Pituitary Gland Adrenal Gland ThyroidParathyroid Thyrotoxicosis Bone Health

Pituitary Gland Adrenal Gland Thyroid/Parathyroid Thyrotoxicosis Bone Health Skin + Heart $100 $100 $200 $200 $300 $300 $400 $400 $500 $500

Adrenal $100 1. 5 cm mass found on CT Scan 1 mg overnight DST cortisol is 3. 3 mg/d. L ↑

What is a mild autonomous cortisol excess (MACE) adrenal adenoma?

Mild Autonomous Cortisol Excess (MACE) • • • 15 -20% of patients with incidentally discovered adrenal tumors have MACE patients lack classical physical features of overt Cushing’s syndrome i. e. striae, thinning of the skin Patients with MACE at higher risk of developing type 2 DM, hypertension, dyslipidemia, obesity, and fractures MACE associated with an increased risk of cardiovascular events 50% of patients see metabolic improvement with adrenalectomy

Increased Cardiovascular Events the Higher the 8 AM Cortisol European Journal of Endocrinology 2017; 177: 73 -83

Adrenal Incidentaloma Definition “Mass lesion greater than 1 cm in diameter discovered “accidentally” during a radiographic examination performed for indications other than an evaluation for adrenal disease. ” Management of the clinically inapparent adrenal mass (incidentaloma). NIH State-of-the-Science Conference Statement Feb 4 -6, 2002.

Adrenal Incidentaloma— Two Important Questions Is the adrenal mass hormonally active? Is the adrenal mass benign or malignant?

CT numbers in Hounsfield Units (HU) Sir Godfrey Newbold Hounsfield HU <10 on unenhanced CT = benign adenoma 100%

Hounsfield Units 9. 8 HU = benign adenoma

Magnetic Resonance Imaging • • • Equally effective as CT. Adenomas are isointense with the liver on T 2 weighted images. Carcinomas are hyperintense compared to the liver on T 2 weighted images.

Magnetic Resonance Imaging— T 2 Weighted Images Isointense Benign Hyperintense Malignant

Adrenal Incidentaloma Take Home Messages • Adrenal masses (incidentalomas) are common and they increase in frequency with age • Adrenal masses may be benign (non-functional), malignant (primary or metastatic), or functional (pheochromocytoma, Cushing’s, aldosteroma or sex-hormone secreting). • Size matters as does the amount of attenuation (Hounsfield Units) in determining whether the mass is benign or malignant.