Endocrine Abstracts

Introduction: Paraneoplastic Cushing’s syndrome is attributed to ectopic ACTH release from a non-pituitary tumor. The lung is frequently the primary site of the underlying neoplasm but sometimes, in cases of advanced metastatic disease, determining the origin may be challenging.

Case presentation: A70-year-old man was reffered to our centre for generalised bone pain, lethargy, and important weight loss in the last six months. Before admission, a contrast-enhanced CT scan of thorax and abdomen revealed multiple lung nodules, mediastinal lymphadenopathy, spinal bone lesions suggestive of metastases (with considerable size and extension in the spinal canal), bilateral adrenal masses (with washout percentage >55%) and a large heterogeneous renal mass. The patient presented poor general condition, immobilisation (mainly due to intense bone pain), pale skin and maleolar petechiae; classical clinical features of hypercortisolism were not present. Moderate hypercalcemia, high inflammatory markers, severe ACTH dependent Cushing’s syndrome and low PTH level were noticed. Spine MRI confirmed the osteolytic lesions and also the spinal cord compression due to important tumoral processes affecting thoracic vertebrae. A percutaneous biopsy of a vertebral metastasis revealed a highly anaplastic tumoral process with renal orgin. Mifepristone and analgesic treatment were initiated with biochemical control of Cushing’s syndrome, but the patient died within 6 weeks from diagnosis.

Conclusions: ACTH-dependent hypercortisolism source is difficult to identify in a patient presenting with multi-organ masses. Although rare, the renal origin of ectopic Cushing’s syndrome should not be disregarded.