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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.


Presentation

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]
Severe Pain
  • Huge adrenal gland metastases displaced the pancreas and caused severe pain with the increase in serum amylase level.[ncbi.nlm.nih.gov]
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]
Epigastric Pain
  • Available from: A 54-year-old man with a 2-month history of dysphagia, epigastric pain, and 15 kg weight loss was referred for upper endoscopy, which revealed a vegetative lesion in the distal part of the esophagus [Figure 1].[eusjournal.com]
Hypotension
  • 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]
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]

Workup

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].

Pericardial Effusion
  • Controlling malignant pericardial effusion by intrapericardial carboplatin administration in patients with primary non-small-cell lung cancer. Br J Cancer. 2000; 83(7): 858-62.[haigan.gr.jp]
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]
Human Papillomavirus
  • Available at ICO Information Centre on HPV and Cancer India Human Papillomavirus and Related Cancers, Fact Sheet; 2017. Available at Burghardt E, Baltzer J, Tulusan AH, Haas J.[ijrcog.org]

Treatment

  • RESULTS: Four patients with adrenal metastasis, right in 2 and left in 2, underwent surgical treatment. Three of the patients developed tumor thrombi in the renal vein or inferior vena cava.[ncbi.nlm.nih.gov]
  • Treatment with curative intent is very rare, but palliative treatment may sometimes be considered when symptoms such as flank pain are observed. Three cases of adrenal gland metastasis were reported.[ncbi.nlm.nih.gov]
  • CONCLUSIONS: The treatment of metastatic adrenal gland with RF broadens the range of treatment of metastatic RCC. The efficacy of this therapeutic modality must be confirmed by larger series with the longest follow-up.[ncbi.nlm.nih.gov]
  • We report a case of follicular thyroid carcinoma discovered after surgical treatment of a toxic multinodular goiter, in which solitary adrenal gland metastasis was detected five years later.[ncbi.nlm.nih.gov]
  • Two-stage surgery is a safe treatment option for giant HCC with synchronous bilateral adrenal gland metastasis.[ncbi.nlm.nih.gov]

Prognosis

  • My prognosis is not good but that is due to the grade of my cancer (four) and the number and distance of mets.[community.macmillan.org.uk]
  • Distant metastasis is very rare in carcinoma of buccal mucosa and has a very dismal prognosis. Distant spread is either related to uncontrolled local disease or inadequate local treatment. Lungs and bones are common site for metastases.[sciencedomain.org]
  • Coping The prognosis with metastatic lung cancer is not what we would wish.[verywell.com]
  • The prognosis is poorer with higher numbers of involved nodes and with metastases to internal organs and distant sites.[dermnetnz.org]
  • The discovery of an oral metastasis has a poor prognosis and its management is not yet standardized.[jomos.org]

Etiology

  • […] carcinoma include metastatic renal cell carcinoma, lung large cell neuroendocrine carcinoma, hepatocellular carcinoma and sometimes melanoma Immunohistochemical markers could be helpful to separate metastatic tumors from primary adrenal cortical tumors Etiology[pathologyoutlines.com]
  • Feminization ( estrogen excess) is most readily noted in men, and includes breast enlargement , decreased libido and impotence . [1] [2] [7] Pathophysiology [ edit ] The main etiologic factor of adrenocortical cancer is unknown, although families with[en.wikipedia.org]

Epidemiology

  • The principal aim of Oncology Letters is to provide the prompt publication of original studies of high quality that pertain to clinical oncology, chemotherapy, oncogenes, carcinogenesis, metastasis, epidemiology and viral oncology in the form of original[ingentaconnect.com]
  • Renal Cell Carcinoma Epidemiology Renal Cell Carcinoma Symptoms Renal Cell Carcinoma Diagnosis Renal Cell Carcinoma Risk Factors[news-medical.net]
Sex distribution
Age distribution

Pathophysiology

  • Feminization ( estrogen excess) is most readily noted in men, and includes breast enlargement , decreased libido and impotence . [1] [2] [7] Pathophysiology [ edit ] The main etiologic factor of adrenocortical cancer is unknown, although families with[en.wikipedia.org]
  • The pathophysiological mechanisms of metastatic dissemination in the oral cavity are not fully understood. In the literature, it appears that dental avulsions are factors favoring metastatic dissemination [ 9 ].[jomos.org]

Prevention

  • Preventative Services Task Force. Guidelines for the treatment of recurrent and metastatic cervical cancer. Oncologist. 2002;7:342. Gadducci A, Tana R, Cosio S, Cionini L. Treatment options in recurrent cervical cancer (Review).[ijrcog.org]
  • So, preventing metastatic lung cancer means preventing or promptly treating primary lung cancer. Certain risk factors that predispose people to lung cancer, such as genetics, are unavoidable. However, other factors can be avoided.[medicalnewstoday.com]
  • Removing the affected adrenal gland can help prevent symptoms from the enlarging adrenal mass and may reduce the risk of further spread of the cancer.[endocrinediseases.org]
  • How can I prevent adrenal cancer? There are no preventable risk factors associated with adrenal cancer so there is no way to prevent adrenal cancer.[oncolink.org]
  • In the general population, it has been estimated that 2-3% of incidentally found adrenal masses are malignant. [2] Preferred examination Noninvasive characterization is important, because it prevents unnecessary biopsy.[emedicine.medscape.com]

References

Article

  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.

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Last updated: 2019-06-28 10:15