Endocrine Abstracts

Introduction: Incidentaloma is a randomly discovered tumor with no apparent secretor activity. The term is mainly used for hypophysis and adrenals. There are relatively few situations where a patient has more than one such mass.

Aim: To present the case of a patient with three tumors: a pituitary mass and bilateral adrenal masses, with clinical manifestations of Cushing’s syndrome.

Case report: A 37-year-old female patient who had for the last three years weight gain (15 kg), abdominal stria, ecchimosis, asthenia, insomnia, emotional lability, hypercholesterolemia, arterial hypertension (maximum 230/120 mmHg), type 2 diabetes mellitus. The hormonal profile showed hypercorticism: basal plasma cortisol of 38.6 ng/ml (normal<22 μg/dl). The low-dose dexamethasone suppression test showed no suppression, neither did the high-dose dexamethasone test (plasma cortisol 30.86 ng/ml). The basal level of ACTH was 8.08 ng/ml. The computed tomography (CT) scan showed a pituitary tumor of 0.7 by 0.3 cm. The adrenal CT revealed bilateral masses of 3.2 by 2.4 cm on the right, and 1.2 by 0.85 cm on the left. The right adrenalectomy was performed, considered as the cause of the Cushing’s syndrome. Immediately after surgery, acute adrenal insufficiency was diagnosed and treated with hemisuccinate of hydrocortisone and electrolytic solutions. The patient recovered but for the next 2 years she had adrenal insufficiency, which was properly substituted. The CT scan showed the reduced dimensions of the left adrenal tumor (0.69 by 0.51 cm) and constant diameters of the pituitary tumor, as they were both incidentalomas.

Conclusion: The difficulties in a patient with Cushing’s syndrome with bilateral adrenal masses and also hypophyseal tumor come from the low specificity of the dexamethasone suppression test. Nevertheless, the triple tumor phenotype is extremely rare but the correct therapeutically management was confirmed by the presence of post surgery adrenal insufficiency and the unchanged diameters of the other two tumors.