The presentation of a patient with an adrenal tumour often causes diagnostic difficulty for the endocrinologist. Adrenal tumours are rare occurrences, particularly when large in size. We present two cases, where large adrenal tumours were found in inpatients on CT scanning and discuss the difficulties which arose in each case when attempting to obtain a definitive diagnosis. Case 1 A 38 year old Bangladeshi woman was being investigated for fevers, sweats and pancytopaenia. She was predominantly hypotensive (with poor left ventricular function on echocardiogram) but experienced episodes of hypertension with pulmonary oedema. Abdominal CT scan showed large (14×8×9 cm) adrenal lesions. Due to her symptoms, phaeochromocytoma was considered but urinary catecholamines and metanephrines were normal as was a MIBG scan. Histology showed lymphoma and her progress with chemotherapy has been good. Case 2 A 72 year old South Asian woman presented with hypertension, hypokalaemia and breathlessness. A chest x-ray showed multiple metastases. Aldosterone was 1799 pmol/l (NR 28445) and plasma renin 28 mU/l (NR 9.823). Abdominal imaging showed a 12×7 cm infiltrating mass in the region of the right adrenal. She was treated with potassium supplementation and spirinolactone, but developed pulmonary oedema and died during her admission. The liver biopsy showed adrenocortical carcinoma. Our cases illustrate the diagnostic difficulty that may occur when a large adrenal tumour is found on abdominal imaging. Large tumours are highly likely to be either malignant or secretory. However, investigation of such tumours, especially in an unwell inpatient, is not straightforward. Histology was diagnostic in both cases but in doing so, it is important to be careful not to precipitate hypertensive crises in phaeochromocytoma and to avoid breaching the capsule of an otherwise intact adrenocortical carcinoma.
Declaration of interest: There is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.
CT scan image showing bilateral large adrenal masses. The right adrenal mass measures 14 cm×8 cm×9 cm. On the left side, the adrenal mass measures 10 cm×3 cm×7 cm.
Funding: No specific grant from any funding agency in the public, commercial or not-for-profit sector.