Posted by Thomas Repas, DO, FACP, FACE, CDE July 6, 2009 11:52 AM
We received an urgent consult request this week to see a young woman with an adrenal mass.
She had rapid onset of weight gain, increased hunger, purple striae, increased abdominal girth and mood changes for the last three months. Her primary care provider was concerned but did not know what the explanation was. He ordered extensive testing without finding any obvious abnormality. Echocardiogram, thyroid and other laboratory studies were negative.
She had urinary retention and was sent to urology. Renal ultrasound was negative. The patient requested to have a CT which identified a heterogeneous 9.0-cm left adrenal mass. The patient subsequently underwent an adrenal biopsy. She tolerated the procedure well and without hemodynamic instability. However, the results were non-diagnostic. She was then sent to see me.
Expert guidelines advise against adrenal biopsy in the routine evaluation of adrenal masses. There are several reasons.
First, adrenal biopsy has not been shown to reliably distinguish between benign or malignant adrenocortical masses. If an adrenal mass is large and/or functional, then it should be resected. Adrenal biopsy does not change one’s management in either of those circumstances.
Second, there have been reports of adrenal carcinoma seeding along the biopsy needle track.
Finally, if a pheochromocytoma were inadvertently biopsied, the consequences could be catastrophic, even fatal.
The only situation where adrenal biopsy is useful is a patient with known or highly suspected other primary malignancy which may have metastasized to the adrenal.
Despite guidelines to the contrary, I continue to see adrenal masses biopsied prior to coming to see me. Often, as was the case with this woman, the adrenal biopsy occurs before biochemical evaluation has been completed. I have seen two cases with serious complications when the adrenal mass turned out to be pheochromocytoma. If I had been asked prior to the biopsy, I would have advised them not to do it and proceed with biochemical evaluation instead.
This woman clearly has Cushing’s syndrome. Her adrenocorticotropic hormone was undetectable, and her 24-hour urine-free cortisol was one of the highest I have ever seen: 1,095 ug/24 hours (upper limits of normal 45). There was no evidence of pheochromocytoma or hyperaldosteronism but dehydroepiandrosterone sulfate was elevated. The rapid onset of symptoms, large tumor size, imaging characteristics and evidence of secretion of more than one adrenal hormone concern me greatly for adrenocortical carcinoma. She will be undergoing surgical resection next week.
I know this is a recurring theme in my posts, but I will make this observation yet again: Why is it that the endocrinologist is so often the last subspecialist to see a patient, including the patient with obvious endocrine disease?
For more information:
- Mazzaglia PJ. Arch Surg. 2009;144(5):465-470.
- Mansmann G. Endocr Rev. 2004;25:309-340.
- NIH Statement on management of the clinically inapparent adrenal mass. 2002 Feb 4-6;19(2):1-23. http://consensus.nih.gov/2002/2002AdrenalIncidentalomasos021PDF.pdf