Endocrine Abstracts

In 1993 a 33-year old female was diagnosed biochemically with both Conn's and Cushing's syndrome. A large right-sided adrenal mass was found on CT scan of the abdomen and a right-sided adrenalectomy was performed. Histology reported a benign, 7 centimetre adrenocortical tumour, secreting both cortisol and aldosterone. Annual assessments of urinary cortisol and plasma aldosterone/renin ratios remained normal until September 2002, when she noticed a weight gain of 6 kilograms and complained of swollen legs. 24 hour urinary cortisol measurements at the time were 211, 298 and 308 nanomols per litre (range 40 - 304). The plasma aldosterone/renin ratio was marginally elevated at 26.0 nanograms per milliunits (Range: 0 - 25) with mild hypokalaemia (3.0 millimols per litre). Amiloride was started. A CT scan of the adrenals showed a small lesion on the upper pole of the right kidney, thought to be due to a cyst secondary to the previous surgery. Multi-disciplinary discussion advocated conservative management in the absence of a surgical target. In October 2003 she presented complaining of shortness of breath. She was diagnosed with a large left pleural effusion. Urinary cortisol at the time was elevated to 779 nanomols per 24 hours. At video-assisted thoracoscopy, she was found to have tumour deposits on both the pleura and diaphragm. Histology confirmed infiltration with metastatic adrenocortical carcinoma. Despite treatment with combination chemotherapy and an octreotide infusion, the serum aldosterone rose to 508 nanograms per litre and the random serum cortisol to 3179 nanomols per litre. Unfortunately the patients passed away 5 months later. Her case shows the difficulties in predicting adrenal tumour behaviour from initial histology.