SUN-490 - Silent Adrenal Bomb- A Rare Case of Sarcoma-Driven Adrenal Apoplexy

A 67-year-old male with a past medical history of hypothyroidism, gout, HTN, HLD, and diet-controlled T2DM presented to the emergency department with one day of generalized abdominal pain which was acute in onset, continuous, gradually progressive, non-radiating, moderate to severe intensity, no specific aggravating or relieving factors & associated with multiple episodes of watery, non-bloody diarrhea. Review of symptoms was positive for nausea. The patient recalled feeling a distinct “pop” in his abdomen the night before while bending forward, which preceded the onset of symptoms.

Vital signs were stable on arrival but appeared in mild distress due to discomfort. Abdomen was soft but diffusely tender, prominently over the epigastric region, left upper and lower quadrants. Guarding was present with normoactive bowel sounds, though no rigidity, or palpable masses were noted. The remainder of his systemic exam was unremarkable.

A contrast-enhanced CT scan of the abdomen & pelvis demonstrated a large, well-circumscribed, hypoattenuating lesion in the left upper quadrant measuring 10–11 cm, presumed to represent an adrenal mass. The lesion was associated with a crescentic periadrenal hematoma extending into the anterior perinephric space and exerting mass effect on the left renal pole. There was no evidence of active contrast extravasation. Notably, the left adrenal gland could not be distinctly visualized, raising concern for adrenal apoplexy.

Hormonal workup showed elevated normetanephrines and metanephrines, and early morning cortisol was low following dexamethasone. PET/CT demonstrated a hypermetabolic adrenal mass without metastatic disease.

The patient underwent embolization of the left middle adrenal artery followed by en bloc surgical resection, which included left adrenalectomy, nephrectomy, and partial colectomy. Postoperative recovery was uneventful with consistent serosanguinous JP drain output. Preliminary pathology of the adrenal mass demonstrated a spindle cell neoplasm suspicious for sarcoma. The case underscores the diagnostic challenge and surgical complexity of adrenal apoplexy due to sarcoma.

Conclusion

Primary adrenal sarcomas are exceedingly rare for malignancies. The most reported subtype is sarcomatoid adrenocortical carcinoma, which is a rare and aggressive variant of adrenal cortical carcinoma. These tumors have rapid locoregional recurrence and metastases, typically resulting in death within months despite treatment. Population-level data from SEER (1973-2013) identified only 61 cases of primary adrenal sarcoma, with a 5-year cancer-specific survival of 42%.has been reported [4]. Diagnosis relies on histopathology and immunohistochemical staining. Early surgical evaluation is extremely essential in such presentations as timely intervention can be lifesaving and provide definitive tissue diagnosis.

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