Annals for Educators - 16 July 2019

Darren B. Taichman

doi:10.7326/AWED201907160

Clinical Practice Points

Natural History of Adrenal Incidentalomas With and Without Mild Autonomous Cortisol Excess. A Systematic Review and Meta-analysis

This systematic review and meta-analysis of 32 studies examines the natural history of adrenal incidentalomas, including malignant transformation and changes in hormone function.

Use this study to:

Start a teaching session with multiple-choice questions. We've provided 2 below!
Ask your learners what evaluations are necessary for incidentally detected adrenal masses (“incidentalomas”). Why are these masses potentially concerning?
How is it determined whether the adrenal mass is functioning or nonfunctioning, and why does it matter?
What did this study find with regard to growth of incidentalomas and development of overt Cushing syndrome?
How reassuring are the findings of this study regarding the need for follow-up? Which incidentalomas should be resected? What questions remain unanswered about the potential development of cortisol excess? Use the accompanying editorial to help frame your discussion.

Patterns of Opioid Administration Among Opioid-Naive Inpatients and Associations With Postdischarge Opioid Use. A Cohort Study

The opioid epidemic has prompted development of guidelines to reduce opioid prescribing for patients at high risk for opioid use disorder. Many of these efforts have focused on patients seen in the outpatient setting, but inpatient opioid use has received less attention. This study describes patterns in timing, duration, and setting of opioid administration among inpatients who were opioid-naive before admission.

Use this study to:

Ask your learners how they treat pain in the hospital. Do they use opioids to treat pain more or less often than in outpatients?
This study noted that most opioid-naive patients received narcotics without prior attempts to control pain with nonopioid analgesics. Ask your learners if they think this happens at your institution. How could this be studied?
Do your learners believe that the needs of clinicians (nurses and physicians) influence the use of opioids to treat pain in hospitalized patients? Why might the physician and/or nurse be motivated to use them?
How is a patient's ongoing need for opioids or other analgesics assessed and monitored at your institution? Why might that be important in light of this study's findings regarding long-term opioid use if these agents are still in use immediately before discharge?

Self-management of Epilepsy. A Systematic Review

This systematic review examines the components and efficacy of self-management interventions for adults with epilepsy.

Use this study to:

Ask your learners how they think epilepsy affects a patient's quality of life.
Teach at the bedside! Talk to a patient with epilepsy and ask how it affects his or her daily life. What about their work? Their daily activities? Their family members?
What is a self-management program? What are its components in epilepsy care? Invite an expert in epilepsy care to join your discussion.
What did this study find with regard to the benefits of self-management programs for patients with epilepsy? Is seizure control the only factor that leads to disability in epilepsy? Use the accompanying editorial to help frame your discussion.
The authors concluded that meta-analysis was difficult because of the heterogeneity and risk of bias among the identified studies. What do each of these mean, and why do they make pooling the evidence in meta-analysis problematic?

Humanism and Professionalism

Assuring Gender Safety and Equity in Health Care: The Time for Action Is Now

As in other industries, sexual harassment is a pervasive problem in health care and medicine, reported by up to 50% of medical students, faculty, and staff. This commentary describes the priorities of the nonprofit organization TIME’S UP Healthcare and its collaborative efforts with the American College of Physicians to address sexual harassment and ensure safety and equity in the health care workplace.

Use this essay to:

Ask your learners whether they believe the work environment at your institution is free of gender bias or other forms of bias. What sorts of bias do they see?
Are expectations the same for men and women during residency? What about for faculty?
What are your residents' expectations for pay when seeking jobs after residency? How do they know what is and is not fair compensation? In what other areas might there be disparities in the jobs they are offered?
In what ways are students and residents subjected to sexual harassment? To whom should they turn for help if such behavior occurs? What should the response be? What if the response is inadequate?

Annals Graphic Medicine - Progress Notes: Sweater

Dr. Natter's clinical confidence unravels like a loose thread from an old sweater.

Use this feature to:

Show the graphic piece to your learners.
Ask whether they have had similar experiences that challenged their self-confidence.
How should we handle such experiences? Is feeling guilty for our mistakes a bad thing?

On Being a Doctor: Building Trust Through Punk Rock

Drs. Moriates and Baig note that trust can be the difference between life and death.

Use this essay to:

Listen with your learners to an audio recording, read by Dr. Michael LaCombe.
Ask your learners to list the circumstances that have led patients to leave “AMA.”
What are common features of such occurrences? Are there problems with communication? With trust? How have the physicians and nurses involved tried to address the problems?
Do we always make as good an effort as we should to improve communication and trust in such situations? Might we be motivated by our own desires and large workloads to “just let the patient leave”?

MKSAP 18 Question 1

A 38-year-old woman is seen in follow-up to discuss the findings of an abdominal and pelvic CT scan done to evaluate renal colic, which has since resolved. The abdominal CT scan showed two small nonobstructing renal calculi in the right kidney and a 1.6-cm left adrenal mass with a density of 21 Hounsfield units (indeterminate for adrenal adenoma). Other than nephrolithiasis, the remainder of the medical history is unremarkable, and she takes no medications.

On physical examination, vital signs and the remainder of the examination are unremarkable.

Laboratory studies show normal serum electrolytes.

Which of the following is the most appropriate test to perform next?

A. 24-Hour urine free cortisol measurement

B. 24-Hour urine total metanephrine measurement

C. Plasma aldosterone-plasma renin ratio (ARR) measurement

D. Serum dehydroepiandrosterone sulfate (DHEAS) measurement

Correct Answer

B. 24-Hour urine total metanephrine measurement

Educational Objective

Screen for adrenal hyperfunction in an incidentally noted adrenal mass.

Critique

The most appropriate next test to perform is a 24-hour urine total metanephrine measurement to screen for pheochromocytoma. Even though this patient does not have hypertension, she should be screened for pheochromocytoma, as these tumors may exist in the absence of typical symptoms or hypertension. Approximately 50% of pheochromocytomas are now first discovered as an incidental adrenal mass. An alternative screening test for pheochromocytoma is measuring the fractionated free plasma metanephrine level. This test has a false-positive rate of approximately 11%, and, therefore, may be considered more useful when suspicion for pheochromocytoma is high. This patient should also be screened for subclinical Cushing syndrome with a 1-mg overnight dexamethasone suppression test. The prevalence of incidentally noted adrenal masses increases with age and is estimated to be about 10% in the elderly. Most lesions are benign, nonfunctioning adenomas, and approximately 10% to 15% secrete excess hormones.

The 24-hour urine free cortisol test is not sensitive enough to diagnose subclinical autonomous cortisol secretion from an adrenal mass. The 24-hour urine free cortisol levels are usually within the normal range in subclinical Cushing syndrome.

The patient does not require screening for primary aldosteronism with a plasma aldosterone-plasma renin ratio (ARR) as she does not have hypertension. Only patients with an incidental adrenal mass and hypertension require screening for primary aldosteronism. Hypokalemia, traditionally thought to be a key feature of primary aldosteronism, is no longer a prerequisite for diagnosis because many patients with this disorder have normal potassium levels.

In women, rapid onset of hirsutism, menstrual irregularities, and virilization should raise suspicion for tumoral hyperandrogenism. Measurement of dehydroepiandrosterone sulfate (DHEAS) is not indicated in this patient, as she did not show signs of hyperandrogenism (hirsutism, deep voice, male pattern balding, clitoromegaly). Serum DHEAS may be measured if signs of significant hyperandrogenism are present in the setting of an adrenal mass that has radiologic features suspicious for malignancy (size >4 cm, heterogeneous enhancement with contrast administration, irregular margins, presence of calcifications or necrosis).

Key Point

Biochemical testing for pheochromocytoma should be undertaken in all patients with an adrenal mass, even in the absence of typical symptoms or hypertension.

Bibliography

Fassnacht M, Arlt W, Bancos I, Dralle H, Newell-Price J, Sahdev A, et al. Management of adrenal incidentalomas: European Society of Endocrinology Clinical Practice Guideline in collaboration with the European Network for the Study of Adrenal Tumors. Eur J Endocrinol. 2016;175:G1-G34. doi:10.1530/EJE-16-0467

MKSAP 18 Question 2

A 45-year-old man underwent abdominal CT imaging for evaluation of bloating and constipation. The CT scan shows a 5-cm right adrenal mass with a density of 42 Hounsfield units and absolute contrast washout of 38% at 10 minutes. Testing for pheochromocytoma and subclinical Cushing syndrome was negative. Medical history is otherwise unremarkable, and he takes no medications.

On physical examination, vital signs and the remainder of the physical examination are normal.

Which of the following is the most appropriate next step in management?

A. Adrenal biopsy

B. Adrenalectomy

C. Mitotane therapy

D. Repeat CT at 6 months

Correct Answer

B. Adrenalectomy

Educational Objective

Treat a large, indeterminate adrenal mass.

Critique

The most appropriate next step in management is adrenalectomy. The patient presented with an incidental adrenal mass with radiologic features that are indeterminate for adenoma and may indicate an adrenal malignancy (size >4 cm, density ≥10 Hounsfield units, and absolute contrast washout <50% at 10 minutes). Benign adrenal adenomas tend to be small (<4 cm), often have an intracytoplasmic fat content and appear less dense on noncontrast CT scan (<10 Hounsfield units), and exhibit rapid contrast washout during delayed contrast imaging (>50% at 10 minutes). These radiologic features are not diagnostic of malignancy, as one-third of benign adrenal masses are lipid poor (≥10 Hounsfield units) and many are larger than 4 cm. However, because adrenal carcinoma is an aggressive tumor and data indicate that prognosis may be more favorable when the disease is diagnosed and treated at an earlier stage, adrenalectomy is usually recommended.

Adrenal biopsy is not routinely indicated in the diagnostic evaluation of an incidentally discovered adrenal mass, even if the suspected diagnosis is primary adrenal malignancy, because adrenocortical carcinoma can be missed due to sampling error. Adrenal biopsy may be indicated when adrenal metastasis or an infiltrative disorder such as infection or lymphoma is suspected. Screening for pheochromocytoma should be performed prior to adrenal biopsy to avoid potential hypertensive crisis during the procedure.

Mitotane, an adrenolytic drug, may be used as adjuvant therapy following primary resection. Adrenalectomy is the first-line treatment of choice for patients with suspected adrenocortical carcinoma.

Repeat abdominal CT imaging at 6 months is suggested for adrenal masses that are small (<4 cm) and have benign radiologic features. The optimal time to repeat CT imaging in the radiologically benign-appearing, or even indeterminate-appearing, incidentally noted adrenal mass, is controversial. Repeat CT imaging is not indicated in this patient with high-risk features for adrenal carcinoma.

This content was last updated in August 2018.

Key Point

Adrenalectomy is recommended for incidental adrenal masses with radiologic features that suggest increased risk of an adrenal malignancy (size >4 cm, density ≥10 Hounsfield units, and absolute contrast washout <50% at 10 minutes).

Bibliography

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Web Exclusives |16 July 2019

Annals for Educators - 16 July 2019 Free

Clinical Practice Points

Natural History of Adrenal Incidentalomas With and Without Mild Autonomous Cortisol Excess. A Systematic Review and Meta-analysis

Patterns of Opioid Administration Among Opioid-Naive Inpatients and Associations With Postdischarge Opioid Use. A Cohort Study

Self-management of Epilepsy. A Systematic Review

Humanism and Professionalism

Assuring Gender Safety and Equity in Health Care: The Time for Action Is Now

Annals Graphic Medicine - Progress Notes: Sweater

On Being a Doctor: Building Trust Through Punk Rock

MKSAP 18 Question 1

MKSAP 18 Question 2

This feature is available only to Registered Users

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Web Exclusives |16 July 2019

Annals for Educators - 16 July 2019 Free

Clinical Practice Points

Natural History of Adrenal Incidentalomas With and Without Mild Autonomous Cortisol Excess. A Systematic Review and Meta-analysis

Patterns of Opioid Administration Among Opioid-Naive Inpatients and Associations With Postdischarge Opioid Use. A Cohort Study

Self-management of Epilepsy. A Systematic Review

Humanism and Professionalism

Assuring Gender Safety and Equity in Health Care: The Time for Action Is Now

Annals Graphic Medicine - Progress Notes: Sweater

On Being a Doctor: Building Trust Through Punk Rock

MKSAP 18 Question 1

MKSAP 18 Question 2

This feature is available only to Registered Users

0 Comments

Related Articles

Journal Club

Related Point of Care

Related Topics

PubMed Articles

Content

Information For

Services

Awards and Cover

Other Resources

Follow Annals On

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