Incidentally discovered adrenal masses (incidentalomas) present challenges both in diagnosis and management. The bilateral adrenal mass carries a risk of hormone hypersecretion, but it could also present a metastasis from another primary carcinoma or be a part of genetic syndrome.
We report a 68 year old patient with bilateral adrenal incidentalomas (revealed accidentally on US, confirmed by abdominal CT in 2015.) left 29 mm, right 33 mm in diameter, radiological characteristics indicating adenoma. Initial diagnostical work up showed subclinical Cushing syndrome with osteoporosis and arterial hypertension as part of clinical presentation. One year later, abdominal CT showed significant enlargement of both adrenal masses (left 50 mm, right 45 mm), still adenomas according to CT characteristics, but post contrast imaging could not be performed due to chronic renal impairment. Her laboratory results were still consistent with subclinical Cushing syndrome, now presenting with osteoporosis, hypertension and glucose impairment with no signs of other excessive hormone secretion but now her chest x-Ray revealed a lesion in her left lung 27 mm in diameter of unknown etiology (although she mentioned lung tuberculosis in her youth). As she did not have any signs of metastatic disease and her tumor markers were normal we decided to perform left adrenalectomy to provide definite diagnosis. Histological finding confirmed adrenal adenoma and hormone reevaluation showed possible excessive cortisol secretion with osteoporosis, but now blood glucose was normal, and anti-hypertensive agents were discontinued due to normal blood pressure. There was no change in the size of the lung lesion on her chest X ray (6 months after) and no signs of metastatic lesions. Thoracic CT and bronchoscopy are planned.
While the initial diagnostic approach is similar to the unilateral incidentaloma, additional testing should be considered in the case of the bilateral adrenal mass and as oppose to unilateral incindentalomas surgery remains the mainstay of treatment in most cases.
20 - 23 May 2017
European Society of Endocrinology