Incidental Findings

by Kevin Pei, MD

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    00:01 I’d like to pose a question to you. What if for another reason, you got a CT scan or an MRI and you find an incidental adrenal mass, what would you do? I’ll give you a second to think about this.

    00:15 Let’s go over incidental findings. This is a favorite topic for surgery residents. I also think it’s very important for your examination. What if an incidental adrenal mass is found? You know before the days of CT scans and MRIs became routine, people didn’t find these.

    00:32 A lot of masses that we find as incidentalomas were in fact clinically insignificant. This is similar in the case of adrenal masses. For various reasons, whether it’s trauma, abdominal pain, the patient may have gotten the CT scan. Here are some questions that I ask myself when I find an incidental adrenal mass. Number one, is it functional? Is it secreting catecholamines, for example? Is it malignant? Has it metastasized to organs like the bone, liver or lymph nodes? What is its size? Remember, there is an association between adrenal masses that are greater than 4 cm and the increased chances of cancer. Therefore, any adrenal masses that you find incidentally that are larger than 4 cm should be subjected to surgery. Although remember, just because the mass is greater than 4 cm doesn’t mean that it’s cancer. Let’s move on to another important syndrome. We see this rarely but it’s a favorite question on tests.

    01:36 What is von Hippel-Lindau syndrome? I’ll give you a moment to think about this.

    01:42 The answer, it’s a combination syndrome including pheochromocytoma much like the multiple endocrine neoplasias. In von Hippel-Lindau, patients also demonstrate cerebellar hemangioblastomas, sometimes renal cell carcinomas, and pancreatic cysts. Specifically, there is a gene mutation in the VHL gene. My next question for you, what is neurofibromatosis type 1? I’ll give you a second to think about this. Answer, it’s also known as von Recklinghausen. It’s a congenital disease of skin, nervous system, bones and endocrine glands. Of course, it includes pheochromocytomas.

    02:25 It’s very popular to talk about these syndromes. I just like to remind you however that most pheochromocytomas are not part of these syndromes. So, if posed with the question on the examination, don’t think about the zebras, think about common things first. This is a picture of a neurofibromatosis patient. These are specific to skin neurofibromatosis. Let’s review some very important clinical pearls and high-yield information. Modern CT scans have increased the detection of incidentalomas. This is very important to know what to do. Just as a review, large incidentalomas should undergo surgery. That’s defined by greater than 4 cm.

    03:11 Functional incidentalomas as defined by metanephrines should also undergo surgery.

    03:16 Aside from those scenarios, it’s probably safe to simply observe with a repeat CT scan.

    03:24 For your examination, remember, do not start a beta blockade preoperatively before alpha blockade. The reason for this is because there will be unopposed alpha adrenergic activity leading to a hypertensive crisis. That may lead to death. If posed with the clinical scenario on how do you prepare a patient for surgery for pheochromocytoma also known as an adrenalectomy, start with phenoxybenzamine for two weeks. Thank you very much for joining me on this discussion of pheochromocytomas.

    About the Lecture

    The lecture Incidental Findings by Kevin Pei, MD is from the course General Surgery.

    Included Quiz Questions

    1. The majority of cases are sporadic.
    2. MEN 2A syndrome
    3. MEN 2B syndrome
    4. Von Hippel-Lindau syndrome
    5. Neurofibromatosis type 1 (von Recklinghausen's disease)
    1. The patient should be prescribed phenoxybenzamine for 2 weeks prior to performing an adrenalectomy.
    2. The patient's blood pressure and heart rate should be controlled with a beta-blocker prior to performing surgery.
    3. The patient should be observed with a repeat CT scan in 3 months since the tumor is less than 4 cm.
    4. The patient should be admitted for emergency tumor resection.
    5. The patient should be screened for cerebellar hemangioblastomas by MRI of the brain.
    1. A non-functional 3 cm adrenal lesion
    2. A functional 1 cm adrenal lesion
    3. A non-functional 5 cm adrenal lesion
    4. A non-functional 6 cm adrenal lesion
    5. A functional 5 cm adrenal lesion
    1. Von Hippel-Lindau syndrome
    2. Neurofibromatosis type 1
    3. MEN 1 syndrome
    4. MEN 2A syndrome
    5. Von Recklinghausen's disease

    Author of lecture Incidental Findings

     Kevin Pei, MD

    Kevin Pei, MD

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