CSEM

CSEM2404 - CSEM Resident Oral Abstract Presentations - Lack of Utility of Adrenal Vein Cortisol Sampling in Bilateral Adrenal Adenomas with Hypercortisolemia

Thursday, November 21, 2024

14:23 - 14:30 AT Time

Location: Argyle A3

Submitting Author(s)

Kara Hawker, MD (she/her/hers)

Endocrinology Resident
University of Ottawa
Ottawa, Ontario, Canada

Disclosure(s): I do not have a relationship with a for-profit and/or a not-for-profit organization to disclose

Presenting Author(s)

Kara Hawker, MD (she/her/hers)

Endocrinology Resident
University of Ottawa
Ottawa, Ontario, Canada

Disclosure(s): I do not have a relationship with a for-profit and/or a not-for-profit organization to disclose

First Author(s)

Kara Hawker, MD (she/her/hers)

Endocrinology Resident
University of Ottawa
Ottawa, Ontario, Canada

Disclosure(s): I do not have a relationship with a for-profit and/or a not-for-profit organization to disclose

Co-Author(s)

AA

AMEL ARNAOUT, MD, FRCPC (she/her/hers)

Endocrinologist
The Ottawa Hospital
University of Ottawa
Ottawa, Ontario, Canada

Disclosure information not submitted.

Abstract:

Background: Among patients with ACTH-independent hypercortisolism with adrenal adenoma(s), adrenal vein sampling (AVS) may be conducted prior to management decisions. Studies evaluating AVS in hypercortisolemia to determine laterality of disease have not established efficacy of the procedure.

Case: A 60-year-old female with Cushing's and bilateral adrenal adenomas with prior non-lateralization on AVS was referred for ongoing care. Weight gain, easy bruising, hypertension requiring two medications, T2DM on treatment, and OSA had developed. Repeat investigations showed serum morning cortisol of 554 (133-547 nmol/L) after 1mg DST, 24-hour UFC of 220 (10-160 nmol/day) then 1246 (60-415 nmol/day) two years later, and bilateral adenoma growth on CT (left: 4.5 to 6.5 cm; right: 1.5 to 2.0 cm). Repeat AVS showed no lateralization. Despite this, she was offered staged left adrenalectomy first. Postoperatively, 24-hour UFC was 83 (60-415 nmol/day). No completion adrenalectomy was required. Subsequently, signs/symptoms concerning for adrenal insufficiency appeared; serum morning cortisol was 116 (133-537 nmol/L), prompting initiation of hydrocortisone 10mg daily. ACTH stimulation test showed suboptimal cortisol response: 194 nmol/L to 435 nmol/L after 60 minutes. She now takes hydrocortisone PRN only. Clinically, she lost 25 lbs, hypertension improved requiring only one antihypertensive, and HbA1c improved to < 6.0% requiring only one antihyperglycemic.

Discussion: Improvement of clinical features of hypercortisolism and normalization of 24-hour UFC after unilateral adrenalectomy suggests the larger adenoma was the source of cortisol excess, despite AVS showing no lateralization. This highlights the inconsistency of AVS protocol for lateralization in adrenal Cushing’s and the need for clinical correlation.