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Endocrine Abstracts (2022) 82 P25 | DOI: 10.1530/endoabs.82.P25

1Department of Endocrinology, Cambridge University NHS Foundation Trust, Cambridge, United Kingdom. 2Department of Nuclear Medicine, Cambridge University NHS Foundation Trust, Cambridge, United Kingdom. 3Department of Radiology, Cambridge University NHS Foundation Trust, Cambridge, United Kingdom

Section 1: Case history: A 69 year old man with chronic obstructive pulmonary disease was admitted with acute onset shortness of breath. A CT pulmonary angiogram revealed no focal lung abnormality but identified an incidental 40 x 32 mm left-sided adrenal lesion. An unenhanced CT, undertaken to characterise the lesion, showed a homogeneous, well-circumscribed appearance with a radiodensity of 4 Hounsfield units. Prior to involvement of the Endocrinology team, a dedicated MRI was also undertaken, which demonstrated signal dropout. Review of historical imaging showed the lesion to be present on a study 12 years earlier, measuring 30mm. Despite the patient”s co-morbidities of type 2 diabetes mellitus, obesity and hypertension – biochemical work-up was not suggestive of an adrenal hypersecretory syndrome. No significant change in size was observed on a repeat adrenal MRI two years later, and chemical shift analysis was again reassuring. Twelve months later, another acute respiratory exacerbation prompted further cross-sectional imaging of the chest. Unexpectedly, multiple scattered pulmonary nodules were seen in both lungs in addition to enlarged thoracic nodes suspicious for metastases. A staging CT showed the adrenal lesion to have enlarged to 50mm and to have changed in morphological appearance.

Section 2: Investigations: Urinary steroid profiling demonstrated a relative increase in progesterone, pregnenediol and 17-hydroxyprogesterone metabolites, suggestive of a malignant adrenocortical tumour. Molecular imaging showed the pulmonary nodules and thoracic nodes to be both FDG and metomidate avid, in-keeping with metastatic adrenocortical carcinoma (ACC).

Section 3: Results and treatment: Given disseminated disease with a poor functional status, a symptom-control approach was adopted following careful MDT discussion.

Section 4: Conclusions and points for discussion: We report the apparent transformation of a benign, non-functioning adrenocortical lesion into a malignancy - 14 years after it was initially imaged. To our knowledge, only two other such cases have been reported in the literature. In order to avoid excessive investigation, and the associated cost, current European Society of Endocrinology Guidelines suggest that non-functioning adrenal incidentalomas with benign features on initial imaging do not require further radiological surveillance. A recent large multi-centre study reported 0 of 98 ACCs to have unenhanced HU <10 or the presence of chemical shift. The only radiological feature of concern for the lesion in our case was size. We suggest that urinary steroid metabolite profiling be considered for all adrenal masses >4 cm, even when they meet other radiological criteria for characterisation as lipid-rich adenomata.

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