Endocrine Abstracts

We present a 44-year-old female referred to us with a two year history of episodic palpitations, chest tightness, headaches and pallor associated with hypertension. She had previously been extensively investigated by neurologists and cardiologists including MRI of the brain, renal ultrasonography, 24 h tape and echocardiography – all normal. Given the history, a CT of the adrenals was performed in 2007 which revealed a 1.5 cm nodule in the right adrenal with abnormal enhancement. The left adrenal was normal. Several 24-h urine collections for catecholamines were done to investigate the possibility of phaeochromocytoma and revealed normal levels apart from a borderline urinary adrenaline on one occasion. Twenty-four hours urinary free cortisol and overnight dexamethasone suppression tests were also normal. As she had persistent and troubling symptoms, CT scan was repeated in February 2008 which showed that the adrenal nodule had increased to 2.2 cm over the preceding 9 months. MIBG scan was performed to assess activity and showed no abnormal uptake. MRI in May 2008 confirmed abnormal enhancement and the nodule was now 3 cm in diameter. With the mass enlarging and the symptomatology it was elected that this lady should undergo right laproscopic adrenalectomy. Despite the lack of positive biochemical and functional imaging findings for a phaeochromocytoma, the history led us to recommend prior alpha-blockade in the form of oral phenoxybenzamine and atenolol and perioperative intravenous phenoxybenzamine. This lady underwent right adrenalectomy on 27th May 2008. Intraoperatively it was noted by the anaesthetist that her blood pressure was labile when the tumour was being handled. Histology showed a well-circumscribed, encapsulated, nodular central lesion which stains positively for chromagranin, synaptophysin and PGP9.5, negative for inhibin and Melan-A, therefore diagnostic for phaeochromocytoma. In conclusion, this case highlights the importance of the clinical history when making a diagnosis as biochemical and functional testing are not 100% reliable. We recommend that with a clinical history typical for phaeochromocytoma despite lack of biochemical and functional evidence, alpha-blockade should be considered prior to surgery.