case_images: PMC10061007_01
case_images: (1A-1D) Contrast-enhanced CT scans of the abdomen (portal-venous phase) showing multiple metastases in the liver, ranging in size from a few millimeters to 40 mm (red arrows), incidentaloma of the left adrenal gland of benign phenotype 20 mm in diameter (white arrow), and primary tumor (red arrow) (1D). (2A-2D) Contrast-enhanced CT (portal-venous phase) scans revealed progression of the metastatic liver disease (red arrows) and a significant change in the left adrenal tumor density (47 HU in native phase) and size (24 x 18mm), arousing suspicion of adrenal metastasis (white arrow), which was not confirmed in final pathology reports. The primary tumor is indicated by a red arrow in (2D). (3A-3D) Post left-sided adrenalectomy contrast-enhanced CT scan showing stable metastatic liver disease, without further progression in terms of intensity, number, and size of metastases, and even with some of the hepatic metastases shrinking (red arrows). The primary tumor is indicated by a red arrow in (3D).
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case_images: There were nearly 30 lesions, which ranged in size from a few millimeters to 40 mm (Figures 1, 1A-D). HU in the native phase and in size of up to 24 x 18 mm, arousing suspicion of adrenal metastasis (Figures 1, 2A-D).
case_images: (A) Somatostatin receptor scintigraphy of the abdomen showing multiple metastases in the liver, primary tumor in the head of the pancreas with high somatostatin receptor expression in all lesions, and incidentaloma of the left adrenal gland without pathological radiolabel uptake. (B, C) Somatostatin receptor scintigraphy showing metabolically receptor-mediated progression within the liver and primary tumor of the pancreatic head. (D) Somatostatin receptor scintigraphy showing metabolic receptor-mediated stabilization within metastatic lesions in the liver, with a decrease in liver size and a primary tumor of the head of the pancreas with similar radioimmunoassay accumulation after CAPTEM therapy.
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case_images: Tektrotyd, Polatom, PL) subsequently confirmed a pathological radiolabel uptake in the pancreatic and liver lesions presented in Figure 2, during initial SRS in June 2020 (Figure 2A). There was no pathological radiotracer accumulation in the left adrenal gland, indicating benign adenoma morphology. HU in the native phase and in size of up to 24 x 18 mm, arousing suspicion of adrenal metastasis (Figures 1, 2A-D).
case_images: ACTH and cortisol levels presented in chronological order.
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case_images: One month later, the patient was readmitted to our Department due to a sudden onset of severe hypercortisolemia, leading to severe hypokalemia (Table 1; Figure 3), increased peripheral edema, and hypertension. Metyrapone treatment in a dose up to 2 g per day and pasireotide s.c. 600 mug bid were promptly initiated together with potassium supplementation, spironolactone, and hyperglycemia treatment, which resulted in significant clinical and biochemical improvement (Table 1; Figure 3). ACTH (+), and a Ki-67 labeling index of 7%-8%. After adrenalectomy, hormonal results revealed a significant decrease in ACTH level, normal morning cortisol levels, and 24-h free urinary cortisol excretion, and a further increase in gastrin concentration (Table 1; Figure 3). During a follow-up hospitalization, laboratory results confirmed prolonged normalization of ACTH and cortisol levels (Table 1; Figure 3). 18F-fluorodeoxyglucose PET-CT imaging ruled out the presence of metastases in the lungs and confirmed the metabolically active process located in the pancreatic head and in the liver. Currently, 1 year after adrenalectomy, we found stable, slightly elevated levels of morning ACTH, normal cortisol with maintained diurnal rhythm, 24-h free urinary cortisol excretion in the upper limit of normal, testosterone concentration within the male range, and elevated but stable gastrin and chromogranin A levels (Table 1; Figure 3).