Endocrine Abstracts

A 75-year-old gentleman was admitted with symptoms of lethargy, abdominal pain, severe nausea and vomiting in January 2008. He had solid transitional cell carcinoma of the bladder, diagnosed in May 2005, when he initially presented with microscopic haematuria. He had further undergone radical cystoprostatectomy and an ileal conduit. The histology showed aggressive tumour (G3pT3a) with vascular invasion but no metastasis. Follow-up CT scans done 9 months later showed a 3.5 cm left adrenal lesion, the appearances of which were thought to be due to adrenal bleed. His subsequent MRI was inconclusive.Subsequent serial CT scans showed increasing para-aortic lymphadenopathy and slight increase in size of adrenal lesion. He then underwent 4 cycles of chemotherapy in January 2007, following which he declined further treatment. He was started on long term anti-emetics for persistent nausea and vomiting post chemotherapy.

On review of symptoms during this admission, he mentioned of being symptomatic with abdominal pain and nausea since his initial surgery, with increasing frequency of vomiting four weeks prior to admission.

He was also noted to have significant postural drop of 30 mmHg. Blood tests showed normal electrolytes and calcium. His AXR showed no evidence of abdominal obstruction.

Due to his underlying metastatic disease and adrenal lesion an endocrine opinion was sought. Short synacthen test showed basal cortisol 257 and 30 min cortisol 280 suggesting secondary adrenal deficiency due to metastatic disease. He was replaced with hydrocortisone with resolution of symptoms and was discharged home.

Metastasis is the cause of adrenal lesions in approximately 50% of patients with underlying malignancy and is frequently bilateral. This case demonstrates the need for early endocrine workup and appropriate steroid replacement in patients with underlying malignancy. It also highlights the need to be aware of this pathology, identification and treatment of which could help with symptom relief in such patients.