A 35-year-old farmer sustains chest injuries following an accident at the farm for which he is subjected to CT imaging of thorax and abdomen which reveals bilateral adrenal mass, measuring 4 cm × 3 cm × 4 cm, homogeneous, smooth walled, isodense with liver and well enhancing on contrast administration. He is asymptomatic prior to the accident. Examination reveals a normally built male, normal vitals, no postural drop in blood pressure. No obvious hyperpigmentation. Biochemical evaluation are all normal except a serum sodium levels of 129 mEq/L. TSH, total T4 levels are normal. At 8 am cortisol is 5 mg/dL with a corresponding ACTH of 100 pg/mL. A synacthen stimulation test with 250 mg given IV is done and 60 min cortisol of 13 mg/dL is obtained. A diagnosis of Addison’s disease is made. Chest X-ray and Mantoux test are normal. 24-hour urine collection for metanephrines is normal. A CT-guided FNAC is performed which reveals 2–4 μm oval, budding yeast forms with a probable diagnosis of histoplasmosis. ELISA for human immunodeficiency virus is negative. Patient is started on hydrocortisone 15 mg/day in two split doses. Patient is given intravenous amphotericin B for two weeks followed by oral itraconazole for one year.
What is the risk of malignant transformation of an adrenal incidentaloma?
Medicine
Risk of malignant transformation of an untreated adrenal incidentaloma, qualified as a benign lesion, subsequently developing malignancy appears to be very low. In patients with adrenal incidentalomas, followed up for an average of 4 years, 5–20% showed mass enlargement >1 cm and/or appearance of another mass in the contralateral gland.
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