Adrenal Insufficiency with Normal Morning Cortisol in a Patient with Metastatic Carcinoma

Presentation Number: SAT-0765
Date of Presentation: June 21st, 2014

Lauren Michelle Maiorini*1 and Lawrence E Shapiro2
1Winthrop University Hospital, Mineola, NY, 2Winthrop Univ Hosp, Garden City, NY

Abstract

Introduction/background:

Adrenocortical insufficiency (AI) is a rare but potentially lethal disease. Compared to the prevalence of adrenal metastases in patients with malignancy, AI in these patients is very uncommon. A salient feature of AI due to adrenal metastases is normal levels of basal serum cortisol.

Clinical Case:

This is a 68 year old female referred for evaluation of hypotension and new onset hyperkalemia. Associated symptoms included severe bilateral flank pain, fatigue and dizziness. She has a history of ovarian carcinoma s/p TAH-BSO. During a chemotherapy treatment session, she became hypotensive and recent labs revealed a potassium level of 6.0 mEq/L. She was known on PET-CT imaging to have bilateral adrenal masses, suspicious for metastatic disease. Given her adrenal masses, hyperkalemia, and hypotension, she was referred to our office for suspected AI. A 250mcg cosyntropin stimulation test was performed. Her baseline serum cortisol level was normal, 15.4 mcg/dL, but the stimulated value was only 16.2 mcg/dL. Despite normal basal cortisol, other values were consistent with adrenal insufficiency: baseline ACTH level of 400 pg/mL, an aldosterone level of <1 ng/dL, and a renin level of 21.55 ng/mL/hour. She was started on Hydrocortisone and Fludrocortisone. Her symptoms of fatigue and orthostasis improved. She died a few months later from her progressive disease.

Discussion:

The adrenal glands are the 4th most common site of distant metastasis. However, adrenal metastases from gynecological neoplasms are relatively rare. AI is typically found in patients with 4cm or larger bilateral adrenal metastases. The features of AI which are treatable may be masked by the symptoms of end stage metastatic disease so the diagnosis can be missed. A literature review revealed that advanced cancer patients have increased levels of basal cortisol but can have biochemical and clinical features of AI. This elevation in cortisol may be due to an activated hypothalamic-pituitary-adrenal axis from increased physiologic stress & interactions between the tumor, the immune system, and the endocrine system. Thus, “normal” basal cortisol concentrations exist in patients with AI due to adrenal metastases. Hormonal replacement therapy may be life-saving and improve quality of life in patients suffering symptoms of adrenal insufficiency.

 

Conclusion:

This is a rare case of ovarian cancer metastasizing to the adrenal glands & causing symptoms and biochemical abnormalities consistent with AI. Evaluation of patients with bilateral adrenal metastases & suspected AI must account for the fact that the HPA axis is activated in patients with malignancy to avoid erroneous exclusion of AI by the presence of normal serum cortisol.

 

Nothing to Disclose: LMM, LES