Endocrine Abstracts

Introduction

The malignancy risk of an adrenal nodule is based on clinical symptoms (rapid onset of hypercortisolism and hyperandrogenism; mass symptoms) and imaging characteristics. These suspicious criteria include boundary irregularities, heterogeneity, dimension>6 cm and density>20 HU (CT). However, these are not absolute criteria.

Case report

We report the case of a 43 years-old female patient with a history of alopecia, decrease in muscular strength, secondary amenorrhea, and easy bruising with 4 years of evolution. Arterial hypertension, diabetes mellitus and dyslipidemia were diagnosed 1 year after. A 20 kg weight gain during the previous 6 months and the appearance of abscessed skin lesions 2 months ago were also refered. Physical examination showed exuberant hypercortisolism. Analytical study revealed the presence of an ACTH-independent Cushing Syndrome: morning and midnight ACTH levels <5 pg/ml (9–52); morning and midnight serum cortisol of 19 and 18 µg/dl (5–25); urine-free cortisol of 841 µg/24 h (10–80); salivary midnight cortisol of 1.7 µg/dl (<0.1); and cortisol of 19 µg/dl after low-dose dexamethasone suppression test. The patient performed an adrenal CT that revealed, in the left adrenal gland, the presence of an 8.3×6.3 heterogeneous nodule with cystic areas, calcifications, without cleavage plan with stomach and spleen and without infiltrative aspects. Based on the high suspicion of adrenal carcinoma, the patient started therapy with ketoconazole 400 mg a day and was referred to adrenalectomy. Histological exam showed a 9 cm adrenal cortex neoplasm with score 1 in modified Weiss criteria (necrosis, reticulin pattern, and Ki<5%). This was compatible with a benign tumour. The patient maintains follow-up under replacement therapy with hydrocortisone, anti-hypertensive and anti-hyperglicemic drugs in progressive reduction. The patient also presents significant improvements in her morphotype, with a relevant weight loss of 27 kg in 5 months.

Conclusion

Imaging results (dimension> 8 cm, heterogeneity and calcifications) raised the suspicion of carcinoma. ACTH independency was also suggestive, as cortisol is the most frequent hormonal secretion associated with malignancy, as well as the age and female sex. However, the slow progression of the disease was a factor that disfavour this hypothesis. Although these imaging signs are more often associated with an aggressive behaviour, only histological results define the exact type of the lesion.