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Lung Cancer |

Spontaneous Adrenal Hemorrhage: A Rare Presentation of Lung Cancer

Faria Nasim, MD; Anas Hadeh, MD; Laurence Smolley, MD; Eduardo Oliveira, MD
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Cleveland Clinic Florida, Weston, FL


Chest. 2013;144(4_MeetingAbstracts):607A. doi:10.1378/chest.1703017
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Abstract

SESSION TITLE: Cancer Case Report Posters II

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Adrenal metastasis from lung cancer is common. Adrenal hemorrhage from lung cancer metastasis to the adrenal gland is extremely rare. We present a case of adenocarcinoma of lung that presented as massive bilateral retroperitoneal hemorrhage from adrenal gland metastasis.

CASE PRESENTATION: 72 year old female with fifty pack-year smoking history was admitted to the intensive care unit with abdominal pain and nausea. She had a distended abdomen with guarding, rebound and Grey Turners sign bilaterally. Her breath sounds were decreased on the right. She was evaluated by a computerized tomography (CT) scan of the chest, abdomen and pelvis with intravenous contrast. Bilateral heterogeneously enhancing adrenal masses measuring 5 cm with a 9 x 5 cm right retroperitoneal multiloculated hematoma were seen. Large right pleural effusion and a 2 cm right hilar lymph node with seen on the CT chest. Pleural fluid cytology was negative for malignancy. An endobronchial ultrasound (EBUS) bronchoscopy with biopsy of the hilar lymph node was diagnostic for adenocarcinoma. MRI confirmed the nature of bilateral peripherally enhancing adrenal masses consistent with hemorrhagic adrenal metastasis. Biochemical testing (serum cortisol, adrenocorticotropic hormone [ACTH], catecholamines, aldosterone, anddehydroepiandrosterone [DHEA]) did not suggest a hormonally active tumor excluding pheochromocytomas and adrenocortical cancers. Patient opted for palliative care.

DISCUSSION: Adrenal metastasis from lung cancer is usually asymptomatic. It is often found during cancer staging imaging. Adrenal hemorrhage is usually diagnosed on CT scan. Magnetic resonance imaging is most accurate for differentiating adrenal mass from hemorrhage. The adrenal gland is highly vascular and particularly susceptible to hemorrhage. Adrenal mass with hemorrhage cannot be biopsied. There are 139 reported cases of spontaneous hemorrhagic adrenal masses identified in literature. Lung cancer was found as a primary cancer in one of these cases. (1) To our knowledge, only five publications have previously described hemorrhagic adrenal metastases from lung cancer (2-3). The case is presented here because of its rarity.

CONCLUSIONS: Hemorrhagic adrenal metastasis from lung cancer is extremely rare although adrenal involvement is common in disseminated cancer. In patients presenting with acute flank or back pain and evidence of retroperitoneal hemorrhage with adrenal metastasis, lung cancer should be considered in the differential diagnosis.

Reference #1: Marti JL et al Spontaneous adrenal hemorrhage with associated masses: etiology and management in 6 cases and a review of 133 reported cases.World J Surg. 2012 Jan;36(1):75-82.

Reference #2: Hiroi N et al Retroperitoneal hemorrhage due to bilateral adrenal metastases from lung adenocarcinoma. J Endocrinol Invest. 2006 Jun;29(6):551-4.

Reference #3: Kinoshita A et al Massive adrenal hemorrhage secondary to metastasis of lung cancer. Intern Med. 1997 Nov;36(11):815-8.

DISCLOSURE: The following authors have nothing to disclose: Faria Nasim, Anas Hadeh, Laurence Smolley, Eduardo Oliveira

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