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Hypercalcaemia of malignancy — MCCQE Part 1 MCQ

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HardWeight LossHypercalcaemia of malignancyMCCQE Part 1

A 62-year-old has a 2.4 cm homogeneous adrenal mass discovered incidentally. Noncontrast attenuation is 6 Hounsfield units. She is normotensive, potassium is normal, and she has no adrenergic spells or overt features of cortisol excess. Which endocrine investigation remains appropriate despite the benign imaging phenotype?

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Correct answer: D — A 1 mg overnight dexamethasone suppression test for autonomous cortisol secretion

A lipid-rich, homogeneous lesion below 10 HU is radiologically reassuring, but benign appearance does not exclude autonomous cortisol secretion. The Canadian Urological Association recommends screening all adrenal incidentalomas for cortisol autonomy, with a 1 mg overnight dexamethasone suppression test preferred when clinically appropriate. An aldosterone-to-renin ratio is targeted to patients with hypertension and/or hypokalaemia, neither of which is present. The same guideline suggests that routine pheochromocytoma screening is unnecessary when an unequivocal adrenocortical adenoma is below 10 HU and there are no symptoms of adrenergic excess. Adrenal biopsy is not a routine first step and must never precede exclusion of pheochromocytoma when biopsy is otherwise contemplated. Lesion size alone does not remove the need for hormonal assessment. Subsequent interpretation and follow-up depend on dexamethasone exposure, drug interactions, comorbidity, imaging certainty, and multidisciplinary review.

Reference: Canadian Urological Association, Incidentally Discovered Adrenal Masses guideline (2023): https://www.cua.org/system/files/Guideline-Files/8248.pdf