Image of the Month—Quiz Case

A woman aged 53 years had a history of slight hypertension without mention of hypertensive crisis and recent onset of weakness and vague abdominal symptoms. Abdominal ultrasound revealed a 7-cm mass in the right adrenal gland.

A complete evaluation was performed. On physical examination, slight obesity was observed (body mass index, 26.5; calculated as weight in kilograms divided by height in meters squared), without virilization signs. Typical Cushing features such as central obesity, moon facies, purple striae on the lower abdomen, and buffalo bump were absent. Laboratory data, including results of endocrinologic tests, were normal (aldosterone, 4.1 ng/dL [to convert to picomoles per liter, multiply by 27.74]; plasma renin activity in orthostatism, 0.17 μg/L/h; cortisol, 4.89 μg/dL [to convert to nanomoles per liter, multiply by 0.331]; adrenocorticotropic hormone, <5 pg/mL [to convert to picomoles per liter, multiply by 0.22]; dehydroepiandrosterone sulfate, 218.52 μg/dL [to convert to micromoles per liter, multiply by 0.027]) except for slight elevation of blood norepinephrine, which was 410.1 pg/mL (reference value, 400 pg/mL; to convert to picomoles per liter, multiply by 5.911) and urinary normetanephrine, which was 1209.2 μg per 24 h (reference value, <600). A computed tomographic scan confirmed the presence of a 7-cm inhomogeneous mass with calcifications, arising from the right adrenal gland. Irregular central areas representing necrosis and hemorrhage were absent (Figure 1).

Figure 1. 

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Computed tomographic scan confirmed the presence of a 7-cm inhomogeneous mass with calcifications, arising from the right adrenal gland.

Surgical removal of the right adrenal gland was planned because of the large diameter of the lesion and suspicion of pheochromocytoma.

The patient had a right laparoscopic adrenalectomy after adequate pharmacologic preparation consisting of α blockade starting 10 days before the operation and β blockade starting 3 days before the operation to reduce the risk of life-threatening tachyarrhythmias.

Surgery was uneventful; neither hypertensive nor hypotensive crises were recorded during the operation. The lesion macroscopically appeared to be a round, firm, pale gray, encapsulated mass (Figure 2).

Figure 2. 

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The lesion macroscopically appeared to be a round, firm, pale gray, encapsulated mass.

A. Pheochromocytoma

B. Schwannoma

C. Ganglioneuroma

D. Cortical adenoma

Answer