Adrenocortical Carcinoma with Suspected Dual Cortisol and Aldosterone Secretion
A Case Report
DOI:
https://doi.org/10.15605/jafes.041.02.5875Keywords:
adrenocortical carcinoma, hyperaldosteronism, hypercortisolismAbstract
Adrenocortical carcinoma (ACC) is a rare malignancy, accounting for 0.05-2% of all malignant tumors. Most cases are sporadic and asymptomatic, often discovered incidentally via imaging. However, 50-60% present with autonomous hormonal secretion, with 45% producing excess cortisol, and only 1% exhibiting mineralocorticoid excess.
We report a 43-year-old Filipino woman with a 6-month history of abdominal bloating, proximal muscle weakness, edema, and hypertension. Laboratory tests showed hypokalemia (serum potassium 2.5-3.05 mmol/L; normal 3.3-5.0 mmol/L). Imaging revealed an incidental right adrenal mass measuring 4.7 x 3.6 x 6.1 cm, with Hounsfield units of 40, along with periportal and paraaortic lymphadenopathies.
Biochemical evaluation indicated primary hyperaldosteronism: suppressed plasma renin (0.97 ng/ml/hr; normal 0.39-3.94 ng/ml/hr), normal plasma aldosterone (21.61 ng/dl; normal 4-31ng/dl), and an elevated aldosterone-renin ratio of 22.27. Confirmatory testing was not done due to undetectable plasma renin, plasma aldosterone >20 ng/dl, and ongoing hypokalemia. Additionally, she had non-suppressed cortisol (31.88 mcg/dl; normal <1.8mcg/dl) on a low-dose dexamethasone test, and low ACTH (2.81 pg/ml; normal 7.7-63.6pg/ml), indicating ACTH-independent Cushing's syndrome. Tests ruled out catecholamine and androgen excess with normal urine metanephrines and serum DHEAS, respectively.
Surgical removal via open adrenalectomy was performed. Histopathology confirmed ACC, supported by immunohistochemistry. Postoperative treatment included radiotherapy and planned adjuvant mitotane therapy. During follow-up, the patient’s blood glucose and pressure worsened, requiring medication adjustments. Unfortunately, the patient succumbed to the disease seven months post-surgery.
This case highlights the importance of thorough evaluation when diagnosing complex cases involving simultaneous cortisol and aldosterone secretion in adrenal tumors, highlighting the challenges and the need for prompt management of this rare coexistence.
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