Endocrine Abstracts

Laparoscopic adrenalectomy has become increasingly popular because of its minimally invasive nature for managing benign pathologies of the adrenals and isolated adrenal metastases, but selection of cases suitable for this surgical procedure is very important.
We report a 61 year old lady who presented with symptoms of easy bruising, flushing, hoarse voice, weight gain and proximal muscle weakness. On examination, she was had moon facies, skin bruising and was hypertensive. Investigations revealed hypokalaemia, hyperglycaemia, slightly deranged liver function tests, raised 24 hour urine cortisol excretion (2130 nanomoles), morning cortisol (718 nanomoles per litre) with lack of suppression to overnight Dexamethasone test and normal ACTH. Computerised tomogram revealed a 5 centimetres adrenal tumour. Cushing's syndrome due to adrenal tumour was diagnosed and was urgently referred to the surgeons who performed laparoscopic right adrenalectomy. The patient felt much better post-operatively and noticed gradual regression of the signs of Cushing's syndrome with normal 24 hour urine cortisol excretion post-operatively.
She presented 10 months post-surgery with small lumps in the upper abdominal wall around the surgical scar for adrenalectomy. An urgent scan revealed 3 separate subcutaneous masses in the right upper quadrant of the abdomen, confirming metastases. She was referred to the surgeons who removed the skin masses and histology confirmed recurrent highly malignant adrenal cortical metastases. A review of her original laparoscopic adrenalectomy histology also confirmed that it was possibly malignant. Since then she has been referred to the oncologists for possible chemotherapy.
This case report emphasises the importance of excluding possible adrenal cortical malignancy in patients considered for laparoscopic adrenalectomy, as such technique might contribute to subsequent tumour recurrence and also peritoneal dissemination. A good patient selection and experience with advanced laparoscopic surgery are requisites for successful use of this surgical technique.