Adrenocortical cancer – rare but gloomy cause of adrenal lesions
Falinska A; Vakilgilani, T; Woods D; Ling Y; Tanday R; Todd JF
Imperial Centre for Endocrinology, Imperial College Healthcare NHS Trust , Hammersmith Hospital, Du Cane Road , London UK
We present a case of 50 year old female who presented to a local hospital with sudden onset severe sharp left flank pain. Urgent CT revealed a mass in the left adrenal gland which was thought to be a supra-renal bleed. It measured 6cm at this point. She was discharged with paracetamol and re-assured. As she was not feeling well, she had an US kidney in private sector 1 month later revealing static appearance of presumed haematoma. Following the period of observation to allow haematoma to re-absorb, she had MRI repeated 6 months after initial presentation. It confirmed 11cm growing mass in left adrenal. At this point, the patient was referred to endocrine services. On further questioning she admitted to recent onset of hirsuitism and her androgens levels were raised (testosterone 20.7nmol/L, normal less than 2.5nmol/L). Additionally she failed overnight dexamethasone suppression tests (9am cortisol 92nmol/L). Her blood pressure was elevated.
Pre-surgery CT adrenal revealed on-going growth of the mass reaching 12.8cm. She had total left adrenalectomy and nephrectomy and macroscopically she was clear of cancer. Histology revealed adrenal cortical cancer with invasion of vessels. Post operatively her adrenal androgens were suppressed consistent with successful clearance of the tumour. She was referred to oncologists and has been started on Mitotate which she tolerating it reasonably well. Post-operative CT scan shows no evidence of recurrence.
Adrenocortical carcinoma has an estimated incidence of around 0.5–2 new cases per million people per year. It is more common in female in the fourth to fifth decades of life. It accounts for around 2-5% of cases of patients with adrenal incidentaloma. This case highlights the importance of appropriate referral of suspected adrenal lesion to endocrinology department to assess functionality and surveillance. Although rare, adrenocortical cancer should always be considered in the differential diagnosis of adrenal lesion over 4cm.