We are excited to see so many of you join our FMEP courses. Several of you have requested we continue to post more practice SAMPs, so here you go!

SAMP

A 66-year-old man presents to the emergency department with severe right-sided flank pain, so he undergoes a CT abdomen for evaluation of nephrolithiasis in the ER. The CT confirms a 3mm kidney stone. He receives IV fluids, morphine, is discharged, and sent to you for follow-up. He presents in your clinic 2 days later feeling much better. You read the CT report and note that, in addition to the 3mm kidney stone identified, the radiologist also reported an incidental 3.2 cm right adrenal mass. He has a history of hypertension and type 2 diabetes, both of which were diagnosed last year. He denies headaches, palpitations, weight loss, or episodic sweating. On examination, he appears well. His BP is 156/92 mm Hg and his HR is 78 bpm. Non-contrast CT report: well-defined adrenal lesion with homogeneous appearance and attenuation of 12 Hounsfield units. (8 points)

1. What is the MOST appropriate next step in evaluation? (1 point)
   1. Given he is asymptomatic, repeat CT in 1 year to see if there is a change in size
   2. Measure plasma-free metanephrines
   3. Proceed to refer to Urology for adrenalectomy
   4. Monitor for now

   Answer: B (Trap: even incidental adrenal masses require biochemical exclusion of pheochromocytoma)

2. Which imaging feature is MOST concerning for adrenal mass malignancy? (1 point)
   1. Smooth margins
   2. Homogeneous density
   3. 8 Hounsfield units on non-contrast CT
   4. Irregular margins with heterogeneous density

   Answer: D

3. True or false: All adrenal incidentalomas larger than 1 cm should be assessed for hormonal hypersecretion. (1 point)

   Answer: True

4. True or false: A nonfunctional adrenal adenoma smaller than 4 cm requires routine long-term radiologic follow-up. (1 point)

   Answer: False

5. List three biochemical tests used in the evaluation of an adrenal incidentaloma. (3 points)

   Answer:
   Overnight dexamethasone suppression test
   Plasma-free metanephrines or 24-hour urinary fractionated metanephrines (pheochromocytoma)
   Aldosterone-to-renin ratio (hyperaldosteronism in hypertensive or hypokalemic patients)

6. True or false: Plasma-free metanephrines or 24-hour urinary fractionated metanephrines are used to exclude pheochromocytoma in adrenal incidentalomas. (1 point)

   Answer: True

Helpful CMAJ Resource:
https://www.cmaj.ca/content/198/2/E48