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Self-Assessment Questions

Urology

Adrenal Neoplasms: Review Questions

Sean M. Doyle, MD, and Maxwell Meng, MD

Dr. Doyle is a resident, and Dr. Meng is an assistant professor, Department of Urology, University of California San Francisco, San Francisco, CA.


Choose the single best answer for each question.


Figure

1. A 57-year-old woman with a history of hypertension treated with metoprolol and lisinopril presents to her primary care physician with dull right upper quadrant pain. On examination, the patient’s blood pressure is 165/92 mm Hg and her heart rate is 94 bpm. Her abdomen is soft and nontender with no palpable masses. Abdominal ultrasonography demonstrates cholelithiasis with no evidence of acute inflammation and a 4.2-cm lesion in or adjacent to the upper pole of the right kidney. Results of laboratory testing demonstrate a serum creatinine level of 1.7 mg/dL, glucosuria, and markedly elevated plasma free metanephrines. What is the most appropriate next step in the evaluation of this patient?

  1. Computed tomography (CT) scan of the abdomen and pelvis
  2. Fine-needle biopsy of the lesion
  3. Magnetic resonance imaging (MRI) of the abdomen and pelvis
  4. Surgical resection
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2. Which autosomal dominant familial syndrome is associated with pheochromocytoma?

  1. Beckwith-Wiedemann syndrome
  2. Multiple endocrine neoplasia (MEN) type I
  3. Neurofibromatosis 2
  4. von Hippel-Lindau disease
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3. A patient with MRI findings shown in the Figure undergoes an ultrasound-guided biopsy. During the procedure, the patient complains of a severe headache and has a blood pressure of 240/120 mm Hg. What is the most appropriate pharmacologic intervention to manage this patient’s high blood pressure?

  1. Metoprolol
  2. Metyrosine
  3. Nifedipine
  4. Phenoxybenzamine
  5. Sodium nitroprusside
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Questions 4 and 5 refer to the following case.

A 65-year-old man with a history of diabetes, hypertension, and melanoma resected 3 years ago undergoes CT of the chest, abdomen, and pelvis during a comprehensive physical. CT demonstrates a 3.3-cm enhancing nodule in the right adrenal gland. Results of laboratory studies, including 24-hour urine free cortisol and plasma free metanephrine testing, are normal.

4. What is the most appropriate next step in the evaluation of this patient?
  1. Fine-needle biopsy of the nodule
  2. Iodine metaiodobenzylguanidine (MIBG) scan
  3. MRI of the abdomen and pelvis
  4. Observation with repeat imaging in 1 year
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5. Surgical resection is subsequently planned for the patient. What is the most appropriate preoperative medication regimen?

  1. Propranolol 10 days preoperatively followed by phenoxybenzamine 3 days preoperatively
  2. Phenoxybenzamine 10 days preoperatively followed by propranolol 3 days preoperatively
  3. Sodium nitroprusside infusion 1 hour preoperatively
  4. No pharmacologic intervention is necessary
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6. What is the most common malignant lesion of the adrenal gland?

  1. Adrenal adenoma
  2. Adrenocortical carcinoma
  3. Malignant pheochromocytoma
  4. None of the above
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7. All of the following statements are correct regarding the National Institutes of Health consensus statement on the management of adrenal incidentaloma EXCEPT

  1. Tumors larger than 6 cm have a high rate of malignancy and should be surgically excised
  2. All patients with an incidentaloma should have plasma free metanephrines levels checked and a 1-mg dexamethasone suppression test
  3. Patients with an incidentaloma and a history of hypertension should undergo serum potassium and plasma aldosterone/renin activity ratio
  4. Both open and laparoscopic adrenalectomy are acceptable approaches to surgical excision
  5. A homogenous mass with CT enhancement less than 10 Hounsfield units is likely a benign adenoma
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