Incidentally Discovered Adrenal Mass in a Patient With a History of Extraadrenal Malignancy: The Role of Adrenal Biopsy

##

Adrenal metastasis should be suspected in any patient with history of extraadrenal malignancy presenting with an indeterminate adrenal mass. The most common extraadrenal malignancies that metastasize to adrenal gland include lung, renal, and gastrointestinal cancers, followed by melanoma, lymphoma, breast, and other cancers. In this case, we illustrate the role of adrenal biopsy in the workup of adrenal mass and discuss the potential of adrenal insufficiency in these patients.

Case Report

The patient was a 77-year-old woman who was referred for evaluation of an incidentally discovered left adrenal mass on a renal ultrasound that was obtained for workup of hypertension and hyperkalemia. A subsequent computed tomography (CT) scan was obtained and demonstrated a heterogeneous left adrenal mass measuring 12.3 × 8.3 × 9.1 cm ( Fig. 3.1 ). No other lesions were seen.

The patient’s past medical history was positive for renal cell carcinoma 12 years prior that was treated with right nephrectomy and right adrenalectomy. Periodic imaging was performed until 5 years prior and was negative for recurrence. At the time of evaluation, she had no symptoms to suggest adrenal hormonal excess and the review of systems was negative.

She had a history of hypertension, dyslipidemia, and type 2 diabetes mellitus. Her medications included amlodipine, losartan, metoprolol succinate, atorvastatin, and metformin. Her body mass index was 42.8 kg/m ² , and the physical examination was otherwise unrevealing.

Investigations

Baseline laboratory testing was obtained and excluded a functioning pheochromocytoma ( Table 3.1 ). Initial testing also demonstrated possible primary adrenal insufficiency with elevated serum corticotropin (ACTH) concentration and low serum cortisol concentration. Follow-up cosyntropin stimulation testing was abnormal, with a peak serum cortisol concentration of 9 mcg/dL.

TABLE 3.1

Laboratory Tests

Biochemical Test	Result	Reference Range
Sodium, mmol/LPotassium, mmol/L8 am serum cortisol, mcg/dLACTH, pg/mLDHEA-S, mcg/dLPlasma metanephrine, nmol/LPlasma normetanephrine, nmol/L	134, 1385.0, 5.25.3, 8.0116<15<0.20.88	135–1453.6–5.27–2510–6015–157<0.5<0.9