Vancouver IM LMR

Thanks Helen Zhao for the excellent review of adrenal incidentalomas!

Slides are available here!

Clinical pearls:

1. Assessment guided by answering two main questions:
   • Is the adrenal mass benign or malignant? – answered by imaging
   • Is the adrenal mass functional (secreting hormones)? – answered by clinical assessment, biochemical workup of hormone excess (cortisol excess eg Cushings/MACS, pheochromocytoma +/- hyperaldosteronism and androgen secretion)
2. Wisdom from our HTN specialist Dr. Kuyper
   • Hyperaldosteronism
     • Confirmatory testing for hyperaldosteronism (eg saline suppression, oral salt load) does not have great test characteristics and can put your patient into heart failure.
     • Generally in unclear situations, interfering medications (eg beta-blockers, ACEi/ARB, CCB, diuretics) may be held and then plasma aldosteronine and renin are re-checked. At this point, it is best to involve a Hypertension specialist (eg HTN clinic) to have this test conducted and interpreted properly!
   • Pheo workup
     • Plasma catecholamines actually preferred but not available here. We order 24 hour urine catecholamines/metanephrines (remember to always include 24 hour creatinine to assess for adequate collection!)
3. In bilateral adrenal incidentaloma, also check 17-hydroxyprogesterone (?congenital adrenal hyperplasia) and screen for adrenal insufficiency if suspected clinically.
4. General principles of adrenal incidentaloma management
   • Cancer or unilateral benign mass with clinically significant hormone excess -> surgery
   • Benign mass without clinically significant hormone excess -> leave alone + repeat imaging in 6-12 months to exclude significant growth