Endocrine Abstracts

JOINT630

Introduction and Background: Prostate cancer, a leading malignancy in men, predominantly metastasizes to the bone and lymph nodes. Adrenal metastases are rare, with bilateral involvement being exceptionally uncommon and signaling advanced disease.

Case Report: We report a case of a 62-year-old chronic smoker presented with progressive obstructive urinary symptoms and gross hematuria. His PSA level was 183 ng/mL, and prostate biopsy confirmed adenocarcinoma. He underwent prostatectomy and bilateral castration, revealing moderately differentiated, infiltrative adenocarcinoma (Gleason 8, ISUP grade 4) with perineural invasion. After a three-year lapse in follow-up, he returned with gastrointestinal symptoms, profound asthenia, hypotension, and generalized melanoderma. Acute adrenal insufficiency was diagnosed (cortisol 3.7 µg/dL, hyponatremia 113 mmol/l) and treated with hydrocortisone replacement and rehydration. Imaging identified bilateral adrenal masses (81 × 52 × 72 mm and 79 × 45 × 78 mm) with necrotic centers spontaneous density of 35 HU, and an absolute washout of 66%. Normal urinary metanephrines excluded pheochromocytoma. PSA had risen to 600 ng/mL, and MRI revealed recurrent prostate tumor with seminal vesicle infiltration and bone metastases. Given the advanced disease and imaging findings, adrenal biopsy was avoided, and the adrenal lesions were attributed to metastatic prostate adenocarcinoma\. Management included Docetaxel-based chemotherapy and hydrocortisone replacement (30 mg/day).

Discussion: Adrenal metastases from prostate cancer occur in 17–20% of cases in autopsy studies, with bilateral cases being particularly rare. Prostate cancer’s preference for bone and lymph nodes is mediated by adhesion molecules and growth factors favoring these sites, while the adrenal gland’s unique microenvironment may deter colonization. Hematogenous spread, however, can involve the adrenal glands in advanced stages. These metastases are often asymptomatic due to the adrenal glands’ functional reserve, with insufficiency manifesting only after more than 90% cortical destruction. While bilateral adrenalectomy may be an option in select cases, non-surgical treatments, such as chemotherapy, are generally preferred to reduce both primary and metastatic tumors. Chemotherapy may preserve the potential for adrenal function recovery, though definitive evidence on reversibility is limited.

Conclusion: Bilateral adrenal metastases in prostate cancer highlight the complexity of metastatic behavior in advanced disease. Comprehensive imaging and biochemical evaluations are essential in symptomatic cases. Research into adrenal microenvironment interactions and steroid biosynthesis pathways in prostate cancer may improve our understanding of metastatic patterns and guide innovative therapies.