Endocrine Abstracts

Introduction: Adrenocortical carcinoma (ACC) is a rare, hormone-producing cancer with an uncertain prognosis^#1. It may present with excess adrenal hormones or symptoms of an abdominal mass. Although many cases are detected as adrenal incidentalomas, the likelihood of an incidentaloma being an ACC is low^#1. We report a case in which a fall uncovered profound autonomous cortisol secretion from an underlying ACC.

Case History: A 74-year-old woman fell from her bed, sustaining a right ankle fracture. CT angiography, performed to exclude limb ischaemia, revealed a large left adrenal mass (10–11 cm) and splenic artery aneurysm. Biochemistry confirmed ACTH-independent hypercortisolism: ACTH <3 ng/l (<50), serum cortisol 1109 nmol/l (185–624), and 24-h urinary cortisol 3332 nmol/day (<200). Urine steroid profiling supported cortisol-secreting adrenal carcinoma. Serum testosterone and metanephrines were normal. Aldosterone (<60 pmol/l) and renin (0.4nmol/l/hr) were suppressed, consistent with cortisol-mediated mineralocorticoid axis suppression. CT adrenal imaging demonstrated a heterogeneous, calcified mass highly suspicious for ACC. She was commenced on spironolactone for refractory hypokalaemia and metyrapone to control cortisol excess. She was transferred to a tertiary centre for adrenalectomy assessment; however, her course was complicated by probable Pneumocystis pneumonia, marked deconditioning, and extensive pustular skin lesions. HSV-1 DNA was detected with secondary bacterial infection, attributed to cortisol-induced immunosuppression. Given her frailty and clinical deterioration, medical rather than surgical management was favoured. She was repatriated for rehabilitation and palliative care, with hypercortisolism controlled on ketoconazole and metyrapone.

Conclusion: This case illustrates how ACC may remain clinically silent until revealed by an unrelated event. Metabolic instability, frailty, and infection risk ultimately necessitated medical rather than surgical management. The case underscores the importance of prompt hormonal assessment and specialist referral when adrenal incidentalomas are identified.

Reference: 1. Fassnacht,M.,et al(2018).Management of adrenocortical carcinoma in adults:. EJE,179(4),G1–G46.