A 42 year old lady initially presented in Poland with haematuria while she was on holiday over Christmas. She had some tests including an ultrasound of the kidney which showed a mass adjacent to the left kidney. The haematuria had settled and she was feeling well apart from non-specific back ache. She worked in a cake factory which she continued to do here in the UK. Her GP requested another ultrasound of her kidneys which showed a solid mass adjacent to the left kidney and a CT abdomen was advised (Feb 17) which found a mass anterior to the left kidney. The radiologists suspected this was arising from the tail of the pancreas. As it was part cystic and part solid, a diagnosis of probably pancreatic cyst adenoma was made. An MRI was requested which demonstrated a 5-cm complex solid and enhancing left retroperitoneal mass but the origin was uncertain, differentials included solid pseudo-papillary pancreatic tumour or retroperitoneal sarcoma. She was reviewed in the Sarcoma MDT and they recommended a laparoscopic biopsy or a surgical excision. She then went on to have a FNA under EUS which stained like an NET. She then was discussed at the hepatobiliary MDT and a NET MDT referral was made who suggested an MIBG scan and 24-hour urine metadrenaline. Meanwhile, she was referred to Endocrinology. In our clinic, on direct questioning she had no symptoms related to adrenaline excess. Her past medical history included an appendectomy, a resected meningioma and high cholesterol. There was no family history suggestive of MEN or a genetic paraganglioma syndrome. On examination, her blood pressure was 213/103 mm Hg. She appeared a fit lady with no stigmata of underlying illness. Her pulse rate was regular. She was commenced on Phenoxybenzamine and slow sodium at this point. An MIBG scan done a month later confirmed the diagnosis of left actively secreting adrenal phaeochromocytoma. She successfully underwent a left laparoscopic adrenelectomy.
Discussion: We did not find any mention of her high BP recordings in any of the correspondence from the GP and various MDTs. If they had noted a finding of significantly raised BP in a previously fit lady with a lesion around the kidney, a possibility of a pheochromocytoma would have been considered much earlier than it was- a simple test which cost nothing would have saved a lot of time and resources.
16 - 18 Apr 2018
Society for Endocrinology