Mifepristone Utilization in Cushing’s From Large Bilateral Adrenal Adenoma Prior to Surgery

Abstract

Utilization of mifepristone was described to mitigate hypercortisolism from bilateral adrenal Cushing’s syndrome. A 47-year-old female on abdominal pain evaluation with CT was found to have a 5.4 × 1.7 × 4.9 cm right adrenal nodule and a 4.3 × 2.9 × 3.3 cm left adrenal nodule with calcification on CT scan with each having density of -3 Housefield units. She had hypercortisolism with testing revealing high urine free cortisol, unsuppressed cortisol on 1 mg and 8 mg overnight dexamethasone suppression testing, high 11 pm salivary cortisol × 2 along with elevated random cortisol and undetectable ACTH. Her DHEA-S, plasma metanephrine, and rostenedione, renin and aldosterone levels were normal. Adrenal venous sampling for lateralization of hypercortisolism source using dexamethasone 2 mg PO Q 6 hours × 1 day, showed adrenal vein epinephrine levels step up > 100 pg/mL, indicating successful catheterization. Each side adrenal vein to vena caval cortisol ratio > 4 was consistent with autonomous cortisol secretion and left to right adrenal cortisol ratio < 2 suggested bilateral adrenal Cushing’s syndrome. She had multiple co-morbidities including uncontrolled hypertension, poor functional status requiring walker and cane, chronic non-healing cellulitis, glucose intolerance and hypokalemia. Mifepristone was initiated for medical management of hypercortisolism prior to surgery, resulting in > 50 lbs weight loss, improved blood pressure, complete healing of chronic lower extremity cellulitis and independent ambulation within 4 months. Initially right adrenal adenoma and then left adrenal adenoma were resected in two separate surgeries and pathology showed bilateral enlarged adrenal glands with multiple adrenocortical nodules without adrenal carcinoma. Mifepristone, FDA approved for inoperable Cushing’s, facilitated pre-surgery optimization by effectively mitigating hypercortisolism. Mifepristone was utilized as a bridge for Cushing’s medical management prior to surgery. J Endocrinol Metab. 2015;5(3):226-228 doi: http://dx.doi.org/10.14740/jem288w