hyponatremia, hyperkalemia. Further testing confirmed low levels of serum cortisol. What is this likely medical diagnosis?

• Hashimoto's thyroiditis
• Addison's disease
• Graves' disease
• Cushing's disease

Multiple Choice

James, a 45-year-old man, presented to the endocrinology clinic with a three-month history of persistent headaches, muscle weakness, and intermittent episodes of palpitations. Clinical examination revealed hypertension, and further investigation demonstrated hypokalemia and metabolic alkalosis. Laboratory tests revealed elevated levels of plasma aldosterone, suppressed plasma renin activity, and an increased aldosterone-to-renin ratio. A contrast-enhanced abdominal CT scan showed an adenoma in the left adrenal gland. What is James' diagnosis?

• Addison's disease
• Primary hyperaldosteronism (Conn's syndrome)
• Secondary hyperaldosteronism
• Cushing's syndrome

Multiple Choice

Emma, a 30-year-old woman, was admitted to the internal medicine ward with a two-month history of progressive weakness, fatigue, and unintentional weight loss. She reported hyperpigmentation of her skin and episodes of dizziness upon standing. On examination, her blood pressure was significantly lower than expected, and she exhibited generalized hyperpigmentation. Laboratory tests revealed hyponatremia, hyperkalemia, and a markedly elevated plasma adrenocorticotropic hormone (ACTH) level. Further testing confirmed low levels of serum cortisol. An adrenocortical antibody test was positive. What is this patient's diagnosis?

• Hashimoto's thyroiditis
• Addison's disease
• Graves' disease
• Cushing's disease

Multiple Choice

What is the suggested testing scheme for subclinical Cushing's according to Dr. Young?

• Morning ACTH, cortisol, DHEAS

• DHEAS > 100: not subclinical Cushing's

• DHEAS < 100: get a 1 mg overnight dex suppression test

• AM cortisol < 1.8: confirm diagnosis

Multiple Choice

Which of the following is a common cause of Cushing Syndrome?

• Underactive thyroid

• Long-term use of corticosteroid medication

• Low blood sugar levels

• Vitamin D deficiency

Multiple Choice

What is the purpose of the low-dose dexamethasone suppression test (DST)?

• To measure blood sugar levels

• To diagnose endogenous hypercortisolism

• To assess kidney function

• To evaluate liver enzymes

Multiple Choice

What does Ms. J's DHEAS level of 75 indicate in terms of her health condition?

• Normal adrenal function

• Possible adrenal insufficiency

• Possible adrenal hyperplasia

• Normal cortisol levels

Multiple Choice

What are the potential consequences of subclinical Cushing's syndrome?

• Metabolic syndrome

• Osteoporosis

• Atrial fibrillation

• All of the above

Open Ended

What is your assessment of Mr. M's condition based on the information provided?

Multiple Choice

What is the role of aldosterone in the regulation of blood pressure?

• Increases blood volume

• Decreases blood volume

• Inhibits renin production

• Promotes vasodilation

Multiple Choice

What testing do you order for the patient?

• Cortisol

• Aldosterone

• Renin

• All of the above

Open Ended

Does the patient have spontaneous hypokalemia and PAC ≥20 ng/dL (555 pmol/L)?

Multiple Choice

What is the significance of PAC and PRA levels in the diagnosis of primary aldosteronism?

• PAC levels indicate aldosterone production

• PRA levels indicate renin production

• Both PAC and PRA levels are used for diagnosis

• PAC levels are irrelevant

Multiple Choice

What conditions should prompt testing for primary aldosteronism?

• HTN and hypokalemia

• Adrenal incidentaloma and HTN

• Onset of HTN at a young age

• Severe HTN

Multiple Choice

What does Ms. M's results show?

• PAC 10

• PAC 15

• PAC 20

• PAC 25

Multiple Choice

What are the treatment options for a patient with a unilateral hypodense nodule greater than 1 cm and less than 2 cm in the setting of marked primary aldosteronism?

• IHA or GRA: Pharmacologic therapy

• APA or PAH: Unilateral laparoscopic adrenalectomy

• Pharmacologic therapy

• Surgery not desired

Multiple Choice

What is the role of Dehydroepiandrosterone sulfate (DHEAS) in the adrenal steroidogenesis pathway?

• It is a mineralocorticoid

• It is a glucocorticoid

• It is a sex hormone

• It is a precursor for cortisol

Multiple Choice

Can’t I just refer to endo!?

• Yes!

• May need to refer for DST

• Likely need expert care for interpretation/diagnosis confirmation

• Can start initial eval and educate patients about next steps

Multiple Choice

What are the first steps in evaluating adrenal incidentalomas according to the summary?

• Imaging and hormone evaluation

• Surgery and imaging

• Hormone testing and follow-up

• Immediate treatment

Poll

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