Endocrine Abstracts

Introduction: Adrenal oncocytoma (AO) and ganglioneuroma (GN) are rare causes of adrenal masses, corresponding usually to nonfunctional and benign tumors. However, 20% of the AO shows some elements of malignancy and 10–20% of them affect adrenal hormone production. GNs account for 0.3%-2% of adrenal incidentalomas, with punctate calcifications in CT imaging being highly suggestive. However, preoperative differential diagnosis remains challenging. Adrenal arterial embolization may reduce tumor bulk and tumor vascularity; sometimes it is performed to suppress excess adrenal hormone production

Patient 1: A 57 years-old female with type 2 diabetes, dyslipidemia and hypertension presented with episodic flushing and right flank pain. Abdominal CT imaging showed a 12 cm enhancing right adrenal mass, wash-out >50%, 35 UH, diverting the right kidney and duodenoum. These findings suggested an atypical appearance. Physical exam revealed class I obesity (BMI 32,8 Kg/m2), high blood pressure (170/80 mmHg), facial and abdominal hirsutism. Blood tests revealed hypercortisolism (cortisol 5,31 mg/dl after 1 mg dexamethasone suppression test; ACTH 15,2 pg/ml) and hyperandrogenism (total testosterone 3,83 ng/ml (0,108-0,569), androstenedione >10,10 ng/ml (0,5-4,7), DHEA-SO4 >3000 mg/dl (29,7-182,2), 17 alpha progesterone 26,68 ng/ml (0,32-2,72). Renin, aldosterone and urinary metanephrines were unremarkable. The patient underwent selective right adrenal arterial embolization; 3 days later she was submitted to right adrenalectomy. Histopathology revealed an oncocytic neoplasm of uncertain malignant potential. After surgery a clinical and hormonal improvement was observed without any signs of disease persistence or recurrence

Patient 2: A 40 years-old male without relevant past medical history, presented an incidental finding in abdominal CT: a suspicious and heterogeneous 8,9 cm right adrenal lesion, with 31 UH and some punctiform calcifications, contacting but not invading right kidney and inferior vena cava. Physical exam revealed BMI 26 Kg/m2, normotensive and without stigmata. He had not any signs or clinical analysis suggesting hypercortisolism. Renin, aldosterone, urinary metanephrines and DHEA-S were normal. He underwent right adrenalectomy; histopathology revealed an adrenal ganglioneuroma (mature type). He had a good postoperative evolution.

Conclusions: In both, adrenalectomy was indicated given the large size and the imaging appearance of adrenal masses. In patient 1, hormonal production raised the suspicion for adrenal carcinoma secreting cortisol and androgens. Adrenalectomy is the gold standard for the treatment of adrenal GNs and AO. Histopathology is necessary to confirm these diagnoses, which usually have a benign prognosis. Adrenal embolization may have a role preoperatively.