Symptoma

Adrenal Gland Metastasis

Adrenal gland metastasis is secondary to disseminated or invaded tumor from another primary malignant lesion. On account of the excellent vasculature in the adrenal gland, it is a common site of metastases rendering incidental findings of lesions in this organ very frequent.

Adrenal gland metastases are found in every other suspected mass lesion of the adrenal gland, most of them are incidental during a radiologic examination of the abdominal cavity. In such cases, the adrenal masses are called incidentalomas [1]. Most common primary sites of adrenal gland metastasis are as follows: lung, breast, kidney, gastrointestinal tract, melanoma, and thyroid gland malignant lesions [1] [2]. A thorough evaluation of these sites is significant in identifying the cause of malignancy. Metastases occur bilaterally in a typical case but can also be unilateral with the mass being smaller in size [3].

Patient's symptoms are due to a mass lesion in the abdominal cavity i.e. chronic pain that is dull and aching in character. The pain usually does not radiate to other anatomical structures and is not provoked or alleviated by any factors.

On examination physicians encounter sensitive, palpable masses in the abdominal cavity. Inspection of other organs may be specific to primary lesions. Nonspecific findings are seen if these lesions remain asymptomatic [4]. Furthermore, patients can exhibit signs of adrenal insufficiency, but such cases are rarely documented. Adrenal insufficiency manifests as hyperpigmentation of the skin (due to high adrenocorticotropic hormone (ACTH) levels), a decrease in blood pressure which can cause serious complications i.e. shock, electrolyte disturbances and reduced blood glucose levels [5].

  • Euthyroid

    Follicular thyroid carcinoma typically manifests under euthyroid conditions, and diagnostic scintigraphy usually identifies a cold nodule. [ncbi.nlm.nih.gov]

    Abstract Solitary adrenal gland metastasis of a follicular thyroid carcinoma presenting with hyperthyroidism Follicular thyroid carcinoma typically manifests under euthyroid conditions, and diagnostic scintigraphy usually identifies a cold nodule. [em-consulte.com]

  • Constitutional Symptom

    Additionally, urinary, respiratory, cardiovascular or constitutional symptoms were negative. [spandidos-publications.com]

  • Chest Discomfort

    discomfort ECG, echocardiography, CT, coronary angiogram ESCC Supportive care N/A ST-segment elevation in leads V2-V4 A mass 66mm4 60 mm, in ventricular septum 4 Tachycardia, hypotension Echocardiography ESCC Supportive care 1 day Wide QRS complexes [omicsonline.org]

  • Left Flank Pain

    Case 1 developed a sole left adrenal gland metastasis with left flank pain 14 months after surgery for large cell carcinoma of the lung. Curative radiotherapy after intra-arterial chemotherapy was given. [ncbi.nlm.nih.gov]

  • Hypotension

    […] radiotherapy 11 month N/A A mass 17 mm in diameter in ventricular septum 3 Chest discomfort ECG, echocardiography, CT, coronary angiogram ESCC Supportive care N/A ST-segment elevation in leads V2-V4 A mass 66mm4 60 mm, in ventricular septum 4 Tachycardia, hypotension [omicsonline.org]

    Adrenal insufficiency ( Addison's disease ): Symptoms of Addison's disease may include weakness, low blood pressure (hypotension), low blood sugar ( hypoglycemia ), a low sodium level in the blood (hyponatremia), and a high potassium level ( hyperkalemia [verywell.com]

    Hemorrhage Extensive adrenal hemorrhage may occur at any age and under various circumstances such as severe stress as in surgery, sepsis, burns, hypotension, trauma, hemorrhagic diathesis and underlying conditions such as adenoma, cyst and tumour. [radiologyassistant.nl]

    Clinical manifestations of adrenal insufficiency include weakness, fatigue, anorexia, nausea, vomiting, constipation, hyperpigmentation, hypotension, vitiligo, electrolyte disturbances (hyponatremia, hyperkalemia, hypercalcemia), azotemia, anemia, and [frontiersin.org]

  • Left Ventricular Dysfunction

    These findings led to the diagnosis of Takotsubo cardiomyopathy left ventricular dysfunction syndrome. This is the first case of Takotsubo cardiomyopathy occurring as a complication during percutaneous ablation of an adrenal gland tumor. [ncbi.nlm.nih.gov]

Adrenal gland metastasis can be identified with magnetic resonance imaging (MRI). The tumors are actively enhanced with contrast, appearing hypointense during T1-weighted imaging and hyperintense in T2 weighted imaging. Likewise, delayed washout is a characteristic of malignant lesions [3].

Fine needle aspiration (FNA) of the possible metastasis can be effective in identifying the primary cause of malignancy. FNA also makes it possible to differentiate between different types of primary adrenal tumors, if adrenal carcinoma is suspected. Although, use of this method is not preferred due to its low accuracy [3].

Ultrasonography of the abdominal cavity is highly sensitive in diagnosing the lesion in neonates and very young children. Adult adrenal glands are hard to identify because of the close visual similarity to fatty tissues which is abundant in the retroperitoneum. Hence, ultrasound results are highly dependent on the experience of a physician and technical aspects of the ultrasonography machine [6]. If lesions are found, a further referral to CT, MRI or PET scan is essential to confirm the diagnosis.

Computer tomography (CT) scans provide the same accuracy as MRI imaging. A contrast enhancement is also used with this method. Nevertheless, radiologic imaging has to be interpreted with caution, because washout nature in benign tumors can resemble hypervascular hepatocellular carcinoma or renal cell carcinoma [7].

For greater accuracy in differentiating benign and malignant adrenal lesions, a positron emission tomography (PET) scan is advisable. Its sensitivity score is as high as 97% and specificity is 91% [8]. Fludeoxyglucose (FDG) is a standard radiotracer used with PET method when handling cancer patients. Adrenal metastases are associated with a high uptake much of this tracer, appearing as enhancing lesions [9]. Physical characteristics include size (metastases typically exceed 4-6 cm in diameter), uneven borders, signs of necrosis and invasion into contiguous anatomical structures. Also, a metastatic lesion can be suspected if the patient has a known primary tumor [10].

  • Hot Thyroid Nodule

    Management of the hot thyroid nodule. American Journal of Surgery 1995 ; 170 : 481-3. [5] Dinneen SF, Valimaki MJ, Bergstralh EJ, Goellner JR, Gorman CA, Hay ID. [em-consulte.com]

  • Wide QRS Complex

    QRS complexes A mass in LA and LV 5 Tachycardia, cold sweating ECG, echocardiography ESCC Surgical resection 1 month Incomplete right Bundle branch block Large amount of pericardial effusion and a mass 4 2 cm in RV 6 Atypical chest pain CT of chest ESCC [omicsonline.org]

  • ST Elevation

    ECG may mimic acute myocardial infarction with ST elevation. Clinicians may raise concerns regarding cardiac metastasis in patients with a history of cancer who present with cardiac symptoms and ECG changes. [omicsonline.org]

  • T Wave Abnormality

    An Electrocardiogram showed sinus tachycardia with frequent ventricular premature complexes, right bundle branch block with marked T-wave abnormality. [omicsonline.org]

  1. Sancho JJ, Triponez F, Montet X, et al. Surgical management of adrenal metastases. Langenbecks Arch Surg. 2012;397:179–194.
  2. Lau J, Balk E, Rothberg M, Ioannidid JP, DeVine D, Chew P, et al. Management of clinically inapparent adrenal mass. Evid Rep Technol Assess (Summ). 2002;56:1–5.
  3. Jain SM. Adrenal incidentaloma: A puzzle for clinician. Indian J Endocrinol Metab. 2013;17(1):S59-S63.
  4. Porwal R, Singh A, Jain P. Retroperitoneal Accessory Spleen Presented As Metastatic Suprarenal Tumour- A Diagnostic Dilemma. J Clin Diagn Res. 2015;9(6): PD07-PD08.
  5. Imaoka Y, Kuranishi F, Ogawa Y, Okuda H, Nakahara M. Adrenal failure due to bilateral adrenal metastasis of rectal cancer: A case report. Int J Surg Case Rep. 2017;31:1–4.
  6. Słapa RZ, Jakubowski WS, Dobruch-Sobczak K, Kasperlik-Załuska AA. Standards of ultrasound imaging of the adrenal glands. J Ultrason. 2015;15(63):377-387.
  7. Zeiger MA, Siegelman SS, Hamrahian AH. Medical and surgical evaluation and treatment of adrenal incidentalomas. J Clin Endocrinol Metab. 2011;96:2004–2015.
  8. Boland GW. Adrenal imaging. Abdom Imaging. 2011;36:472–482.
  9. Choi YA, Kim CK, Park BK, et al. Evaluation of adrenal metastases from renal cell carcinoma and hepatocellular carcinoma: use of delayed contrast-enhanced CT. Radiology. 2013;266:514–520.
  10. Sancho JJ, Triponez F, Montet X, et al. Surgical management of adrenal metastases. Langenbecks Arch Surg. 2012;397:179–194.