A 76yr old lady presented to A&E with 'collapse and fall', 2 days following self-discharge for the same complaint. She had a medical history of type 2 diabetes on Gliclazide 80 mg o.d. and osteoarthritis of the spine.
She was noted to be tanned with pigmented palmar creases and had marked postural hypotension. Biochemistry showed serum sodium 124 millimols per litre, potassium 4.6 millimols per litre and cortisol 43 nanmols per litre. A short synacthen test confirmed the diagnosis of hypoadrenalism with a baseline and a 30 minute serum cortisol of 88 and 99 nanomols per liter respectively. ACTH was 513 nanograms per litre. She was commenced on hydrocortisone and fludrocortisone with improvement in her symptoms.
CT scan of the abdomen showed bilateral adrenal masses, 2 'non-specific' Liver lesions and confirmed the findings of bilateral pleural effusions on chest xray. CT guided biopsy of the right adrenal mass was unsuccessful. Tumour markers were negative except for a markedly raised CA125 and CA19-9. A mammogram was normal. Repeat physical examination revealed a 2x1 centimetre mass in the outer upper quadrant of the left breast. Ultrasound guided core biopsy initially showed a grade 3 infiltrating duct carcinoma but further examination and immunohistochemistry of the specimen was suggestive of an angiosarcoma of the breast. It was assumed that her adrenal masses were secondary to breast cancer. Her general condition deteriorated and she died. A post-mortem examination was not done.
Adrenal metastases are common in patients with cancer. Post-mortem studies report adrenal secondaries in up to 30% of patients with malignancy. Clinically overt adrenal failure, however, is rare in these patients. As far as we are aware, this is the first reported case of adrenal failure secondary to metastasis from a breast angiosarcoma.
22 - 24 Mar 2004
British Endocrine Societies