Endocrine Abstracts

A 69-year-old lady presented with pancreatitis, which was managed conservatively and resolved. However, imaging identified a 4 cm left adrenal lesion. She had no features of Cushing’s syndrome, and was normotensive, but serum potassium was low. Renin:aldosterone ratio was normal. She failed a low dose dexamethasone suppression test (LDDST). She underwent laparoscopic adrenalectomy. Histology showed an adrenocortical carcinoma extending into the adjacent adipose tissue. Sixteen months postoperatively she failed an LDDST. A MRI adrenals showed a 1.5×1.4 cm soft tissue mass, thought to represent recurrence of the adrenocortical carcinoma. She underwent repeat surgery with removal of the recurrent tumour, the left kidney, the spleen and a segment of colon. The histology showed multifocal adrenocortical carcinoma involving the previous surgical bed. She was commenced on a course of mitotane. Twenty-two months after her initial surgery, imaging was performed in view of abdominal pain. This showed local recurrence and peritoneal deposits.

A 60-year-old man was referred to our centre with a diagnosis of ACTH independent Cushing’s syndrome and a 7.6 cm right adrenal mass, after presenting with hypertension. A CT with contrast suggested that this was a benign lesion. He underwent an open adrenalectomy, as the lesion was closely applied to the liver. Histology identified an adrenocortical tumour with a high mitotic rate and a Ki67 index >5%. This was consistent with an adrenocortical carcinoma, and there was evidence of involvement of peri-adrenal fat. He subsequently underwent chemotherapy with mitotane.

Mitotane is a synthetic derivative of the insecticide DDT. It inhibits cortisone metabolism, and also has cytotoxic effects on the adrenal cortex. Its role in the management of adrenocortical carcinoma is unclear. Recent retrospective data suggest that it should be used as adjuvant treatment following surgery, and should not be solely reserved for recurrent disease. The rarity of adrenocortical carcinoma makes the undertaking of adequately powered randomised trials difficult.