A 22-year-old female comes with an incidentally detected mass in the right adrenal gland of 2 cm size detected during a CT scan done for abdominal pain. She has no hypertension, no cushingoid features and no virilization. She has no family history of multiple endocrine neoplasia. She has no history of renal calculi. The cause of abdominal pain is finally diagnosed as abdominal migraine. How will you evaluate this case of adrenal incidentaloma? An adrenal “incidentaloma” is an adrenal mass, generally 1 cm or more in diameter that is discovered ‘incidentally’ during a radiologic examination performed for indications other than an evaluation for adrenal disease. The definition of incidentaloma excludes patients undergoing imaging procedures as part of staging and work-up for cancer and patients with symptomatic adrenal disease not elicited due to oversight. Adrenal incidentaloma is not a single entity; rather it is an ‘umbrella’ defini-tion comprising a spectrum of different pathological entities that share the same path of discovery. The widespread use of computed tomography (CT), diagnostic ultrasound, and magnetic resonance imaging (MRI) has resulted in the frequent incidental discovery of asymptomatic adrenal masses. The optimal diagnostic approach to a patient who has an adrenal incidentaloma is by taking a careful history and performing a physical examination, focusing on the signs and symptoms suggestive of adrenal hyperfunction or malignant disease followed by hormonal testing, when indicated. The two important questions to be answered at the end of evaluation are: • Does the patient have a lesion suggestive of malignancy? • Is the lesion hormonally active? • Do you want any further information from the CT scan done?
Describe the laboratory evaluation in a patient with adrenaln incidentaloma?
Medicine
All subjects with an incidentally discovered adrenal mass should be screened for both catecholamine overproduction and hypercortisolism, with the exception of patients with adrenal masses whose imaging characteristics are typical for myelolipomas or adrenal cyst. Adrenomyelolipoma is a rare, benign tumor consisting of mature adipose tissue with variable amounts of hematopoietic elements (Table 13.2).
All patients undergo the following work-up.
• Electrolytes: Hypokalemia may suggest hyperaldosteronism; hypokalemia may be present in Cushing's syndrome.
• Fasting lipid profile: Hyperlipidemia may be present in Cushing's syndrome.
• Fasting blood glucose: Hyperglycemia may be present in Cushing's syndrome or pheochromocytomas
• Screening test for Cushing's syndrome with late night salivary cortisol or overnight (1 mg) dexamethasone suppression test (OST).
• Screening for pheochromocytoma with fractionated plasma metanephrines. Patients with HTN should also have plasma renin/aldosterone ratio measured to assess for hyperaldosteronism. If screening for hormonal activity is positive, further testing is indicated to confirm hormonal autonomy.
Subclinical Cushing’s syndrome: Best strategy for measurement of autonomous adrenocortical secretion is by an overnight dexamethasone (1 mg) suppression test. The use of a cortisol level greater than 1.8 μg/dL with sensitivity of >95% is standard to define abnormal values according to this test. A cut-off point of 5 μg/ dL was associated with a specificity of 100% and a sensitivity of 58% in 1 study, whereas a lower cut-off point of about 1.8 μg/dL had a 75% to 100% sensitivity and a 72% to 82% specificity. Hence, we recommend use of the higher cut-off point (5 μg/dL),which has a higher specificity.
The specificity of the 1 mg overnight dexamethasone suppression test is 91%; if the result is abnormal-confirmatory testing should be performed to rule out a false positive result. Serum cortisol ≥5 μg/dL at 21–23 hours are appropriate diagnostic criteria for SCS.
• Clinically silent pheochromocytoma: Measurement of fractionated meta-nephrines and catecholamines in a 24-hour urine specimen is recommended for all patients with adrenal incidentalomas. Elevated levels of fractionated metanephrines, catecholamines, or both has high sensitivity and specificity for pheochromocytoma.
• Primary aldosteronism: Reasonable screening test is the ratio of the ambulatory morning plasma aldosterone concentration to plasma renin activity, If this ratio is high, the diagnosis of primary aldosteronism should be confirmed by an additional measurement of mineralocorticoid secretory autonomy.
• Blood levels of androgens (testosterone and dehydroepiandrosterone sulphate) or estrogens (estradiol) are not routine, but measured when there are signs or symptoms of virilization in women or feminization in men.
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