SUN-386 Problems In Adrenal Incidentaloma Diagnostics In Clinical Practice

Abstract

Background: Differential diagnosis of adrenal incidentaloma determines the tactics of both therapeutic treatment of the patient and surgical intervention [1]. However, even compliance with strictly regulated algorithms of differential diagnosis does not always allow the accurate diagnosis. Clinical case: A 39-year-old patient B. addressed the clinic about the lesion of the left adrenal gland. From the history it is known that since 2014 (35 years old) he has been suffering from arterial hypertension being on three-component hypotensive therapy with periodic crises up to 200/100 mmHg. In January 2018 as a result of the renal ultrasonography the lesion was verified in the projection of the upper pole of the left kidney. The adrenal CT with contrast confirmed the lesion of the left adrenal gland size 41*42*56 mm density at the native research 33 HU, absolute washout percentage of 30%. The patient was referred to an endocrinologist. Objectively: BMI-29 kg/m2, BP 160/90 mmHg, HR-80 per minute. A preliminary diagnosis was made - an incidentaloma of the left adrenal gland. The hormonal activity of the lesion was determined. According to the suppressive test with 1mg dexamethasone, plasma cortisol suppression did not occur. The levels of ACTH as well as the values of metanephrine and normetanephrine in daily urine were within normal limits. On the basis of normal values of metanephrine and normetanephrine in the urine daily as well as high-density CT values in the native phase and the delay of contrast in the delayed phase together with the large size of the lesion and high growth rate, pheochromocytoma was eliminated and glucocorticoid-producing adrenocortical cancer was verified. Laparoscopic adrenalectomy was performed on the left. However, according to the histological examination, pheochromocytoma was revealed. To confirm the diagnosis the biopsy material was sent to an expert-level institution, where pheochromocytoma/paraganglioma with a high risk of metastasis was also verified, Ki 67<1%. The patient was finally diagnosed with pheochromocytoma of the left adrenal gland glucocorticoid secreting. After the surgery, hemodynamic parameters stabilized. Conclusion: On the example of this case, we have demonstrated that compliance with strictly regulated algorithms of differential diagnosis does not always allow an accurate diagnosis. Thus, at the preoperative stage all the data indicated in favor of adrenocortical cancer while the immunohistochemical study after the operation verified pheochromocytoma. Thus, research should be continued to improve the diagnostic algorithm of incidentaloma of the adrenal gland. Reference: (1) Ierardi A.M., Petrillo M.,Patella F.,Biondetti P.,Pesapane F., Fumarolla E.M.,Angileri S.A., Pinto A., Dionigi G., Carrafiello G.Interventional radiology of the adrenal glands: current status. Gland Surg 2018;7(2):147-165.