Correct!
4. Consider bilateral adrenalectomy
Given the evidence of ectopic ACTH production with the inability to locate the source of ACTH production and clear evidence of Cushing syndrome, the only available approach to alleviate the patient’s hypercortisolism is by removing the target of ACTH-induced cortisol production- the adrenal glands.
The patient underwent laparoscopic bilateral adrenalectomy, with removal of large, hyperplastic adrenal glands, without complication. Over the subsequent 4 years, the patients Cushing syndrome improved, her shortness of breath resolved, her skin bruising regressed, her weight decreased, her hypertension resolved, and her diabetes was more readily controlled. Her overall cushingoid appearance resolved. Approximately 6 years following her adrenalectomy, the patient’s shortness of breath returned, she gained weight, and her diabetes again became difficult to control. A repeat chest CT (Figure 7) was performed.
Figure 7. Representative images from the axial enhanced chest CT obtained 6 years following initial presentation and subsequent bilateral adrenalectomy, following recurrence of symptoms suggesting Cushing syndrome.
Which of the following represents an appropriate interpretation for this examination? (Click on the correct answer to be directed to the tenth of twelve pages)