Endocrine Abstracts

Introduction: The aim of this project was to review all adrenal masses ≥ 10 cm managed in our organisation over a 10-year period (2012-2022).

Results: 20 adrenal masses ≥10 cm in maximal diameter were identified (range 10-32 cm, average 16.6 cm, 6 above 20 cm and one above 30 cm). Age at presentation was 17-80 y (mean 56.3 y, 50% F). Duration of symptoms: 1 day-18 months, mean 7.5 months with 6 presenting acutely. Follow-up period: 1 month-122 months, mean 35 months. Aetiology: 11/20 Adrenocortical carcinoma (ACC), 2/20 presumed ACCs, 7/20 as follows: 15 cm malignant melanoma (MM) metastasis (met) presenting 6 years post pT1N0M0 skin MM excision; growing MM metastasis (12 cm) despite immunotherapy; renal cell carcinoma (RCC) met in metastatic RCC (4 cm ipsilateral and 13 cm contralateral adrenal met); 10 cm pheochromocytoma [PASS 12, pT2(R0)N0M0] presented with acute coronary syndrome; 18 cm myelolipoma presented with acute abdomen due to intralesional haemorrhage; 13 cm adrenal cyst and 29 cm well-differentiated retroperitoneal liposarcoma. 17/20 (85%) had malignant aetiology. 11/20 (55%) alive at time of abstract submission. ACC in 13/20: 7/13 found to have hormonal hypersecretion (4 cortisol, 1 oestradiol, 1 combined cortisol, aldosterone & androgens). 2/13 presented with symptoms of hormone excess (gynaecomastia, severe hypertension), 11/13 with abdominal pain. 9/13 had surgery [2/9 surgery + mitotane, 2/9 surgery + mitotane + locoregional metastases control (with met resection, ablation, radiotherapy)], 1/13 mitotane only, 2/13 symptom control only (analgesia, laxatives). ACC staging at diagnosis: Stage 2: 6 patients (with three progressing to stage 4 within 6 months-3 years; 3 remain alive); Stage 3: 4 patients (one died within a month post diagnosis, 3 progressed to stage 4; 2 remain alive); Stage 4: 3 patients (all died within 4 months). Median overall survival of ACC cohort 20.0 months (95% CI 5.6 to 34.4).

Discussion: Some adrenal masses can reach huge proportions before their presentation. ACC was detected in 65%. Even at stage 2 at diagnosis, mortality and risk of progression to metastatic disease was very high. Prognosis at stage 4 at diagnosis is extremely poor and all died within 4 months post presentation. Ipsilateral adrenal metastases in RCC can occur in 6-29% especially in pT3, but bilateral adrenal or contralateral metastases are rare. Large 13 cm contralateral RCC met in our patient was therefore unusual. Significant size of adrenal MM metastases at diagnosis and their resistance/escape from immunotherapy suggest that adrenal microenvironment might be a ‘sanctuary site’ as suggested in our two melanoma cases and literature.