Case Report Urol Int 1992;49:222-223
Karin C. van Dalen Mels F. van Driel Han J.A. Mensink
Involvement of the Inferior Caval Vein in Adrenal Metastasis
Department of Urology, University Hospital Groningen, The Netherlands
Key Words
Abstract
Adrenal glands Metastasis Vena cava inferior Lung neoplasms
A patient was referred to our hospital for resection of a large renal cell carci noma with invasion of the inferior caval vein, diagnosed as such with CT, angiography and cavography. The history mentioned partial resection of the left lung for lung carcinoma 16 months before. At operation the tumor could not be removed, the patient died because of postoperative pulmonary compli cations. Autopsy and histopathological examination revealed a large meta static tumor of the previous lung carcinoma in the left adrenal gland. The clinical implications and some diagnostic methods are discussed.
Tumor thrombosis of the inferior caval vein is usually associated with primary renal cell cancer. To our knowl edge only one case of metastatic tumor in the adrenal gland extending into the inferior caval vein has been reported before [1], We present another case, illustrating the pitfalls of epidemiology.
Case Report A 57-year-old patient was referred to our department for evalua tion and treatment of a mass in the left flank. The patient had under gone resection of the upper lobe of the left lung for an undifferen tiated large cell carcinoma 16 months previously. At the time of tho racotomy there were no signs of local or distant métastases. He presented with complaints of lethargy, weight loss and severe pain in the left flank. On physical examination a large mass in the left upper abdomen could be palpated. CT scanning from the top of the lung down to the pubic bone demonstrated a large left-sided retro peritoneal mass with a diameter of 25 cm protruding into the inferior caval vein and the patient was suspected to have a renal cell cancer (fig. I ). No local recurrence or other signs of the previous lung carci noma could be detected. Cavography showed extension of the tumor up to the hepatic level and a nearly total occlusion of the left renal vein (fig. 2). Bone scanning and ultrasound examination of liver and spleen revealed no métastasés. With regard to the atypical form of the tumor, selective angiography was made, which showed down
Received: February 18. 1992 Accepted: March 17, 1992
wards displacement of the left renal artery. Typical tumor vasculari zation was not seen. At laparotomy, a tumor could be palpated in the left renal vein with invasion into its wall and likewise into the caval vein. The supe rior mesenteric artery appeared to be involved in the tumor process. The tumor mass was considered inoperable. Postoperatively, the patient developed severe pulmonary complications including infec tion associated with pulmonary embolism. Slow deterioration fol lowed and the patient succumbed 26 days after surgery. Autopsy revealed large plugs of tumor tissue partially obstructing the right pulmonary artery. The left kidney showed no abnormality, but it was caught in a tumor mass measuring 26 X 16 X 16 cm. The left adrenal gland could not be identified. The tumor ascending from the left suprarenal vein nearly occupied the total luminal space of the inferior caval vein up to the diaphragm. Comparison by immunohistochemical investigation of stored frozen material of the lung carcinoma and tumor tissue obtained at autopsy showed identical characteristics, strongly suggesting that the process ascending from the left adrenal gland was a metastasis of the previous lung carcinoma.
Discussion
A metastatic lesion in the adrenal gland involving the caval vein is extremely rare. Only one similar patient has been reported before, a 60-year-old patient who presented with a metastatic tumor to the adrenal gland and throm bosis of the caval vein 8 years after partial resection of an undifferentiated lung cancer [1]. Yet extension of tumor
Dr. K.C. van Dalen Department of Urology University Hospital Groningen PO Box 30.001 NL-9700 RB Groningen (The Netherlands)
© 1992 S. Karger AG. Basel 0042-1138/92/0494-0222 $2.75/0
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/8/2018 12:34:31 AM
Introduction
Fig. 1. CT scanning demonstrated a large retroperitoneal process on the left side with extension into the inferior caval vein.
Fig. 2. Cavography showed a nearly total occlusion of the left renal vein.
tissue into the inferior caval vein is a well-recognized and fairly common event in renal cell cancer occurring in 4 10% of the cases [2, 3], These data explain how an abdominal mass can erro neously be taken for primary renal cell cancer [4]. In our case the correct diagnosis could have been made earlier considering the following well-known and documented facts. The adrenal gland is regarded as the site of preference for hematogenous metastases of lung cancers. In 160 autopsies of lung cancer patients, 57 metastases were found to be located in the adrenals [5], Comparing CT scans made of patients with lung can cer within 90 days before death and at autopsy, a sensitiv ity was found of only 20-40% for detection of adrenal metastasis by CT scan [6]. Pagani [7] published a study of
172 patients presenting with non-small-cell lung carcino ma, of whom 20 had a metastatic lesion in the adrenal gland evident on CT scanning [7], This diagnosis was his tologically confirmed by a percutaneous needle biopsy in 95%. One patient turned out to have a benign adenoma. No complications of these biopsies were mentioned. Cytological confirmation has been advocated by Nosher et al. [8]. Fine-needle aspiration of lesions involv ing the kidney and the adrenal gland provided the correct diagnosis with an accuracy of 95 % without any complica tion. With the knowledge of the history of the patient and the referred literature, in our case fine-needle aspiration or percutaneous needle biopsy should have been consid ered and would have prevented an unnecessary surgical procedure and its complications.
References
2
3
Ritchey ML, Kinard R. Novicki DE: Adrenal tumors: Involvement of the inferior vena cava. J Urol 1987:138:1134. Patel NP, Lavengood RW: Renal cell carcino ma: Natural history' and results of treatment. J Urol 1978:119:722. Waters WB. Richie JP: Aggressive surgical ap proach to renal cell carcinoma: Review of 130 cases. J Urol 1979;122:306.
4
5
6
Bailey MJ, Williams JE. Riddle PR: Metastatic deposits from a previously treated carcinoma of the lung presenting as a renal cell carcinoma. BrJ Radiol 1986:59:333. Abrams HL. Spiro R. Goldstein N: Metastases in carcinoma. Analysis of 1,000 autopsied cases. Cancer 1950:1:74. Allard P, Yankashas BC, Fletcher RH. Parker LA, Halvorsen RA Jr: Sensitivity and specific ity of computed tomography for the detection of adrenal metastatic lesions among 91 autop sied lung cancer patients. Cancer 1990:66:457.
7
8
Pagani JJ: Non-small cell lung carcinoma adre nal metastases: Computed tomography and percutaneous needle biopsy in their diagnosis. Cancer 1984:53:1058. Nosher JL, Amorosa JK. Lciman S, Plafker J: Fine needle aspiration of the kidney and adre nal gland. J Urol 1982:128:895.
223
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/8/2018 12:34:31 AM
1
Karin C. van Dalen Mels F. van Driel Han J.A. Mensink
Involvement of the Inferior Caval Vein in Adrenal Metastasis
Department of Urology, University Hospital Groningen, The Netherlands
Key Words
Abstract
Adrenal glands Metastasis Vena cava inferior Lung neoplasms
A patient was referred to our hospital for resection of a large renal cell carci noma with invasion of the inferior caval vein, diagnosed as such with CT, angiography and cavography. The history mentioned partial resection of the left lung for lung carcinoma 16 months before. At operation the tumor could not be removed, the patient died because of postoperative pulmonary compli cations. Autopsy and histopathological examination revealed a large meta static tumor of the previous lung carcinoma in the left adrenal gland. The clinical implications and some diagnostic methods are discussed.
Tumor thrombosis of the inferior caval vein is usually associated with primary renal cell cancer. To our knowl edge only one case of metastatic tumor in the adrenal gland extending into the inferior caval vein has been reported before [1], We present another case, illustrating the pitfalls of epidemiology.
Case Report A 57-year-old patient was referred to our department for evalua tion and treatment of a mass in the left flank. The patient had under gone resection of the upper lobe of the left lung for an undifferen tiated large cell carcinoma 16 months previously. At the time of tho racotomy there were no signs of local or distant métastases. He presented with complaints of lethargy, weight loss and severe pain in the left flank. On physical examination a large mass in the left upper abdomen could be palpated. CT scanning from the top of the lung down to the pubic bone demonstrated a large left-sided retro peritoneal mass with a diameter of 25 cm protruding into the inferior caval vein and the patient was suspected to have a renal cell cancer (fig. I ). No local recurrence or other signs of the previous lung carci noma could be detected. Cavography showed extension of the tumor up to the hepatic level and a nearly total occlusion of the left renal vein (fig. 2). Bone scanning and ultrasound examination of liver and spleen revealed no métastasés. With regard to the atypical form of the tumor, selective angiography was made, which showed down
Received: February 18. 1992 Accepted: March 17, 1992
wards displacement of the left renal artery. Typical tumor vasculari zation was not seen. At laparotomy, a tumor could be palpated in the left renal vein with invasion into its wall and likewise into the caval vein. The supe rior mesenteric artery appeared to be involved in the tumor process. The tumor mass was considered inoperable. Postoperatively, the patient developed severe pulmonary complications including infec tion associated with pulmonary embolism. Slow deterioration fol lowed and the patient succumbed 26 days after surgery. Autopsy revealed large plugs of tumor tissue partially obstructing the right pulmonary artery. The left kidney showed no abnormality, but it was caught in a tumor mass measuring 26 X 16 X 16 cm. The left adrenal gland could not be identified. The tumor ascending from the left suprarenal vein nearly occupied the total luminal space of the inferior caval vein up to the diaphragm. Comparison by immunohistochemical investigation of stored frozen material of the lung carcinoma and tumor tissue obtained at autopsy showed identical characteristics, strongly suggesting that the process ascending from the left adrenal gland was a metastasis of the previous lung carcinoma.
Discussion
A metastatic lesion in the adrenal gland involving the caval vein is extremely rare. Only one similar patient has been reported before, a 60-year-old patient who presented with a metastatic tumor to the adrenal gland and throm bosis of the caval vein 8 years after partial resection of an undifferentiated lung cancer [1]. Yet extension of tumor
Dr. K.C. van Dalen Department of Urology University Hospital Groningen PO Box 30.001 NL-9700 RB Groningen (The Netherlands)
© 1992 S. Karger AG. Basel 0042-1138/92/0494-0222 $2.75/0
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/8/2018 12:34:31 AM
Introduction
Fig. 1. CT scanning demonstrated a large retroperitoneal process on the left side with extension into the inferior caval vein.
Fig. 2. Cavography showed a nearly total occlusion of the left renal vein.
tissue into the inferior caval vein is a well-recognized and fairly common event in renal cell cancer occurring in 4 10% of the cases [2, 3], These data explain how an abdominal mass can erro neously be taken for primary renal cell cancer [4]. In our case the correct diagnosis could have been made earlier considering the following well-known and documented facts. The adrenal gland is regarded as the site of preference for hematogenous metastases of lung cancers. In 160 autopsies of lung cancer patients, 57 metastases were found to be located in the adrenals [5], Comparing CT scans made of patients with lung can cer within 90 days before death and at autopsy, a sensitiv ity was found of only 20-40% for detection of adrenal metastasis by CT scan [6]. Pagani [7] published a study of
172 patients presenting with non-small-cell lung carcino ma, of whom 20 had a metastatic lesion in the adrenal gland evident on CT scanning [7], This diagnosis was his tologically confirmed by a percutaneous needle biopsy in 95%. One patient turned out to have a benign adenoma. No complications of these biopsies were mentioned. Cytological confirmation has been advocated by Nosher et al. [8]. Fine-needle aspiration of lesions involv ing the kidney and the adrenal gland provided the correct diagnosis with an accuracy of 95 % without any complica tion. With the knowledge of the history of the patient and the referred literature, in our case fine-needle aspiration or percutaneous needle biopsy should have been consid ered and would have prevented an unnecessary surgical procedure and its complications.
References
2
3
Ritchey ML, Kinard R. Novicki DE: Adrenal tumors: Involvement of the inferior vena cava. J Urol 1987:138:1134. Patel NP, Lavengood RW: Renal cell carcino ma: Natural history' and results of treatment. J Urol 1978:119:722. Waters WB. Richie JP: Aggressive surgical ap proach to renal cell carcinoma: Review of 130 cases. J Urol 1979;122:306.
4
5
6
Bailey MJ, Williams JE. Riddle PR: Metastatic deposits from a previously treated carcinoma of the lung presenting as a renal cell carcinoma. BrJ Radiol 1986:59:333. Abrams HL. Spiro R. Goldstein N: Metastases in carcinoma. Analysis of 1,000 autopsied cases. Cancer 1950:1:74. Allard P, Yankashas BC, Fletcher RH. Parker LA, Halvorsen RA Jr: Sensitivity and specific ity of computed tomography for the detection of adrenal metastatic lesions among 91 autop sied lung cancer patients. Cancer 1990:66:457.
7
8
Pagani JJ: Non-small cell lung carcinoma adre nal metastases: Computed tomography and percutaneous needle biopsy in their diagnosis. Cancer 1984:53:1058. Nosher JL, Amorosa JK. Lciman S, Plafker J: Fine needle aspiration of the kidney and adre nal gland. J Urol 1982:128:895.
223
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/8/2018 12:34:31 AM
1
