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© 2001 American Society for Clinical Oncology
Unusual Presentations of Thoracic TumorsCase 1. Acute Adrenal Insufficiency Due to Metastatic Lung CancerVeterans Affairs Medical Center and University of North Dakota School of Medicine and Health Sciences, Fargo, ND A 64-year-old, previously healthy man with a 40-pack-year history of smoking presented to the emergency room with complaints of sudden abdominal pain and diaphoresis. Past medical history was significant for dyslipidemia, for which he was being treated with atorvastatin. The patient had no complaints of cough, hemoptysis, chest pain, or dyspnea. Family history was noncontributory. Physical examination at presentation revealed an afebrile, markedly hypotensive (blood pressure, 80/50 mm Hg), and tachycardic (heart rate, 110 beats/min) individual with no other definite abdominal or systemic findings. Initial testing showed a normal hemogram, and the chemistry panel was significant for hyperkalemia (serum potassium, 6.1 mmol/L). The patient had normal urinalysis results and normal renal and hepatic function. Evaluation for possible myocardial injury (ECG and cardiac enzymes) was unrevealing. Chest x-ray showed a large left hilar mass (Fig 1). The patient was admitted to the intensive care unit with a diagnosis of shock and started on intravenous crystalloids, dopamine, and norepinephrine. It was noted at that time that he required large doses of both vasopressors to maintain a mean arterial pressure above 60 mm Hg. An emergent echocardiogram was negative for pericardial effusion or systolic dysfunction. A computed tomography (CT) scan of the chest showed a large 6 x 4-cm left hilar mass (Fig 2, arrows) suggestive of lung cancer. The mass extended into the mediastinal anteroposterior window and abutted the pulmonary artery. CT scan of the liver and adrenal glands revealed large, hypodense adrenal glands (Fig 3, A) suggestive of metastases with bilateral necrosis. The liver and spleen (Fig 3, L and S, respectively) were normal. At this time, the serum cortisol level was 3.0 µg/dL, and the calculated transtubular potassium gradient was 1.6, both of which—in conjunction with the clinical picture—led to a diagnosis of acute adrenal insufficiency. The patient responded clinically to intravenous hydrocortisone and volume resuscitation. Bronchoscopic biopsy of the left lung mass was significant for sheets of small, oval-shaped malignant cells (Fig 4, arrows) consistent with small-cell lung carcinoma. Combination chemotherapy with cisplatin and etoposide was initiated. However, 10 days later he succumbed to septic shock complicating neutropenia.
Solitary adrenal metastasis from lung cancer with no other site of involvement is relatively rare, although adrenal involvement is common in patients with widely disseminated malignancy.1 Few publications have described adrenal metastasis (from lung cancer) leading to an adrenal-deficient state.1-5 Most of these reports were secondary to adrenal hemorrhage. The signs and symptoms of a severe adrenal insufficiency include abdominal or back pain, palpable mass, shock, high fever, hypotension that is resistant to vasopressors, anemia, hyperkalemia, hyponatremia, and sudden death occurring a few hours to several days after the insult.6 Whereas hemorrhagic adrenal tumor is identified on CT scans as a round or oval, large, suprarenal mass with a focal area of hyperdensity, necrosis secondary to tumor often appears hypodense.7,8 Adrenal metastases from lung cancer are usually asymptomatic, and signs and symptoms at presentation are usually nonspecific.2 However, in patients known to have lung cancer who develop acute abdominal or back pain associated with a palpable abdominal mass, hypotension unresponsive to vasopressor therapy, and hyperkalemia, adrenal insufficiency should be considered.1,5 Masses apparent on CT and magnetic resonance imaging scans in conjunction with timely serum cortisol levels and inappropriately low transtubular potassium gradients are useful for confirming the diagnosis. Acute adrenal insufficiency (Addison’s disease) occurring as a result of adrenal metastasis is extremely rare. To our knowledge, fewer than 10 patients with adrenal hemorrhage secondary to metastases from lung cancer have been reported.1-5 The majority had acute onset of severe abdominal pain, and five presented with anemia secondary to hemorrhage; none presented with Addison’s disease. The prognosis was poor in these patients. Our case is the first reported case of small-cell lung carcinoma presenting as Addison’s disease. REFERENCES 1. Kinoshita A, Nakano M, Suyama N, et al: Massive adrenal hemorrhage secondary to metastasis of lung cancer. Intern Med 36: 815-818, 1997[Medline] 2. Rowinsky EK, Jones RJ, Abeloff MD: Massive adrenal hemorrhage secondary to metastatic lung carcinoma. Med Pediatr Oncol 14: 234-237, 1986[Medline] 3. Shah HR, Love L, Williamson MR, et al: Hemorrhagic adrenal metastases: CT findings. J Comput Assist Tomogr 13: 77-81, 1989[Medline] 4. Outwater E, Bankoff MS: Clinically significant adrenal hemorrhage secondary to metastases: Computed tomography observations. Clin Imaging 13: 195-200, 1989[Medline] 5. Yamada AH, Sherrod AE, Boswell W, et al: Massive retroperitoneal hemorrhage from adrenal metastasis. Urology 40: 59-62, 1992[Medline] 6. Boneri A, Oroll SR: Adrenal hemorrhage and necrosis in the adult, a clinicopathological study of 23 cases. Acta Med Scand 175: 409-413, 1964[Medline]
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Wolverson MK, Kannegiesner H: CT of bilateral adrenal hemorrhage with acute adrenal insufficiency in the adult. Am J Roentgenol 142: 311-314, 1984 8. Liu L, Haskin Me, Rose LI, et al: Diagnosis of bilateral adrenocortical hemorrhage by computed tomography. Ann Intern Med 97: 720-721, 1982 This article has been cited by other articles:
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Copyright © 2001 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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