a case on adrenal mass

a case on adrenal mass

Paper details:
The notional word count is 2000 words in total. In addition please ensure that you reference your answer fully and appropriately.
The case
A 68 year old lady is referred to your Endocrine Unit following the identification on ultrasound of a 3 cm adrenal mass. The ultrasound was performed for microscopic haematuria and the renal tract was unremarkable, although a liver cyst was also reported.
1. Describe the key points to determine in the history and examination (6 marks)
2. Describe the next radiological investigation you would do if there was no further contribution whatsoever from the history and examination and provide a justification (2 marks)
In fact the history was notable for the following;
Transient visual loss ascribed to a possible TIA 3 years earlier, for which the patient was on clopidogrel
Malignant melanoma completely excised 5 years earlier
The examination was unremarkable apart from the scar from the melanoma excision with a resting heart rate of 76bpm and a BP of 144/76mmHg with no postural drop. The patient stood from a chair with ease but due to back pain, had some difficulty standing from a squat.
3. List your differential diagnosis as things stand in order of likelihood (2 marks)
4. What non-radiological investigations would you request at the same time as requesting your scan (3 marks)
At the follow up appointment, selected results included;
CT adrenals; 3.4×2.4cm right adrenal mass with HU of 24 pre-contrast and washout of 19%. Marked early post-contrast enhancement was observed. A simple liver cyst of 3.8cm was noted and incidental degenerative changes noted of the spine.
9am Cortisol of 354nmol/l falling to 36nmol/l after a formal 48 hour low dose dexamethasone suppression test
2 x 24 hour catecholamine collections were within normal limits
5. Describe, with explanation and caveats, how you would interpret each of the three results above (6 marks)
6.Relist your differential diagnosis in order of likelihood (2 marks)
7. Describe what other investigations you might like to do (if any) and what management plan you are going to advise (3 marks)