Endocrine Abstracts

COVID-19 pandemic obliged physicians to find out alternative options to classical pathways, to lower viral spread and related dangers as well as to cope with redeployment of personnel and resources. We describe here two cases in whom surgery for adrenal Cushing’s syndrome (CS) and pheochromocytoma (PHEO) was deferred due to the unavailability of surgical facilities.

Case no 1: A 69-yo woman was evaluated for CS. Type 2 diabetes mellitus was diagnosed some years before and a 35-mm right adrenal mass incidentally found at US; no endocrine work-up was performed. Progressively clinical picture worsened and physical examination suggested ACTH-independent hypercortisolism, confirmed by endocrine work-up performed in January 2020. The whole picture was so severe that she was not considered suitable for surgery that became anyway inaccessible due to pandemic. Ketoconazole was given up to 400 mg/day with a progressive reduction in CLU values. Due to the occurrence of symptomatic hypoadrenalism, a block-and-replace therapy with cortisone acetate was started, obtaining a progressive and persistent improvement in clinical/biochemical picture. Due to the persistence of pandemic and the unavailability of surgical facilities for not urgent surgeries, patient is still waiting surgery. Case no 2: In an 83-yo woman, abdominal plastic surgery was complicated by hypertensive crisis, acute pulmonary edema, cardiogenic shock, acute renal failure; multiple stenoses were disclosed at coronary-angiography, reverse Takotsubo at ventriculography. Abdominal CT disclosed a 45×31 mm left-adrenal lesion consistent with PHEO, confirmed by Endocrine-workup. Recovery of systolic function and pressure control were obtained with doxazosin (in addition to ongoing lowering blood pressure treatment. The planning of adrenal resection was postponed due to an adrenal hematoma developed while on LMWE treatment; the subsequent CT showed hematoma reabsorption but in the meanwhile there was the outbreak of the pandemic. The patient was monitored throughout subsequent months with telemedicine controls, confirming optimal pressure control; she underwent laparoscopic-adrenalectomy without any peri-operative complications. A post-op CT and hormonal evaluation did not disclose any tumor remnant/relapse and the patient has an optimal pressure without any anti-hypertensive treatment.

Conclusion: This change of the mainstay of treatment for adrenal hypersecreting lesions due to pandemic could offer a new therapeutic paradigm of these diseases in cases when surgery is contraindicated for severe comorbidities.