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Prior to the Mayo Clinic evaluation, the patient had an abdominal CT scan performed for resistant hypertension. The scan revealed prostate enlargement with seminal vesicle invasion and multiple areas of intraperitoneal metastases. Prostate biopsy showed two distinct diagnoses of small cell carcinoma and prostate adenocarcinoma. Further laboratory studies confirmed severe corticotropin (ACTH)-dependent hypercortisolism, which was determined to be due to ectopic ACTH production from prostate small cell carcinoma.

Given the unresectable nature of the prostatic small cell carcinoma and the severe clinical and biochemical presentation, the decision for bilateral adrenalectomy was made and performed seven days after the initial abnormal dexamethasone suppression result. Perioperatively, the patient was initiated on glucocorticoid and mineralocorticoid replacement therapy.

Anticoagulation was started given the increased thrombosis risk, and antibacterial prophylaxis was initiated. One week after surgery, the patient was discharged to a skilled nursing facility to continue rehabilitation with a plan to follow up with Medical Oncology for management of the underlying malignancy.