Adrenal Cortical Tumors — MCQs
VMA is elevated in which of the following condition?
Which test is essential in a patient with suspected Cushing's syndrome for diagnosis confirmation?
What is the most common adrenal incidentaloma?
The most appropriate first-line imaging modality to detect adrenal metastasis due to bronchogenic carcinoma is:
Which of the following is false about pheochromocytoma?
A 45-year-old develops dysphagia 3 months post thyroidectomy. Most likely cause?
A patient has Cushing syndrome due to an adrenal tumor. Which drug should be given?
Stab wounds of the kidneys involve other abdominal organs in a high percentage of cases. Of the organs listed, which one is least likely to be damaged in this patient?
Where is a bruit typically heard in the thyroid gland?
Thyroxine is used in the treatment of which thyroid cancer?
Adrenal Cortical Tumors Indian Medical PG Practice Questions and MCQs
Question 1: VMA is elevated in which of the following condition?
- A. Tuberous sclerosis
- B. Addison disease
- C. Pheochromocytoma (Correct Answer)
- D. Conn Syndrome
Explanation: Pheochromocytoma - Pheochromocytoma is a tumor of the adrenal medulla that secretes excessive amounts of catecholamines (epinephrine and norepinephrine). - Vanillylmandelic acid (VMA) is a breakdown product of these catecholamines [1], so its levels are elevated in the urine of patients with pheochromocytoma. Tuberous sclerosis - Tuberous sclerosis is a genetic disorder characterized by the growth of numerous non-cancerous tumors in various organs. - While it can be associated with renal angiomyolipomas or brain lesions, it does not directly cause elevated VMA levels. Addison disease - Addison disease is characterized by adrenal insufficiency [2], meaning the adrenal glands produce insufficient amounts of hormones like cortisol and aldosterone. - This condition is not associated with the overproduction of catecholamines or elevated VMA. Conn Syndrome - Conn syndrome (primary hyperaldosteronism) is due to an overproduction of aldosterone by the adrenal glands, often caused by an adrenal adenoma [3]. - Aldosterone is a mineralocorticoid, and its overproduction does not lead to increased catecholamine metabolism or elevated VMA levels.
Question 2: Which test is essential in a patient with suspected Cushing's syndrome for diagnosis confirmation?
- A. Serum aldosterone
- B. Serum renin
- C. Plasma ACTH
- D. 24-hour urine cortisol (Correct Answer)
Explanation: ***24-hour urine cortisol*** - This test measures the **total amount of cortisol excreted** in the urine over a 24-hour period, reflecting the average daily cortisol production. [1] - An **elevated 24-hour urine free cortisol** is a primary diagnostic test to confirm hypercortisolism in suspected Cushing's syndrome. [1] *Serum aldosterone* - This test is primarily used in the diagnosis of **hyperaldosteronism**, such as Conn's syndrome, which causes hypertension and hypokalemia. - While related to the adrenal glands, **aldosterone levels are not directly used to diagnose Cushing's syndrome**. *Serum renin* - This test is part of the workup for **hypertension** and is used in conjunction with aldosterone to assess the **renin-angiotensin-aldosterone system**. - It is **not a direct or essential test** for the diagnosis of Cushing's syndrome. *Plasma ACTH* - While **plasma ACTH** is crucial for differentiating between different causes of Cushing's syndrome (e.g., ACTH-dependent vs. ACTH-independent), it is **not the initial diagnostic test to confirm the presence of hypercortisolism**. [2] - **Confirmation of cortisol excess** typically precedes ACTH measurement to determine the etiology. [2]
Question 3: What is the most common adrenal incidentaloma?
- A. Aldosterone producing
- B. Pheochromocytoma
- C. Endocrine inactive tumors (Correct Answer)
- D. Cortisol producing
Explanation: ***Endocrine inactive tumors*** - The majority, about **70-85%**, of adrenal incidentalomas are **benign, non-secretory adenomas**, which are often referred to as endocrine inactive tumors. [1] - These tumors do not produce excess hormones and are typically discovered incidentally on imaging performed for other reasons. *Cortisol producing* - While **cortisol-producing adenomas** are a type of functional adrenal tumor, they represent a smaller percentage of incidentalomas, usually less than 10%. - These can lead to **Cushing's syndrome**, but most incidentalomas causing hypercortisolism are subclinical. *Aldosterone producing* - **Aldosterone-producing adenomas**, which cause primary aldosteronism, are also less common than inactive tumors, accounting for about 1-5% of incidentalomas. [1] - They are typically associated with **hypertension** and **hypokalemia**. *Pheochromocytoma* - **Pheochromocytomas**, which secrete catecholamines, are rare adrenal incidentalomas, making up less than 5% of cases. - These tumors can cause **hypertension**, **tachycardia**, and other symptoms related to catecholamine excess. [1]
Question 4: The most appropriate first-line imaging modality to detect adrenal metastasis due to bronchogenic carcinoma is:
- A. PET scan
- B. MRI of the abdomen
- C. Adrenal radionuclide scan
- D. Contrast Enhanced CT abdomen (Correct Answer)
Explanation: **Contrast Enhanced CT abdomen** - **Contrast-enhanced CT abdomen** is generally considered the most sensitive and cost-effective imaging modality for detecting **adrenal metastases**. - It allows for detailed visualization of adrenal gland morphology, including size, shape, and enhancement patterns, which can help differentiate benign from malignant lesions. *PET scan* - While **PET (Positron Emission Tomography) scans** are highly sensitive for detecting metabolically active metastatic disease, they are often used as a secondary imaging modality to characterize indeterminate lesions found on CT or MRI. - **PET scans** can have false positives in benign adrenal tumors (e.g., adenomas rich in fat) and are less readily available or higher in cost for initial screening compared to CT. *MRI of the abdomen* - **MRI of the abdomen** can be very useful for further characterization of adrenal masses, especially for distinguishing between lipid-rich adenomas and metastases. - However, for initial detection, especially in the context of screening for distant metastases from bronchogenic carcinoma, **CT is generally preferred due to its wider availability, speed, and lower cost**. *Adrenal radionuclide scan* - **Adrenal radionuclide scans** (e.g., using MIBG or iodocholesterol) are primarily used for functional imaging of adrenal glands, typically to detect specific types of tumors like pheochromocytomas or aldosteronomas. - These scans are **not sensitive for detecting adrenal metastases** from bronchogenic carcinoma, as the metastatic lesions do not typically exhibit the specific uptake patterns targeted by these radiotracers.
Question 5: Which of the following is false about pheochromocytoma?
- A. Surgery is the treatment of choice
- B. VMA (vanillylmandelic acid) is a diagnostic test
- C. Propranolol is the preferred drug for hypertension control (Correct Answer)
- D. Catecholamines are a diagnostic test
- E. Most pheochromocytomas are benign
Explanation: ***Propranolol is the preferred drug for hypertension control*** - Propranolol, a **beta-blocker**, is generally contraindicated as monotherapy in pheochromocytoma because blocking beta-receptors unopposed can lead to a **hypertensive crisis** due to unopposed alpha-adrenergic vasoconstriction. - **Alpha-blockers** (e.g., phenoxybenzamine) are the first-line agents for hypertension control, followed by beta-blockers once adequate alpha-blockade is established. *Surgery is the treatment of choice* - **Surgical resection** of the tumor is indeed the definitive treatment for pheochromocytoma once the patient has been appropriately prepared with alpha-blockade. - This approach aims to remove the source of excessive catecholamine production and resolve the associated symptoms. *VMA (vanillylmandelic acid) is a diagnostic test* - **VMA** is a metabolic breakdown product of catecholamines, and its measurement in a **24-hour urine collection** is a long-standing method for diagnosing pheochromocytoma. - Elevated VMA levels indicate overproduction of catecholamines, which is characteristic of the tumor. *Catecholamines are a diagnostic test* - Measuring **plasma free metanephrines** and **24-hour urinary fractionated metanephrines** (which are methylated metabolites of catecholamines) are highly sensitive and specific diagnostic tests for pheochromocytoma. - Elevated levels confirm the excessive secretion of these hormones by the tumor. *Most pheochromocytomas are benign* - Approximately **90% of pheochromocytomas are benign**, with only about 10% being malignant. - The **"rule of 10s"** is a helpful mnemonic: 10% bilateral, 10% extra-adrenal, 10% malignant, 10% familial, and 10% occur in children.
Question 6: A 45-year-old develops dysphagia 3 months post thyroidectomy. Most likely cause?
- A. Recurrent tumor
- B. RLN palsy
- C. Adhesions (Correct Answer)
- D. Esophageal injury
Explanation: ***Adhesions*** - **Adhesions** are the **most common cause** of delayed dysphagia occurring 3 months post-thyroidectomy. - **Perithyroidal and periesophageal adhesions** develop as part of the healing process and can cause esophageal compression, restriction of laryngotracheal mobility, or tethering of the esophagus. - The **3-month timeline** is classic for scar tissue maturation and adhesion formation, which peaks between 2-6 months post-operatively. - Patients typically describe **mechanical dysphagia** (difficulty with solid foods initially) and a sensation of tightness or fullness in the neck. - Management is usually **conservative** with time and reassurance, though severe cases may require surgical adhesiolysis. *Esophageal injury* - **Esophageal injury** during thyroidectomy is **extremely rare** (<0.1% incidence) due to the anatomical plane of dissection. - If it occurs, it typically presents **immediately or within days** post-operatively with severe symptoms such as fever, mediastinitis, subcutaneous emphysema, chest pain, and sepsis. - A **3-month delayed presentation** would be highly unusual and not the "most likely" cause in this clinical scenario. *RLN palsy* - **Recurrent laryngeal nerve (RLN) palsy** causes **hoarseness and voice changes** due to vocal cord paralysis, not dysphagia. - While bilateral RLN injury can cause airway obstruction and aspiration, it does not typically cause true dysphagia (difficulty swallowing solids/liquids). - RLN palsy manifests **immediately post-operatively** when the patient is extubated, not months later. *Recurrent tumor* - **Recurrent thyroid cancer** causing dysphagia at 3 months post-operatively is **extremely unlikely**. - Tumor recurrence typically takes **months to years** to develop and would be accompanied by other findings such as a palpable neck mass, lymphadenopathy, or recurrent laryngeal nerve involvement. - The short time frame makes this diagnosis improbable unless dealing with anaplastic carcinoma, which is rare.
Question 7: A patient has Cushing syndrome due to an adrenal tumor. Which drug should be given?
- A. Ketoconazole (Correct Answer)
- B. Spironolactone
- C. Hydrocortisone
- D. Dexamethasone
Explanation: ***Ketoconazole*** - **Ketoconazole** is an antifungal agent that also inhibits several enzymes involved in **steroidogenesis**, including 17α-hydroxylase and 11β-hydroxylase. - This action helps to reduce the overproduction of **cortisol** in Cushing syndrome caused by an adrenal tumor. *Hydrocortisone* - **Hydrocortisone** is a glucocorticoid itself and would exacerbate the symptoms of **Cushing syndrome** by adding to the already elevated cortisol levels. - It is used for **cortisol replacement therapy** in conditions like Addison's disease, where cortisol levels are low. *Dexamethasone* - **Dexamethasone** is a potent synthetic glucocorticoid used to suppress **ACTH production** in cases of ACTH-dependent Cushing's syndrome (e.g., Cushing's disease) or to diagnose Cushing's syndrome. - In an adrenal tumor, which is **ACTH-independent**, dexamethasone would not reduce cortisol production but could instead worsen the hypercortisolism. *Spironolactone* - **Spironolactone** is an **aldosterone antagonist** and a weak antiandrogen, primarily used for conditions like hyperaldosteronism, heart failure, and hirsutism. - It has no direct effect on the overproduction of **cortisol** from an adrenal tumor in Cushing syndrome.
Question 8: Stab wounds of the kidneys involve other abdominal organs in a high percentage of cases. Of the organs listed, which one is least likely to be damaged in this patient?
- A. Spleen
- B. Stomach (Correct Answer)
- C. Inferior vena cava
- D. Left adrenal gland
Explanation: ***Stomach*** - The **stomach** is located in the **intraperitoneal space**, relatively anteriorly and centrally in the abdomen, while the kidneys are **retroperitoneal** and posteriorly positioned. - Most renal stab wounds occur from a **posterior or posterolateral approach**, making the anteriorly located stomach the **least likely** organ to be injured in conjunction with kidney trauma. - Its high mobility and gas content also offer some degree of protection by allowing it to shift with impact or absorb some of the force without penetrating injury. *Spleen* - The **spleen** is located in the left upper quadrant, in close anatomical proximity to the left kidney, making it highly susceptible to injury in cases of left renal stab wounds. - Its delicate, vascular nature makes it prone to significant bleeding even from minor trauma. *Inferior vena cava* - The **inferior vena cava (IVC)** lies in the retroperitoneum, anterior to the spine and medial to the kidneys, making it vulnerable to deep penetrating wounds that reach the posterior abdominal cavity. - Injury to the IVC can lead to massive hemorrhage and is a life-threatening complication. *Left adrenal gland* - The **left adrenal gland** is located superior and slightly medial to the left kidney, directly in the retroperitoneal space. - A stab wound to the left kidney has a high probability of also involving the closely associated left adrenal gland due to their anatomical proximity.
Question 9: Where is a bruit typically heard in the thyroid gland?
- A. Upper pole (Correct Answer)
- B. Lower pole
- C. Middle part
- D. Lateral aspect
Explanation: **Explanation:** The presence of a thyroid bruit is a classic clinical sign of **Graves' disease** (toxic diffuse goiter). It occurs due to the hyperdynamic circulation and significantly increased vascularity of the gland. **Why the Upper Pole is Correct:** The bruit is most commonly heard over the **upper pole** of the thyroid gland. This is because the **superior thyroid artery**, a direct branch of the external carotid artery, enters the gland at the upper pole. Due to its proximity to a major high-pressure arterial trunk and its relatively superficial location, the turbulent blood flow (hypervascularity) is most audible at this site. **Analysis of Incorrect Options:** * **Lower Pole:** While the inferior thyroid artery (from the thyrocervical trunk) supplies the lower pole, it is situated deeper and has a more tortuous course, making a bruit less likely to be localized here compared to the superior pole. * **Middle Part & Lateral Aspect:** These areas represent the body of the lobes. While vascularity is increased throughout in Graves' disease, the primary inflow points (the poles) are the high-yield areas for auscultation. **High-Yield Clinical Pearls for NEET-PG:** 1. **Bruit vs. Thrill:** A bruit is an auditory sign (auscultation), whereas a **thrill** is its tactile equivalent (palpation). Both indicate Graves' disease. 2. **Differential Diagnosis:** A thyroid bruit must be distinguished from a **venous hum** (disappears with pressure over the internal jugular vein) and a **carotid bruit** (heard lateral to the gland). 3. **Significance:** The presence of a bruit is highly specific for Graves' disease and helps differentiate it from other causes of thyrotoxicosis, such as toxic multinodular goiter or thyroiditis.
Question 10: Thyroxine is used in the treatment of which thyroid cancer?
- A. Medullary
- B. Radiation induced
- C. Anaplastic
- D. Papillary (Correct Answer)
Explanation: **Explanation:** The correct answer is **Papillary Thyroid Carcinoma (PTC)**. **Why Papillary is Correct:** Papillary and Follicular thyroid cancers are **Differentiated Thyroid Cancers (DTC)**. These tumor cells retain receptors for **Thyroid Stimulating Hormone (TSH)**. TSH acts as a growth factor for these cells; elevated levels can promote tumor recurrence or progression. By administering exogenous **Thyroxine (L-Thyroxine)** in supra-physiological doses, we initiate a negative feedback loop that suppresses pituitary TSH secretion. This "TSH Suppression Therapy" deprives the residual cancer cells of their growth stimulus, thereby reducing recurrence rates and improving survival. **Why other options are incorrect:** * **Medullary Thyroid Cancer (MTC):** Arises from parafollicular C-cells (which produce calcitonin), not follicular cells. These cells do not have TSH receptors; therefore, TSH suppression with thyroxine has no therapeutic effect on the tumor itself. * **Anaplastic Thyroid Cancer:** This is an undifferentiated, highly aggressive tumor. The cells have lost all functional characteristics of normal thyroid tissue, including TSH receptors, making thyroxine therapy ineffective. * **Radiation-induced:** While radiation is a major risk factor for Papillary carcinoma, the term describes the etiology rather than the pathological type. The treatment depends on the resulting histology (usually Papillary). **High-Yield Clinical Pearls for NEET-PG:** * **Target TSH levels:** For high-risk DTC patients, the target TSH is usually **<0.1 mU/L**. For low-risk patients, it is **0.1–0.5 mU/L**. * **Side Effects:** Long-term TSH suppression can lead to **osteoporosis** (especially in post-menopausal women) and **atrial fibrillation**. * **Follow-up:** Serum **Thyroglobulin (Tg)** is used as a tumor marker for DTC follow-up after total thyroidectomy.
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