Endocrine Abstracts

A 60-year-old gentleman of previously good health presented with a 6 months history of resistant hypertension, newly diagnosed Diabetes Mellitus, worsening obesity and proximal muscle weakness. Clinical examination revealed a buffalo hump, truncal obesity, paper thin skin with bruising and proximal muscle wasting. His biochemistry showed elevated midnight cortisol levels, no suppression of cortisol post high dose dexamethasone and an undetectable ACTH. Accompanying abnormalities included low gonadotrophin levels, persistent hypokalaemia and derangement of the liver enzymes. A CT scan of his chest, abdomen and pelvis showed two masses in the right adrenal measuring 7.2×6.2×5.7 cm and 2.8 cm in diameter respectively. There was no evidence of surrounding structure invasion but considerable intraabdominal and intrahepatic fat was noted. The diagnosis of ACTH independent Cushing’s syndrome secondary to adrenal tumours was made. The patient was initially treated with Ketoconazole but due to further deterioration of his liver function was switched to Metyrapone which was titrated to suppress cortisol levels for 6 weeks. Oral hypoglycaemic agents and potassium replacement were also added to the treatment regime. A laparoscopic adrenalectomy was attempted but due to the size of the adrenal masses the procedure was converted to an open one. The right adrenal was successfully excised and there was no intraoperative evidence of surrounding structure invasion. Three weeks post operatively the doses of his antihypertensives were reduced, the oral hypoglycaemic agents stopped and he had normal cortisol responses. Histology of the excised mass was compatible with adrenal cortical carcinoma. He was started on Mitotane. His prognosis is expected to be good in the absence of metastatic spread which is found at presentation in 75% of patients with adrenal carcinoma.