Endocrine Abstracts

A 52-year-old female presented with acute left flank pain after experiencing intermittent pain, weight gain, mood disturbances and hirsutism for six months. A CT scan of the abdomen and pelvis revealed a large heterogeneous 10x7x15 cm mass in the left adrenal gland with local invasion. The patient had a past medical history of right invasive ductal carcinoma and had undergone a wide local excision. She was referred to the Endocrine team.

Biochemical Investigations:

The initial biochemical investigations revealed unsuppressed cortisol levels on ONDST and elevated serum androgens. Pre-operative Biochemical tests:

Normal

The patient’s urine steroid profile (USP) exhibited a relative increase in androstenedione/testosterone metabolites androsterone, aetiocholanolone, DHA, the DH metabolite androstenediol-17β (1010 μg/l) and the 17-hydroxypregnenolone metabolite pregnetriol (1719 μg/l). There was a modest elevation of adrenocortical carcinoma (ACC) specific marker tetrahydro-11-deoxycortisol (196 μg/l). These findings were considered pathological in post-menopausal women and suggestive of adrenocortical carcinoma (ACC).

Staging and Treatment:

As part of tumour staging, an FDG-PET scan was performed, which showed an intensely FDG-avid left adrenal mass consistent with a primary adrenal malignancy. There was no evidence of distant metastasis. Following discussion in the Adrenal Multidisciplinary meeting (MDT), the patient underwent a left oncological adrenalectomy. The surgery was complicated by haemorrhage due to left kidney blood vessels infiltrating the mass, and part of mesocolon and left kidney were attached to the mass, requiring resection. She was commenced on hydrocortisone 10 mg twice daily post-operatively. Histology confirmed ACC with a Ki67 of 80-90%. A genetic panel was completed, which came back negative for Li Fraumeni syndrome.

Post-operative Biochemical Investigations:

Following surgery, repeat biochemical assessment revealed undetectable DHEAs and androgen metabolites. Repeat USP showed previous androgen metabolite levels were low (and appropriate for age), whilst DHA metabolites and 17-hydroxypregnenolone metabolite pregnenetriol were not detected.

Post-operative Biochemical tests:

Serum Androgens:

She has been initiated on mitotane as part of adjuvant chemotherapy. She is remains under surveillance with USP every 3-6 months.