Category: Adrenal Disorders
Adrenal metastases are found in about 50% of cases of malignant melanoma and are often clinically and biochemically silent. We present a case of adrenal metastasis recurring 12 years after the primary diagnosis.
Results : A 69 year old lady with history of hypertension and type 2 diabetes mellitus presented with right flank pain radiating to the back for two months. She had also lost 30 lbs in this same time frame. She was diagnosed with melanoma on her right arm 12 years prior which was subsequently removed surgically but she refused chemotherapy. She denied episodes of headache, dizziness or palpitations. No reported history of Hypokalemia . CT and MRI abdomen showed complex cystic and solid right suprarenal mass ( 16.1 cm x 13 cm ) with a differential diagnosis of a hematoma vs an adrenal cortical carcinoma. Hormonal work up was negative for Cushing’s syndrome, pheochromocytoma and hyperaldosteronism. DHEA-sulfate level was normal. She subsequently had an open adrenalectomy and the pathology showed malignant melanoma. Post-operatively, her early am cortisol and electrolytes were normal
Melanoma is known to metastasize to the adrenal glands because of their rich supply of sinusoidal blood supply. They can present years after treatment of the primary lesion. An adrenal mass greater than 5 cm in diameter, with central or irregular areas of necrosis/hemorrhage is characteristic of a metastasis from malignant melanoma. Pre-operative evaluation of DHEA-S, primary aldosteronism, Cushing’s syndrome and pheochromocytoma needs to be performed. Detailed imaging ( CT, MRI and PET ) should be obtained. Biopsy of potentially resectable lesions is contraindicated, because of the resulting tumor spill. Open adrenalectomy is the preferred approach for known or suspected adrenocortical carcinoma. Ipilimumab, a checkpoint inhibitor was the first agent to demonstrate improved objective survival in patients with metastatic melanoma. Pembrolizumab and nivolumab have also been approved for treating patients with ipilimumab-refractory cases.
Adrenal metastases are not uncommon with malignant melanoma and can still occur many years after the diagnosis. Our case highlights the importance of long term follow up in these cases.
Marshall University Joan C.Edward School of Medicine
Huntington, West Virginia
Finished Internal Medicine Residency at Richmond University Medical Center and currently in the second year of endocrinology fellowship