Editing Diagnosis and Evaluation of Adrenal Mass (section)

=== Labs ===

* See 2011 CUA Incidental Adrenal Mass Guideline [https://test.urologyschool.com/index.php/CUA:_Adrenal_Mass_(2011) Notes]
* '''<span style="color:#ff0000">Hypercortisolism'''
** '''<span style="color:#ff0000">Assessed by overnight low-dose (1 mg) dexamethasone suppression test</span>''' (sensitivity: 85-90 specificity: 95-99)
*** Consideration can be given to using the 24-hour urine free cortisol (sensitivity: 80-98, specificity: 45-98) for screening, with the low dose 1 mg dexamethasone suppression test used to differentiate Cushing’s from subclinical Cushing’s syndrome if the cortisol level on the 24-hour test is elevated.
*** Further [https://www.ncbi.nlm.nih.gov/pubmed/31069279 details on hypercortisolism testing]
* '''<span style="color:#ff0000">Pheochromocytoma'''
** '''<span style="color:#ff0000">Assessed by 24-hour urine metanephrines and catecholamines'''
*** '''Fractionated plasma metanephrines''' is a newer test that may be more sensitive, but less specific. As such, its use '''should be reserved for confirmatory testing as opposed to primary screening'''.
**** Plasma metanephrine testing may not be widely available outside select centers, therefore 24-hour urinary metanephrines is suggested for initial screening.
* '''<span style="color:#ff0000">Hyperaldosteronism'''
** '''<span style="color:#ff0000">Assessed in hypertensive patients by upright plasma aldosterone concentration to plasma renin ratio (ARR).'''
*** '''Pre-testing considerations'''
****'''Mineralocorticoid receptor blockers (e.g. spironolactone) and some diuretics, particularly potassium sparing diuretics (e.g. amiloride, triamterene) and potassium wasting diuretics (e.g. furosemide, HCTZ, indapamide), should be discontinued at least 4 weeks prior to the ARR'''
**** If ARR results are not diagnostic and hypertension can be controlled with relatively noninterfering antihypertensives, withdrawal of other potentially interfering medications (angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, renin inhibitors, dihydropyridine calcium channel antagonists, β-blockers, central α-2 agonists and non-steroidal anti-inflammatory drugs) for at least 2 weeks prior to a repeat ARR is recommended.
**** '''Patients should be informed to liberalize salt intake leading up to the test to ensure accurate results'''
*****Acute fluctuations in dietary sodium are reported to not affect the diagnostic accuracy of the ARR
** '''Normokalemia occurs in up to 50% of patients with hyperaldosteronism.'''
*** Traditionally, hyperadlosteronism has been clinically associated with hypertension and hypokalemia
* '''<span style="color:#ff0000">Adrenal Sex Steroid Hypersecretion'''
** '''<span style="color:#ff0000">Routine testing of incidentalomas for sex hormones is not currently recommended'''
*** '''Hypersecretion of adrenal sex steroids by adrenal masses, especially incidentalomas, is exceedingly rare and typically present with concomitant clinical symptoms (i.e., feminization or virilization)'''
**'''Assessed with (2):'''
**#'''Serum DHEA-S'''
**#'''24-hour urine 17-ketosteroids'''
* '''<span style="color:#ff0000">Confirmatory hormonal testing for all positive screening tests is recommended to limit false positive results and unnecessary surgery'''