Endocrine Abstracts

Adrenal incidentalomas (prevalence between 0.4 and 7%) have become a very common clinical problem, the major concern being the risk of malignancy and hormone overproduction.

A 57-year-old woman was admitted for asthenia and uncontrolled hypertension. The only relevant clinical signs were abdominal obesity (BMI=31.1 kg/m²) and hypertension. Abdominal ultrasonography showed a voluminous left adrenal solid mass of 10/9 cm, with well-defined sharp borders, hypoechoic with necrotic areas and hyperechogenic foci of scars and calcifications. The differential diagnosis of an atypical adenoma and pheochromocytoma or adrenocarcinoma was difficult.

Laboratory assays revealed hypercortisolism, indicated by the loss of the circadian rhythm of cortisol secretion: cortisol value at 8 a.m. of 7.84 μg/dl and at midnight of 11.2 μg/dl, elevated free 24 h urinary cortisol of 731.4 μg/24 h (normal range: 50–190 μg/24 h), no suppression at overnight dexamethasone suppression test (cortisol of 5.46 μg/dl), low ACTH level of < 1 pg/ml and decreased cortisol level <50% at the high dose dexamethasone test. Plasmatic metanephrines, normetanephrines, renine and aldosterone were normal. Abdominal CT scan indicated a tumoral left adrenal mass of 10/8.5/8.5 cm, well defined, inhomogeneous, with microcalcifications, <10 HU, induced caudal displacement of the left kidney, no lymphadenopathy or other visceral involvement. She underwent left laparoscopic adrenalectomy. The histopathological evaluation indicated Ki67<1% and chromogranin, synaptophysin, calretin, protein S100, inhibin were isolated low positive; PanCK, EMA were negative; CD31 showed the capillary network, without emboli; vimentin was positive; suggesting an atypical adenoma and excluding an adrenocarcinoma, a kidney and liver tumor, but also a pheochromocytoma. Two weeks after surgery, a large ischemic vascular attack occurred, with poor prognosis. We should keep in mind that voluminous cortisol-producing adrenal adenomas could have clinically inapparent features, but with hidden vascular damages and increased cardiovascular risk.