U013
Subclinical
Cushing’s in a case of adrenal incidentaloma.
Valsalakumari P,
Acharya J, Akavarapu S, Thukral
S, Palazzo F, Todd JF
Abstract:
A 52 year old lady
was referred to our endocrine services after a left retroperitoneal adrenalectomy for an adrenal incidentaloma. Her past medical history is significant for
lymph node positive invasive ductal carcinoma grade 2 with vascular invasion.
She has had a modified radical mastectomy with radiotherapy and chemotherapy
and currently is on Tamoxifen. Staging CT scan for
breast cancer showed a left 3.5 cm adrenal incidentaloma
“well defined with pre contrast Hounsfield units <12 and absolute washout of
8%” and it was removed. Post operatively she was found to have a cortisol of
<20nmol/l suggestive of subclinical cushing’s
syndrome. Histopathology showed a left benign adreno-cortical
adenoma.
She also has primary
hypothyroidism for which she takes Levothyroxine 125mcg daily. There is no
history of diabetes or hypertension.
She was commenced on
hydrocortisone replacement dose and recovered well. On a follow up visit, she
was quite keen to come off steroids. A short synacthen
test was organised 2 months after surgery which
showed an adequate rise of cortisol to 568nmol/l suggestive of adrenal recovery
and hydrocortisone was stopped. She continues to remain very well without any evidence of local
recurrence of the tumor.
Incidentally
discovered adrenal masses are mostly benign lesions, often arbitrarily
considered as nonfunctioning tumors. Recent studies, however, have reported
increasing evidence that subtle cortisol production and abnormalities in the
hypothalamic-pituitary-adrenal (HPA) axis are more frequent than previously
thought. Laparoscopic adrenalectomy performed by
skilled surgeons appears more beneficial than conservative management for these
patients with a subsequent improvement in metabolic and hormonal abnormalities.
General view that surgical resection should be reserved for those with
worsening of hypertension, abnormal glucose tolerance, dyslipidemia, or
osteoporosis is debatable as little information is available about the natural
history of this condition.