Poster Presentation ESA-SRB 2023 in conjunction with ENSA

Introduction:

Primary Adrenal Melanoma (PAM) is an extremely rare malignancy, with fewer than twenty-five cases described. The symptoms are non-specific and it may present as an adrenal incidentaloma. PAM is diagnosed by histopathology and exclusion of primary melanoma from other sites. Although adrenal metastases from skin melanoma are more common, PAM is a differential diagnosis in a unilateral adrenal mass that appears malignant if there is no history of malignancy or skin lesion.

Case:

We present a 69 year old lady with an incidental right adrenal mass measuring 85x60x72 mm (density of 34 Hounsfield Units) with inferior vena cava extension and bilateral pulmonary lesions. There were no clinical or biochemical features of hormone excess (Table 1). FDG-PET showed intense FDG avidity of the adrenal mass and pulmonary lesions. Based on imaging characteristics and in the absence of extra-adrenal malignancy, the presumptive diagnosis was a non-functioning adrenocortical carcinoma. She unfortunately developed new onset haemoptysis and underwent bronchoscopy to localise the source of bleeding. The pulmonary lesions were inaccessible for bronchoscopic biopsy. There were unforeseen complications post-procedure with decreased conscious state, necessitating intubation and management in the Intensive Care Unit. CT imaging post-procedure showed new pulmonary emboli and a 25% increase in the volume of the adrenal lesion. MRI showed diffuse hypoxic-ischaemic brain injury. At the family’s request, she underwent CT-guided adrenal core biopsy which revealed the unexpected finding of melanoma. There were no skin lesions identified. Due to poor neurological recovery, the decision was made for palliative care following extensive discussion with her family.

Conclusion:

Adrenal biopsy is not routinely recommended for diagnosis unless there is evidence of metastatic disease that precludes surgery and histopathology is required to guide oncological treatment. In this case, a diagnosis of melanoma would have broadened therapeutic options if the patient’s clinical state had improved.