Endocrine Abstracts

Background: Adrenocortical carcinoma (ACC) is a rare malignant tumour of the adrenal cortex with an incidence of 0.7-2.0 per million per year. The majority are steroid-producing with non-ACTH dependent hypercortisolism the most frequent biochemical abnormality. Around 10-15% of cases are picked up incidentally on abdominal imaging. Management of ACC during the covid-19 pandemic poses specific challenges. We present the case of a 69-year-old man who was found to have a massive incidental ACC and whose investigations and management were complicated by infection with covid-19.

Case: The patient had a background of heart failure, hypertension and benign prostatic hyperplasia. He was admitted with shortness of breath due to bilateral PEs. An incidental mixed attenuation adrenal lesion measuring 19 x 11 x 18 cm was identified on CTPA. On clinical examination, he was noted to have marked proximal myopathy. Initial biochemical investigations revealed hypernatraemia and hypokalaemia and baseline endocrine investigations showed a morning cortisol of 634 nmol/lwith suppressed ACTH. Further work up including FDG-PET CT, 24-hour urine cortisol, urine steroid profile (USP) and overnight dexamethasone were planned. However, prior to completing these investigations, the patient was admitted with covid-19 pneumonitis, necessitating oxygen therapy and IV dexamethasone. This posed specific challenges in diagnosing clinically significant cortisol excess while on glucocorticoid treatment. Ultimately, persistently elevated cortisol levels between 600-900 nmol/ldespite 6.6 mg IV dexamethasone were suggestive of autonomous cortisol secretion. USP results obtained during the admission confirmed ACC. The patient was rapidly weaned from dexamethasone and initiated on metyrapone with hydrocortisone and spironolactone. Due to his pre-existing comorbidity and the additional impact of covid pneumonitis on his performance status, he was deemed unfit for surgery and mitotane by the adrenal MDT and a palliative care approach was adopted.

Discussion: Studies in to the impact of covid-19 on ACC management and prognosis are limited. Contracting covid-19 has implications for ACC management, including use of mitotane and chemotherapy which are both contraindicated during covid infection, as in this case. In addition, ACC and glucocorticoid excess both increase the risk of complications from covid-19 with a greater burden of metastatic disease associated with increased mortality. This case illustrates some of the challenges in managing ACC when complicated by covid-19 infection as well as the poor prognosis of patients facing this combination of disease entities.