A 42 year old male was referred to the endocrine clinic with accelerated hypertension (190/110) and an elevated aldosterone renin ratio (59). CT adrenal scan revealed a 16 mm diameter mass in the posterior limb of the right adrenal gland which was confirmed to be hyperfunctioning through adrenal vein sampling. Laparoscopic adrenalectomy was performed and histology confirmed cortical adenoma of the right adrenal gland consistent with Conns syndrome.
His BP initially normalised post operatively and biochemically his Conns syndrome had been cured. However over the next 4 months the BP subsequently increased to the point of requiring four antihypertensive agents. MRA of renal arteries showed no evidence of renal artery stenosis but surprisingly showed a right adrenal mass measuring 26 mm in size (despite successful surgery & consistent histology) He also reported deep seated RUQ pain. After discussion at the surgical MDT, a repeat exploration revealed an organised haematoma behind the vena cava. Surgical evacuation was carried out but limited due to its position welded to the vena cava.
His RUQ pain and difficulty controlling his BP persisted so he had a repeat CT A/P five months later which revealed a 35 mm soft tissue lesion in the right suprarenal region thought to represent haematoma or recurrent tumour. Over the next 2 years further imaging with another CT and MRI scan showed no significant change in the right suprarenal mass. Biochemically there was no sign of a functional adrenal adenoma.
Further exploration revealed a cricket ball size inflammatory mass around what was essentially his original surgicel (absorbable haemostatic material from his surgery). Histology confirmed a fibrotic/foreign body reaction. Post operatively his pain has now almost resolved.
This case illustrates 3 different causes of an adrenal mass in the same patient.