Endocrine Abstracts

Introduction: Adrenal incidentalomas are a frequent finding (1.4-7.3% on abdominal CT) and increasingly common with age, obesity, diabetes and hypertension. When approaching adrenal masses, clinicians should exclude malignancy and hormonal hypersecretion. Black adrenal adenomas (BAA), first reported in 1938, are rare benign adrenocortical tumours with black/brown appearance, containing lipofuscin. Most are non-functional, rarely inducing hypercortisolism. We present a case of a woman with a BAA and autonomous cortisol secretion(ACS), with great response to surgery.

Case Report: Female, 58 years-old. Referred to the Endocrinology consult in February 2019 for a left adrenal incidentaloma, diagnosed in 2017, in a colon cancer follow-up CT. She complained of insomnia but denied headaches, hypertensive crisis, spells, proximal muscular weakness, weight gain, hirsutism, previous cardiovascular events. Medical history: arterial hypertension, type 2 diabetes mellitus, dyslipidemia, depression, and colon carcinoma treated with right colectomy in 2017. Medication: perindopril, indapamide, amlodipine, metformin, dulaglutide, empagliflozin, insulin glargine, lorazepam, venlafaxine, mirtazapine, amissulpride, rosuvastatin and ezetimibe. No relevant family history. Physical examination: round facies and supraclavicular fat pads. Weight 68.5 kg, height 1.50 m, BMI 30.4 kg/m2. BP 120/80 mmHg, HR 95 bpm. No hirsutism, acantosis nigricans, abdominal striae or bruising. Initial workup showed urinary free cortisol 129.6 and 118.24 µg/24 h, cortisol after 1 mg dexamethasone 13.1 and 16.9 µg/dl, urinary free cortisol in spot urine 36.2 nmol/mmol Cr, late-night salivary cortisol 0.278 µg/dl and 0.258 µg/dl, ACTH<5.00 pg/ml. Plasma and urinary metanephrines, aldosterone-renin ratio, TSH, creatinine and potassium were normal. HbA1c 10.9%, total cholesterol 127 mg/dl, triglycerides 333 mg/dl, LDL-c 23 mg/dl. CT: Nodule in the left adrenal gland, 25 mm, density not compatible with adenoma. MRI: Solid oval nodule in the left adrenal gland, 25 mm, absence of fat content. Osteodensitometry: lumbar spine T-score -3.4. Diagnosis Adrenal adenoma with ACS and multiple comorbidities (hypertension, hypertriglyceridemia, diabetes and osteoporosis).

Treatment: Left adrenalectomy in June 2021. Histology: cortical adrenal adenoma. Abundant pigment suggesting a black adenoma. Follow-up: She lost 13 kg and suspended insulin and most hypertensive agents. Transient hypocortisolism, treated with hidrocortisone. HbA1c 6.3%, morning cortisol 3.4 µg/dl, ACTH 39.5 pg/ml, total-cholesterol 122 mg/dl, triglycerides 363 mg/dl, LDL-c 38 mg/dl.

Discussion: This case highlights the importance of treating hypercortisolism to effectively control its comorbidities, cardiovascular risk factors and quality of life. In our patient, ACS originated from a BAA. Functional BAAs usually exceed 20 mm in diameter, which was the case of our patient. After surgery, there was marked improvement of hypercortisolism-associated conditions. Therefore, early detection of Cushing syndrome in adrenal incidentalomas is essential, especially when multiple comorbidities are present and undercontrolled with medication.