Endocrine Abstracts

An adrenal ‘incidentaloma’ is an adrenal mass, discovered serendipitously during a radiological examination performed for indications other than an evaluation for adrenal disease. We present a case of a 66-year-old lady with an unexpected finding of a 3 cm right adrenal mass and multiple liver lesions suggestive of metastatic disease following investigations for a suspicious lung lesion which turned out to be an infective process. Liver biopsies revealed hepatic nodular hyperplasia with early cirrhosis. She was discharged pending outpatient hepatic investigations. Her General Practitioner found her to have a high testosterone level (6.9 nmol/l) when she presented with hirsutism, at which point she was referred to our unit. She had a previous hysterectomy and a left sided oophorectomy. Both testosterone and cortisol failed to suppress following an overnight dexamethasone suppression test. Subclinical Cushing’s was confirmed following extended testing. Catecholamines, renin and aldosterone ratios were normal. Left adrenalectomy was performed with steroid cover. Post-operative testosterone was 0.4 nmol/l. Histology showed micronodular cortical hyperplasia. The focus of her initial investigations centred on exclusion of a malignant process but failed to investigate the adrenal incidentaloma. This was likely to be ignored as the adrenal size was not suggestive of a malignant process. In a report for adrenal incidentalomas, a diameter greater than 4 cm was shown to have 90% sensitivity for the detection of adrenocortical carcinoma but low specificity. The size of an adrenal incidentaloma should not preclude hormonal evaluation. When two separate pathologies are present with no unifying diagnosis, it should trigger further investigations for a potential second diagnosis.