A recognised complication of small cell lung cancer is adrenocorticotrophic hormone hypersecretion (ACTH). The profound biochemical derangement and subsequent symptomatology can be resistant to established medical therapeutic interventions. Our case illustrates the role of low risk palliative laparascopic surgery for resistant disease.
Mr SR, a 47yr ex-smoker presented with breathlessness and haemoptysis of 3 months duration, there was no past medical or occupational history of note. Examination revealed reduced breath sounds on the right, nil else. Chest radiograph confirmed a right hilar mass. Histology following mediastinoscopy confirmed small cell lung cancer. Oncologist commenced Carboplatin and Etoposide with thoracic, cranial and abdominal radiotherapy. Our patient returned complaining of lethargy, weakness, anorexia, weight gain, polyuria and polydipsia. Examination at the time confirmed a Cushingoid appearance with a proximal myopathy, hypertension and ankle oedema. Investigations: Urine Free Cortisol > 22,000 nanomol per 24hour, ACTH 314 nano gram per litre, hypokalaemia and secondary diabetes mellitus, confirmed Cushing's Syndrome secondary to ACTH hypersecretion from a small cell lung carcinoma. Despite blocking regimes with Metyrapone, Ketoconazole and Mitotane, biochemical evidence of steroid excess remained. Symptomatic treatment with diuretics, ACE inhibition, potassium supplementation and sulphonylureas were poorly tolerated and minimally effective. He thus, underwent laparascopic bilateral adrenalectomy resulting in biochemical cure, and excellent symptomatic control of previous steroid excess. In-patient stay was short and no postoperative complications were incurred.
Our case illustrates the effective use of a low risk laparascopic procedure for palliation of symptoms in ectopic ACTH hypersecretion resistant to medical therapy.
22 - 24 Mar 2004
British Endocrine Societies