Diagnostic Value of Biochemical Parameters in the Differential Diagnosis of an Adrenal Mass

[Minimally invasive surgery of retroperitoneal paragangliomas : Synopsis of personal experiences]

Retroperitoneal paragangliomas are rare tumors with the characteristics of adrenal pheochromocytomas. They may occur sporadically or in conjunction with hereditary syndromes. Diagnostic methods in paragangliomas include testing of catecholamine secretion and imaging procedures. The first choice treatment is surgical removal, which in the author's opinion is preferably by minimally invasive approaches. Infrarenal paragangliomas should be excised using a laparoscopic transabdominal procedure. For suprarenal tumors the retroperitoneoscopic approach should be used.

Biventricular Cardiac Hypertrophy in a Patient with Primary Aldosteronism and Atrial Septal Defect

Patient: Female, 33

Final Diagnosis: Primary aldosteronism • heart failure • atrial septal defect • biventricular cardiac hypertrophy

Symptoms: Dyspneu • muscular weakness

Medication: Spironolactone • ACE inhibitor

Clinical Procedure: Captopril suppression test • adrenalectomy • right cardiac catheterization

Specialty: Endocrinology and Metabolism • Cardiology

PREDICTIVE VALUE OF CHROMOGRANIN A IN A DIAGNOSIS TOWARDS PHEOCHROMOCYTOMA IN ADRENAL INCIDENTALOMA

Context

Some adrenal tumors, such as pheochromocytoma, can be life-threatening. Therefore it is crucial to distinguish them from other lesions, especially prior to surgery. Chromogranin A (CgA) seems to potentially be a good marker for tumors of chromaffin origin.

Objective

To assess the differentiating value of CgA in the diagnostic work-up of pheochromocytoma.

Design

Retrospective study of operated patients with adrenal incidentaloma with lesions > 10 Hounsfield's units (HU) on CT.

Subjects and methods

Thirty patients (11 males, 19 females; aged 61.5±21 years) were enrolled in the study. Patients using medications interfering with the assessment of CgA and metanephrines were excluded. Two groups were formed: those with pheochromocytoma (Ph, n=16) and those with non-pheochromocytoma (N-Ph, n=14) lesions. Data included radiological features of masses, serum CgA and 24-hour urine metanephrines (24 - HUM) concentrations.

Results

No difference in 24-HUM level nor tumor size or density was found between groups Ph and N-Ph. Median serum CgA concentration was higher in Ph group compared to the N-Ph: 99.35 (68.12-172.73) vs. 52.92 (34.37-101.26) ng/mL, respectively (P=0.04). In Ph group, the size of the lesion correlated negatively with density (r= -0.53, P=0.042). No significant correlation in CgA, 24-HUM, density or size of the lesion was found. Performed curve receiver operating characteristic (ROC) showed AUC=0.7232 for CgA. Taking into account CgA serum value of ≤ 50 ng/mL (sensitivity: 93.75%, specificity: 50.00%, P=0.012), we proposed an algorithm for management of lesions > 10 HU on CT.

Conclusion

CgA level ≤ 50 ng/mL might be useful in initial screening evidence for the exclusion of pheochromocytoma. It is crucial to eliminate factors interfering with the measurements.

Virilizing adrenal ganglioneuroma in a woman with subclinical Cushing syndrome

OBJECTIVE

To describe a patient with a virilizing adrenal ganglioneuroma and subclinical Cushing syndrome.

METHODS

Detailed clinical, laboratory, radiologic, and pathologic findings are presented, and the pertinent literature is reviewed.

RESULTS

A 56-year-old postmenopausal woman was referred for evaluation of a 3.6- by 3.0-cm right adrenal mass, which had been diagnosed during a work-up for hirsutism. A bilateral oophorectomy done 2 months before the presentation failed to correct the elevated testosterone levels. On examination, she had severe hirsutism on her face, chest, back, and extremities, as well as male pattern baldness and clitoromegaly. Biochemical evaluation showed elevated total and free serum testosterone levels of 319 ng/dL (reference range, 20 to 70) and 78 pg/mL (reference range, 1 to 9), respectively, values in the adult male range. The serum dehydroepiandrosterone sulfate level was 117 microg/dL (reference range, 10 to 152), and the urine free cortisol was 10.4 microg/24 h (reference range, <45). A laparoscopic adrenalectomy revealed a 5.0-cm adrenal ganglioneuroma containing nests of adrenocortical cells. On the first day postoperatively, the serum cortisol level was <1.0 microg/dL. At 1 month after adrenalectomy, the total and free testosterone levels had declined to 16 ng/dL and 3.1 pg/mL, respectively. At 2 months postoperatively, normal results of a cosyntropin stimulation test (basal and peak cortisol levels of 13.6 and 20.0 microg/dL, respectively) indicated recovery of the hypothalamic-pituitary-adrenal axis.

CONCLUSION

To our knowledge, this is the first case report of a virilizing adrenal ganglioneuroma with this unique pathologic finding and concomitant subclinical Cushing syndrome.