58-Year-Old Man With Hypertension and Diffuse Swelling
Martin van Zyl, MBChB; Korosh Sharain, MD; and Christopher M. Wittich, MD, PharmD
A 58-year-old previously healthy man presented to the clinic with an 8-week history of swelling involving his face and both knees, ankles, and hands. He reported a 4.5-kg weight gain over the same time period. He also noted persistent flushing of his face and a sensation of pressure behind his eyes with no headache or visual changes. He did not have palpitations, short- ness of breath, chest pain, paroxysmal nocturnal dyspnea, or orthopnea. Frothy urine and hematuria were not reported. He had no joint pain, rash, abdominal fullness, easy bruising, or striae. The patient took no prescrip- tion, over-the-counter, or illicit drugs. His med- ical history was unremarkable. He was a lifelong nonsmoker, rarely consumed alcohol, and lived an active lifestyle. The patient presented for annual health care visits and was up-to-date on all preventive services.
On examination, the patient was alert and had obvious facial plethora. Vital signs were as follows: blood pressure (BP), 194/108 mm Hg (average of 3 readings, roughly equal in both arms); pulse rate, 92 beats/min and regular; respiratory rate, 18 breaths/min; and body mass index, 25.2 kg/m2. Of note, the patient was normotensive at a clinic visit 10 months previously. Cardiac examination revealed normal rate and rhythm, normal heart sounds, and no murmurs or gallops. His lungs were clear on auscultation, and his neck veins did not appear distended. Pulses were symmetric with no radioradial or radiofemoral delay. Examination of the abdomen revealed no organomegaly, masses, audible bruits, or clin- ical ascites. Moderate pitting edema of the lower extremities was present to the midshin. Both hands were diffusely swollen with no evidence of synovitis. Funduscopic examina- tion demonstrated a normal optic disc.
Initial laboratory evaluation yielded the following results (reference ranges provided
parenthetically): hemoglobin, 16.2 g/dL (13.5- 17.5 g/dL); leukocytes, 11.6 x 109/L (3.5-10.5 × 109/L); platelet count, 133 × 109/ L (150-450 × 109/L); sodium, 139 mmol/L (135-145 mmol/L); potassium, 3.9 mmol/L (3.6-5.2 mmol/L); calcium, 8.9 mg/dL (8.5-10.2 mg/dL); fasting glucose, 99 mg/dl (70-100 mg/dL); creatinine, 1.0 mg/dL (0.8- 1.3 mg/dL); N-terminal pro-B-type natriuretic peptide, 178 pg/mL (<300 pg/mL); and thyro- tropin, 2.1 mIU/L (0.27-4.2 mIU/L). Urinalysis was negative for protein and hemoglobin. Elec- trocardiography revealed normal sinus rhythm with no ST-, T-, or Q-wave changes. Chest radiography demonstrated a normal cardiac shadow and clear lungs.
1. Which one of the following terms best classifies the patient’s presentation?
a. Normal BP
b. Prehypertension
c. Stage 1 hypertension
d. Stage 2 hypertension
e. Hypertensive emergency
The Seventh Report of the Joint National Committee on Prevention, Detection, Evalua- tion, and Treatment of High Blood Pressure (JNC 7)1 classified hypertension as follows: normal BP, systolic less than 120 mm Hg and diastolic less than 80 mm Hg; prehyper- tension, systolic BP of 120 to 139 mm Hg or diastolic BP of 80 to 89 mm Hg; stage 1 hyper- tension, systolic BP of 140 to 159 mm Hg or diastolic BP of 90 to 99 mm Hg; and stage 2 hypertension, systolic BP of 160 mm Hg or higher or diastolic BP of 100 mm Hg or higher. The JNC 7 also required that the BP be consistently elevated at each of 2 or more office visits at least 1 week apart. The JNC 8 report did not address the classification of hypertension and focused primarily on treat- ment. Of note, our patient had been advised to purchase an automated home BP cuff and
See end of article for correct answers to questions.
Resident in Internal Medicine, Mayo School of Graduate Medical Education, Mayo Clinic, Rochester, MN (M.v.Z., K.S.); Advisor to residents and Consultant in General Internal Medicine, Mayo Clinic, Rochester, MN (C.M.W.).
reported systolic BPs above 180 mm Hg over several weeks, confirming the diagnosis of stage 2 hypertension in the absence of evidence for end-organ damage. Hypertensive emergency is defined as a systolic pressure of 180 mm Hg or higher and/or a diastolic pres- sure of 120 mm Hg or higher with evidence of end-organ dysfunction (such as encephalopa- thy, papilledema, or myocardial ischemia) requiring immediate BP reduction with paren- teral agents.
Patients with stage 2 hypertension rarely respond to a single antihypertensive agent, and the JNC 7 recommends starting combina- tion therapy in this population. This approach is controversial among clinicians who may argue that starting 2 drugs simulta- neously could lead to an unpredictable BP response with possible confounding in the event of intolerance or allergy. For our patient, chlorthalidone, a potent yet well-tolerated thiazide diuretic with a long half-life, and lisi- nopril, an angiotensin-converting enzyme in- hibitor with nephroprotective benefits, were chosen as a 2-agent combination for stage 2 hypertension. Calcium channel blockers were initially avoided because of the potential for worsening peripheral edema. The patient remained very active, and ß-blockers were also not chosen because of concern regarding poor tolerability. After 2 weeks, the patient’s edema improved in the setting of diuretic use, but his BP remained elevated at 166/92 mm Hg with a heart rate of 72 beats/min. Initi- ation of amlodipine, a calcium channel blocker, resulted in improved BP control at 139/82 mm Hg.
2. In addition to the evaluation obtained thus far, further investigation should be performed next for which one of the following conditions?
a. Essential or primary hypertension
b. Renovascular and endocrine disease
c. Primary intrinsic renal disease
d. Coarctation of the aorta
e. “White coat” hypertension
Any patient with severe hypertension or an acute increase in BP who has had previously normal values should undergo investigation for secondary causes of hypertension. There- fore, stopping the work-up at the diagnosis
of essential hypertension would not be appropriate. Renovascular disease and endo- crinopathies including hypercortisolemia, pheochromocytoma, and primary hyperaldos- teronism are all causes of secondary hyperten- sion and need to be further evaluated. The history, physical examination findings, and laboratory results thus far are not sufficient to exclude these conditions. Primary renal dis- ease is unlikely given the patient’s normal creatinine concentration and unremarkable urinalysis results. The patient’s age at presenta- tion and symmetric BP readings with no pulse delays make coarctation of the aorta an improbable scenario. White coat hypertension is a diagnosis that applies to patients who exhibit modestly elevated BPs in health care settings but normal home and ambulatory BP recordings. Our patient had markedly elevated in-office as well as home BP readings.
Additional evaluation yielded an undetect- able aldosterone concentration, undetectable plasma renin activity, normal plasma fraction- ated metanephrine level, and a 24-hour urinary free cortisol level of 841 µg/24 h (3.5-45 µg/24 h). Renal artery Doppler ultra- sonography revealed normal renal arteries and normal renal parenchyma but incidentally demonstrated a 7-cm irregular right-sided adrenal mass. Subsequent testing yielded a suppressed corticotropin level of 5.6 pg/mL (10-60 pg/mL), an elevated dehydroepian- drosterone sulfate concentration of 291 ug/ dL (35-179 µg/dL), and an elevated 17-hydroxyprogesterone level of 244 ng/dl (<220 ng/dL). Androstenedione and estradiol levels were unremarkable.
3. On the basis of the results of these inves- tigations, which one of the following is the most likely cause of this patient’s hypertension?
a. Pheochromocytoma
b. Corticotropin-dependent Cushing syndrome
c. Corticotropin-independent Cushing syndrome
d. Primary hyperaldosteronism
e. Exogenous glucocorticoid intake
Plasma fractionated metanephrine levels are highly sensitive for the diagnosis of pheo- chromocytoma, and our patient’s normal value
makes this diagnosis unlikely. On the basis of the patient’s clinical features, markedly elevated urinary free cortisol level, and the presence of an adrenal mass, Cushing syndrome was diagnosed. Corticotropin- dependent Cushing syndrome is heralded by an elevated corticotropin concentration, due either to pituitary or ectopic hyperproduction. The patient in this case had an appropriately suppressed corticotropin level and therefore has corticotropin-independent Cushing syndrome. A ratio of plasma aldosterone concentration to renin activity of greater than 20 is suggestive of primary hyperaldosteron- ism, most often caused by an aldosterone- producing adrenal adenoma (Conn syndrome). Both values are low in this patient, suggesting an etiology for hypertension that is not associated with renin or aldosterone hy- persecretion. Although exogenous intake of glucocorticoids such as hydrocortisone may result in excess urinary cortisol with a sup- pressed corticotropin concentration, the eleva- tion of dehydroepiandrosterone sulfate and 17-hydroxyprogesterone in this case suggests endogenous hyperproduction of adrenocor- tical hormones.
In view of the abnormal laboratory and ultrasonography findings, additional work-up of the adrenal mass was pursued.
4. Which one of the following is the best test to perform next to determine the nature of the patient’s adrenal mass?
a. Computed tomography (CT) with intra- venous contrast medium
b. Magnetic resonance imaging
c. [ C]-Metomidate positron emission to- mography (PET)
d. Fine-needle aspiration biopsy
e. Surgical excision
An adrenal mass should be suspected in all patients with corticotropin-independent Cushing syndrome. In our patient, an adrenal mass was incidentally detected on ultrasonog- raphy; however, this testing modality cannot provide the information necessary to differen- tiate the common types of adrenal mass-benign adenoma, pheochromocytoma, adrenocortical carcinoma (ACC), and metasta- tic disease. Computed tomography adrenal protocol with intravenous contrast medium
is well validated and the imaging test of choice for differentiating adrenal masses. In addition, CT allows operative planning and staging in the event that the mass represents a primary or metastatic neoplasm. Magnetic resonance imaging offers little additional information at a considerably increased cost and is not recommended as an initial imaging test. [11C]-Metomidate is an agent with high affin- ity for adrenocortical enzymes. [11C]-Metomi- date PET is useful for imaging adrenocortical metastases but is unable to differentiate benign and malignant adrenocortical tumors. Fine- needle aspiration biopsy has utility in diag- nosing metastatic disease, but the technique results in a specimen that lacks surrounding architecture and is unable to distinguish a benign cortical adenoma from ACC. The nature of the adrenal tumor must be eluci- dated before surgical excision because meta- static disease often requires systemic therapy, primary tumors may require open surgical exploration, and benign masses can often be removed with minimally invasive techniques.
Adrenal CT revealed a 6.1×5.8×7.4-cm nodular right adrenal mass partially compress- ing, but not invading, the inferior vena cava. The mass exhibited areas of calcification as well as central and peripheral contrast enhancement. Also noted was an unenhanced attenuation average of 30.2 Hounsfield units (HU) with 20% contrast washout at 10 minutes. The left adrenal gland appeared normal, and no other abdominal abnormalities were detected.
5. The imaging and laboratory characteris- tics are most consistent with which one of the following diagnoses?
a. Pheochromocytoma
b. Benign cortical adenoma
c. Adrenal metastasis
d. Adrenal cyst
e. ACC
The CT imaging characteristics of a pheo- chromocytoma include increased unenhanced attenuation (>20 HU), size greater than 4 cm, increased vascularity, cystic and hemorrhagic changes, and delay in contrast washout (<50% over 10 minutes).2 Many of these characteristics are met by this patient’s mass, but pheochromocytoma tends to be well
circumscribed and does not result in overpro- duction of adrenocortical hormones. Although benign adrenal adenomas may produce excess cortisol, these tumors are typically small (<4 cm), round, well encapsulated, and homoge- neous with low unenhanced attenuation (<10 HU) and rapid contrast washout (>50% over 10 minutes).2 Lung, pancreatic, colorectal, and breast cancers have the poten- tial to metastasize to the adrenal glands, and these metastatic lesions are more commonly diagnosed than primary adrenal tumors. These masses are identical to ACC on imaging but have a tendency to be bilateral and eventually result in adrenal hypofunction rather than hyperfunction. Adrenal cysts do not have a solid component, and the characteristic appearance allows them to be easily differenti- ated from other lesions. Our patient’s adrenal mass and excess corticosteroid production are most consistent with a hyperfunctioning ACC: irregular shape, large size (>4 cm), unilateral, inhomogeneous density, calcifica- tion, locally invasive, high unenhanced attenu- ation (>20 HU), and delay in contrast washout (<50% over 10 minutes).2
Staging CT of the chest yielded no evidence of metastatic disease. The patient underwent an uncomplicated open adrenalec- tomy and exploratory laparotomy. Histopath- ologic studies confirmed poorly differentiated ACC with clear resection margins. Adjuvant mitotane chemotherapy was initiated with a temporary corticosteroid course for expected adrenocortical insufficiency secondary to hy- pothalamic suppression. Antihypertensive medications were discontinued postopera- tively. At outpatient follow-up 3 weeks later, the patient reported marked improvement in the diffuse swelling. He was taking no antihy- pertensive medications, and his BP was 118/72 mm Hg.
DISCUSSION
Adrenocortical carcinoma is a rare malignant tumor of the adrenal gland with an incidence of approximately 2 per million per year in the general population.3 Nonetheless, this diagnosis should be considered as part of the appropriate evaluation of secondary hyperten- sion and incidental adrenal masses. Of all patients undergoing advanced imaging of the abdomen, an estimated 4% to 6% will have
an adrenal incidentaloma.2 Between 2% and 5% of these masses will result in a diagnosis of ACC, with most being attributable to nonfunctioning cortical adenomas.2 The inci- dence of ACC appears to be increasing with the improved detection of incidental adrenal masses over the past decade. A slight female predominance (approximately 2:1) and a bimodal distribution in the age at diagnosis have been described, with peaks before the age of 5 years and again in the fourth to fifth decade of life.3 Most cases are sporadic, but several hereditary cancer syndromes including multiple endocrine neoplasia type 1, Beckwith-Wiedemann syndrome, and Li-Fraumeni syndrome are strongly associated with ACC.4
More than 60% of adults with ACC present with clinical symptoms of excess hormone production, with the remainder having nonfunctioning tumors producing compressive, metastatic, or constitutional symptoms.3 Cushing syndrome predominates as the most common presentation in patients with functioning masses (45%), followed by a combination effect of glucocorticoids and androgens (25%) and virilization alone (10%).3 Symptoms of glucocorticoid excess usually develop rapidly over 3 to 6 months and consist of weight gain, edema, weakness, or insomnia. The acuity may explain the occa- sional absence of classic features of chronic Cushing syndrome such as characteristic adi- pose tissue redistribution as well as skin and muscle atrophy.
History and physical examination should focus on excluding features of more common diagnoses including pituitary adenomas, pheo- chromocytoma, renovascular disease, and hyperaldosteronism. Even in patients with asymptomatic incidentalomas, determining secretory status is important with a laboratory evaluation for glucocorticoid excess, pheo- chromocytoma, hyperaldosteronism, and hyperandrogenism.5 Computed tomography with intravenous contrast medium remains the most important first-line imaging modality for differentiating larger heterogeneously enhancing ACCs from smaller lipid-rich benign adenomas.2 Histopathologic examina- tion is required to confirm the diagnosis; how- ever, needle aspiration biopsy is unable to differentiate benign from malignant
adrenocortical masses, and a surgical approach is recommended.
The TNM (tumor, node, metastasis) system is most widely used for staging, and CT of the chest, abdomen, and pelvis is gener- ally sufficient for initial evaluation. Only 6% of ACCs are diagnosed at a size of 5 cm or less (stage I), with 42% of patients presenting with a tumor greater than 5 cm but localized to the adrenal gland (stage II).º Local invasion into surrounding tissues, the inferior vena cava, renal veins, and lymph nodes (stage III) occurs in 16% of patients without distant metastases.º The most common sites of distant spread for ACC are the liver, lungs, and bone and are present in 36% of patients at presenta- tion (stage IV).3,6
Prompt and complete surgical excision is the only potentially curative intervention for localized ACC. Open unilateral adrenalectomy is considered the criterion standard approach because some studies-although inconsis- tently so-have documented earlier and more frequent recurrence with laparoscopy.’ 7 Functioning masses result in hypothalamic- pituitary-adrenal axis suppression and require perioperative glucocorticoid support. Following resection, adjuvant therapy may be provided in those with a high risk of recur- rence based on tumor stage, grade or prolifer- ation, and completeness of resection. Mitotane is a drug that has a cytotoxic effect preferen- tially on adrenocortical tissue while inhibiting steroidogenesis and has been reported to reduce the rate of recurrence of ACC in randomized trials.8 Posttreatment surveillance is recommended with CT or PET at regular 3- to 6-month intervals. The 5-year survival for localized disease is 82%, 61%, and 50% for stage I, II, and III disease, respectively.“
In those with metastatic, unresectable, or recurrent ACC, mitotane may be combined with systemic chemotherapy (such as etopo- side, doxorubicin, and cisplatin) to enhance
cytotoxic activity in adrenocortical cells and has an overall response rate of 49%.9 Nonethe- less, the prognosis for stage IV disease is poor, and 5-year survival is less than 15%.
In conclusion, severe or resistant hyper- tension in a previously normotensive patient should prompt an evaluation for secondary causes. Adrenocortical carcinoma, although rare, is an important cause of Cushing syndrome and adrenal masses with a potential for disastrous outcomes if missed or neglected.
Correspondence: Address to Christopher M. Wittich, MD, PharmD, Division of General Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (wittich. christopher@mayo.edu).
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CORRECT ANSWERS: 1. d. 2. b. 3. c. 4. a. 5. e