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Adrenal mass

Adrenal mass. Cushing’s Syndrome. Taylor Wofford September 18, 2009. Diagnosis. Excess glucocorticoid Timing of symptoms Severity of symptoms Cause of symptoms. Frequency of causes of Cushing’s syndrome. Hypothalamic-Pituitary-Adrenal Axis. Cushing’s Syndrome. Blood clots?

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Adrenal mass

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  1. Adrenal mass

  2. Cushing’s Syndrome Taylor Wofford September 18, 2009

  3. Diagnosis • Excess glucocorticoid • Timing of symptoms • Severity of symptoms • Cause of symptoms

  4. Frequency of causes of Cushing’s syndrome

  5. Hypothalamic-Pituitary-Adrenal Axis

  6. Cushing’s Syndrome Blood clots?  IOP, cataracts

  7. Comparing Obesity vs. Cushing’s

  8. Testing to establish the diagnosis of Cushing's syndrome* Diagnostic testing algorithm UpToDate

  9. Indeterminate ACTH Testing • Cortocotropin Releasing Hormone stimulation test • When CRH is given, ACTH-dependent disease should produce an increase in ACTH and cortisol • Draw labs  dose of CRH  measure change 45 min post.

  10. ACTH-dependent workup • MRI-pituitary • CRH stimulation test AND • High dose dexamethasone suppression test • Nonpituitary tumors associated with ectopic ACTH are completely resistant to feedback inhibition • 8mg dex po at 2300. measure serum cortisol at 0800 next day. <5 μg/dL=pituitary source.

  11. ACTH-dependent workup-2 • Inferior petrosal sinus sampling • If ACTH secretion is coming from a pituitary source, inferior petrosal sinus ACTH levels will be greater than peripheral ACTH levels • Central-to-peripheral ratio of ≥2.0 pre-CRH or ≥3.0 post-CRH = pituitary source

  12. ACTH-independent workup • Adrenal CT or MR imaging • Thin cuts • Masses often difficult to differentiate. ?PET.

  13. Adrenal mass

  14. Adrenal histology • No one characteristic feature • Weiss score 0-9 • Nuclear grade • Mitotic rate • Atypical mitosis • Character of cytoplasm • Architecture of tumor cells • Necrosis • Invasion of venous structures • Invasion of sinusoid structures • Invasion of the capsule of the tumor

  15. Steroid synthesis pathway

  16. Infectious complications of Cushing’s syndrome • Cryptococcosis • Aspergillosis • Nocardiosis • Pneumocystis carinii • Staph aureus • Candida albicans • Alternariosis • Tinea

  17. Bibliography • Graham BS, Tucker WS, Opportunistic infections in endogenous Cushing’s syndrome. Ann Intern Med 1984 Sep;101 (3):334-8. • http://images.google.com/imgres?imgurl=https://courses.stu.qmul.ac.uk/smd/kb/resources/endocrinologyresource/21-36.JPG&imgrefurl=http://flipper.diff.org/app/items/info/418&usg • http://models.cellml.org/workspace/bingzheng_zhenye_liansong_1990/@@rawfile/f475e016ed033c4b3dda595794addb2c8a6bcdc9/bingzheng_1990.png • http://www.scielo.br/img/revistas/abem/v51n8/17f2.gif • Up To Date • Dr. O’Connell and Dr. DeCherney, UNC Endocrinology

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