Endocrine Abstracts

Introduction: Adrenal incidentalomas (AIs) are increasingly being identified due to more frequent use of cross-sectional imaging modalities. Recent studies reported AIs being identified in 7.3% of abdominal CT imaging. Most adrenal incidentalomas are adenomas that may have secretory activity.

Case Report: An 80-year-old lady presented to our Emergency department with one week’s history of worsening right eye bulging and discomfort. She was found to have right proptosis on examination with no clinical evidence of hormonal excess or deficiency, and her initial blood tests were unremarkable. Her general practitioner arranged for an outpatient CT scan of the chest, abdomen and pelvis that took place earlier that day prompted by the history of anorexia and weight loss of 6kg over two months duration. This CT scan showed a heterogenous solid right adrenal mass measuring 6.9 x 8.1 x 7.8 cm, with numerous enlarged retroperitoneal lymph nodes and nodular thickening of the left adrenal gland. Our Ophthalmology colleagues recommended arranging a MRI orbit, which showed a poorly enhancing right orbit mass measuring 2.4 x 1.7 x 2.0 cm partially encases the optic nerve. Urgent plasma metanephrines and urine steroid profile were sent prior to biopsies, and the treating team was advised to avoid beta blockade pending the results. The patient was found to have a palpable firm right neck lump during her admission and a CT-neck scan confirmed right upper cervical lymphadenopathy. The Ophthalmology team advised that biopsying the orbital mass would be challenging, therefore a right submandibular lymph node biopsy was performed after the plasma metanephrines and urine steroid profile showed normal results. Histology showed a diffuse large B-cell lymphoma of non-germinal centre phenotype. The Haematology team commenced the patient on R-CHOP chemotherapy. The patient was discharged home with follow up with our Haematology and Ophthalmology colleagues. We plan to arrange for abdominal cross-sectional imaging to monitor the response of the adrenal mass to chemotherapy.

Discussion: The adrenal gland involvement in lymphoma is reported in up to 24% of the cases. While benign cortical adenomas are the most common cause for AIs, other differential diagnoses include pheochromocytoma and adrenocortical carcinoma. This case highlights the importance of the prompt multidisciplinary workup and management approach. Careful assessment is required to evaluate for the presence of hormonal deficiency or excess in every case.