Double trouble: two cases of dual adrenal pathologies in one adrenal mass

Research output: Contribution to journalArticle

Authors

  • Christine J H May
  • Kassiani Skordilis
  • John Ayuk
  • Rachel K Crowley

Colleges, School and Institutes

External organisations

  • Obesity Immunology Group, Education and Research Centre, St. Vincent's University Hospital, University College Dublin, Dublin 4, Ireland.

Abstract

Context Adrenal incidentalomas (AI) represent an increasingly common problem in modern endocrine practice. The diagnostic approach to AIs can be challenging and occasionally reveals surprising features. Here we describe two rare cases of complex adrenal lesions consisting of phaeochromocytomas with synchronous metastases from extra-adrenal primaries. Case descriptions Patient 1 - a 65-year-old gentleman with a newly diagnosed malignant melanoma was found to harbour an adrenal lesion with suspicious radiographic characteristics. Percutaneous adrenal biopsy was consistent with adrenocortical adenoma. After excision of the skin melanoma and regional lymphatic metastases, he was followed up without imaging. Three years later, he presented with abdominal discomfort and enlargement of his adrenal lesion, associated with high plasma metanephrines. Adrenalectomy revealed a mixed tumour consisting of a large phaeochromocytoma with an embedded melanoma metastasis in its core. Patient 2 - a 63-year-old lady with a history of NF-1-related phaeochromocytoma 20 years ago and previous breast cancer presented with a new adrenal lesion on the contralateral side. Plasma normetanephrine was markedly elevated. Elective adrenalectomy revealed an adrenal tumour consisting of chromaffin cells intermixed with breast carcinoma cells. Conclusions Adrenal incidentalomas require careful evaluation to exclude metastatic disease, especially in the context of a history of previous malignancy. Adrenal biopsy provides limited and potentially misleading information. Phaeochromocytomas are highly vascularised tumours that may function as a sieve, extracting and retaining irregularly shaped cancer cells, thereby yielding adrenal masses with intriguing dual pathology. Learning points: Adrenal incidentalomas require careful evaluation focused on exclusion of underlying hormone excess and malignant pathology. Adrenal biopsy can be misleading and should only be considered in select cases. Phaeochromocytomas harbouring intratumoural metastases from other, extra-adrenal primary malignancies represent rare pathological entities that highlight the complexities that can be presented by adrenal tumours.

Details

Original languageEnglish
Article numberEDM180151
JournalEndocrinology, diabetes & metabolism case reports
Volume2019
Publication statusPublished - 23 Mar 2019

Keywords

  • 2019, Abdominal discomfort, Adrenal, Adrenalectomy, Adrenocortical adenoma, Adult, Alpha-blockers, Amlodipine, Anastrozole, Angiotensin receptor antagonists, Bendroflumethiazide, Beta-blockers, Breast cancer, CT scan, Chemotherapy, Chromogranin A, Dacarbazine, Deep vein thrombosis, Doxazosin, Female, Fine needle aspiration biopsy, Haematoxylin and eosin staining, Histopathology, Immunohistochemistry, Incidentaloma, Lymphadenopathy, MIBG scan, Male, March, Metanephrines, Metastatic melanoma, Normetanephrine, Oncology, Phaeochromocytoma, Phenoxybenzamine, Propranolol, Skin biopsy, Tumours and neoplasia, Ultrasound scan, Unique/unexpected symptoms or presentations of a disease, United Kingdom, White