A 42 year old gentleman was referred to endocrinology clinic by a consultant urologist due to an incidental finding of a 14 mm adrenal nodule on the patients right adrenal gland. He was originally seen by gastroenterology having been referred due his 7 year history of twice yearly attacks lasting around 30 min, comprising of flushing of the face, palpitations, burning sensation in his stomach, sweating, vomiting and loose bowel motions. The gastroenterology consultant did not feel this was a gastro problem and arranged CT chest/abdo/pelvis for exclusion of carcinoid and phaeochromocytoma. The CT scan showed a 13 mm left lower lobe lesion (likely bronchocele suggested respiratory follow up), a left lower pole renal lesion (possible early neoplasm for ultrasound and MDT follow up) and a right adrenal soft tissue nodule measuring 14 mm (referred to endocrinology). The urology consultant saw the patient who had now had an MRI and the renal lesion had been identified as a Bosniak 3 cyst (50% chance of malignancy). The plan was to monitor the cyst and likely excise it but only once the adrenal lesion had been dealt with. The MRI had shown this to not have characteristics typical of an adenoma with phaeochromocytoma being possible. A 24 hour urine collection for metanephrines had been sent with results awaited at this stage. The urologist organised an MIBG scan to further image the adrenal lesion. The patient was then seen in clinic in the endocrinology department. He and his wife were understandably anxious about all that was going on. The urine collection had demonstrated normetanephrine output of 2.15 (reference range 03.00), metanephrine output of 1.52 (reference range 01.40) and 3-methoxytyramine output of 2.52 (reference range 0.572.30). Chromogranin A and B results were also available and were within the reference ranges. A set of plasma metanephrines had been taken and these too were well within the reference ranges. The various results were explained to the patient and he was referred to the endocrinology MDT meeting. A repeat set of 24 hour urinary metanephrines was requested. The MIBG result was available not long after the clinic appointment and this showed an MIBG avid right adrenal nodule consistent with phaeochromocytoma. The endocrinology MDT meeting concluded this was an early phaeochromocytoma. The patient was referred for excision and alpha and beta blocking arranged. The lesion was excised uneventfully and histology confirmed the phaeochromocytoma diagnosis.
16 - 18 Apr 2018
Society for Endocrinology