A 65 year old government officer presented to ophthalmologist with sudden visual loss in the right eye. Noted to have a retinal haemorrhage and significantly elevated blood pressure. GP was asked to investigate further.
For reasons unclear yet fortuitous, the initial imaging arranged was a CT CAP which demonstrated a large adrenal mass (9 cm well defined, heterodense, retroperitoneal right soft tissue mass of 4070 HU with areas of necrosis) hence referral.
On review the patient gave a 6 month history of rapid weight gain, ankle swelling, thin skin with easy bruising and muscle weakness.
Physical examination was consistent with Cushings syndrome and this was confirmed biochemically. Urine steroid profile showed increased cortisol metabolites in keeping with Cushings but no steroid markers to suggest cancer.
Patient underwent right laparoscopic adrenalectomy; histology consistent with an adrenocortical carcinoma. Tumour had a mitotic count of 15 per 50 HPF indicating low grade. Patient was prescribed mitotane which she was unable to tolerate.
Post-op PET/CT reported a right cervical soft tissue mass. On US scan this was described as a 35×25 mm cyst in right side of neck at the level of thyroid cartilage; additionally a 10 mm U2 nodule in right lobe of thyroid gland was noted.
An US guided biopsy of the cystic mass was performed the histology suggestive of metastatic (adrenal) disease although features were not typical for adrenocortical carcinoma. Following excision of the neck mass, histopathology reported lymph node containing metastatic papillary thyroid carcinoma.
Patient proceeded to total thyroidectomy and neck dissection; histology reported a 9 mm classical papillary thyroid microcarcinoma with venous invasion. Radioiodine therapy is scheduled.
A recent PET/CT has shown disease recurrence in the right surgical bed and additionally a peritoneal nodule in the right upper quadrant of the abdomen with further surgery planned.