Pulmonary metastases to the adrenal gland are common. Malignant endocrine tumors infrequently metastasize to the lungs and treatment options are limited. Primary adrenal tumors with metastases to the lung are even more uncommon. We present a rare case of endobronchial metastasis from a primary adrenocortical cancer.
A 61 year-old white female with known adrenocortical carcinoma diagnosed in August 1998 presented to our pulmonary clinic for abnormal radiographs. The patient initially presented in August 1998 with signs and symptoms of virilization. She was subsequently diagnosed with stage IV adrenocortical carcinoma. She underwent a surgical resection of the right adrenal gland and right kidney that same year. She received no further therapy and has been followed with DHEA-S levels and serial thoraco-abdominal CT scans every 3-5 months. Serial thoracic CT scans were normal until January 2005 (Figure 1). The patient was asymptomatic. Physical examination was normal and did not reveal lymphadenopathy. Patient has a 20 pack year history of smoking which stopped 6 years ago. Pertinent laboratory include a pre-operative DHEA-S level of 797 micrograms/deciliter (normal: 60-255μg/dl), post-operative levels of 12μg/dl (8/98), 57μg/dl (6/01) and 151μg/dl (1/05) respectively. Patient underwent a fiberoptic bronchoscopy which revealed a smooth, well rounded endobronchial lesion in the right lower lobe (Figure 2). This area was washed, brushed and biopsied. The biopsy results revealed metastatic adrenocortical carcinoma.
Adrenal tumors are usually suspected when the patient presents with signs and symptoms of excessive cortisol secretion. Often, tumors are found incidentally on abdominal CT scans. When symptoms are present they include oligomenorrhea, hirsutism, acne, purple striae, osteoporosis, and muscle wasting. Though no clear epidemiological data exists, adrenal tumors with metastases to the lung are uncommon. Furthermore, endobronchial metastases from nonpulmonary tumors are uncommon.1 CT scans are effective in localizing metastatic disease to the lung. The diagnosis can be confirmed by serum assays for excess hormone secretion.Survival in patients with adrenocortical confined to the adrenal gland at resection is 30% at 5 years, but the median survival of patients with metastatic disease is six months.2 Mitomycin is used when metastatic disease is present with mixed results.
Thoracic manifestations of adrenocortical carcinoma are infrequent and not well documented. We cared for a patient with metastatic disease at diagnosis in 1998 that initially had a favorable response to surgery alone. Over six years later the patient presented with endobronchial metastasis from an intra-abdominal adrenocortical carcinoma. There were no abnormalities of the serial hormone assays. Though there has been a case report of endobronchial pheochromocytoma, A MEDLINE search in the English language revealed no cases of endobronchial involvement from a primary adrenocortical carcinoma.3 The patient is currently undergoing chemotherapy.
Himanshu Desai, None.