Background: It is common practice to test most if not all adrenal hormones in the workup of an adrenal nodule to assess function prior to biopsy or surgery. The primary concern being performing a biopsy on a catecholamine producing tumor and the potential consequences associated with doing so.
Clinical
Case: 46-year-old male with prior history of follicular lymphoma first discovered on colonoscopy treated 1 year prior. Initial PET-CT showed hypermetabolic lymph nodes in the chest and abdomen as well as a 5 x 4 cm left adrenal lesion first thought to be a large lymph node. He was treated with rituximab with resolution on his PET-CT in all areas other than the left adrenal lesion noted on prior PET-CT. He underwent evaluation for a catecholamine producing tumor and when that returned negative, he was scheduled for biopsy of the lesion. Biopsy showed adrenal cortical adenoma. The rest of his biochemical workup was completed showing an elevated DHEA-S and an elevated urinary free cortisol but was otherwise normal. Given constellation of findings, the patient was scheduled to undergo unilateral adrenalectomy. He underwent adrenalectomy with surgical oncology and was found to have stage 4 adrenal cortical carcinoma. He is currently being treated with radiation and Mitotane.
Conclusion: Many tests used to workup adrenal cortical carcinoma have lower than ideal sensitivity and specificity including tissue biopsy. Combining the size of the nodule with multiple tests of even with less-than-ideal sensitivity and specificity along with patient history increased clinical suspicion enough to justify proceeding with surgery.
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