Ann Thorac Surg 2002;74:924-926
© 2002 The Society of Thoracic Surgeons
Case report
Synchronous presentation of primary non-small cell lung carcinoma and pheochromocytoma
Edward P. Chen, MDa,
Collin J. Weber, MDb,
C. Daniel Smith, MDb,
Joseph I. Miller, Jr, MD*a
a Division of Cardiothoracic Surgery, Emory University Affiliated Hospitals, Atlanta, Georgia, USA
b Division of General Surgery, Emory University Affiliated Hospitals, Atlanta, Georgia, USA
Accepted for publication April 1, 2002.
* Address reprint requests to Dr Miller, Division of Cardiothoracic Surgery, Emory University School of Medicine, 1365 Clifton Road, NE, Atlanta, GA 30322, USA
e-mail: judy_lawson{at}surgery.eushc.org
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Abstract
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A 54-year-old man was diagnosed with a 3.2-cm primary right lower lobe non-small cell lung cancer and a synchronously present 2.5-cm right adrenal gland mass. Workup of the adrenal lesion revealed a pheochromocytoma. The patient underwent combined mediastinoscopy, laparoscopic right adrenalectomy, and right thoracotomy with right lower lobectomy. This case illustrates the importance of establishing a firm diagnosis for all synchronously present adrenal lesions that are discovered in the setting of primary lung carcinoma.
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Introduction
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Unilateral adrenal gland enlargement is present in approximately 4% to 8% of patients with otherwise operable non-small cell lung carcinoma [1]. Approximately 26% to 40% of these lesions will ultimately prove to be cancerous [1]. However, the inverse is also important; that is, in the setting of an operable non-small cell lung cancer and unilateral adrenal mass, the lesion should not be considered malignant without further evaluation, as 60% to 74% will ultimately prove to be benign [1, 2]. Percutaneous needle aspiration biopsy has traditionally been recommended in such patients to ensure appropriate therapy [1]; however, new imaging modalities are emerging that may potentially reduce the need for needle biopsy [3]. The case of a patient with a synchronously present lung cancer and pheochromocytoma is reported.
A 54-year-old man presented with a 2-month history of progressive cough associated with one episode of hemoptysis. A computed tomography (CT) scan was obtained, which revealed a 2.5-cm mass in the superior segment of the right lower lobe as well as two right hilar lymph nodes measuring 1.5-cm in greatest dimension. Fine-needle aspiration of the lung lesion revealed adenocarcinoma. In addition, the patient was found to have a 2.5-cm right adrenal gland mass. Fine-needle aspiration of the right adrenal gland surprisingly revealed neuroendocrine cells consistent with pheochromocytoma. The patient had no history of hypertension, tachypalpitations, headaches, flushing, or any family history of hypertension or other endocrine disorders. He had no problems with hypertensive crisis at the time of the biopsy. Urine metanephrine levels were elevated. Further workup included magnetic resonance imaging (MRI) of the abdomen, which revealed bright activity in the right adrenal lesion on T2 weighted images that enhanced after intravenous contrast administration, consistent with pheochromocytoma, without any evidence of extra-adrenal activity. A positron emission tomography scan revealed increased metabolic activity in both his lung and adrenal lesions. The patient also had an MRI of the brain, which showed no evidence of metastases, and a fiberoptic bronchoscopy, which revealed no endobronchial lesions. He was premedicated with 
- and ß-blocking agents for 10 days before surgery and then underwent combined mediastinoscopy, laparoscopic right adrenalectomy, and right lower lobectomy by means of a right posterolateral thoracotomy. Given the patient’s normal preoperative cardiac function, he was monitored intraoperatively with a central venous catheter. Because positron emission tomography scanning is not completely accurate in detecting mediastinal lymph node involvement in the setting of lung carcinoma, mediastinoscopy was performed first and revealed no adenopathy. Laparoscopic right adrenalectomy was performed second. A 2-cm tumor on the medial edge of the right adrenal gland, which did not invade the surrounding tissues and would thus be considered benign, was identified and removed with the entire gland. A single pulmonary lesion was identified in the superior segment of the right lower lobe as well as one enlarged hilar lymph node. Final pathology results showed the adrenal mass to be a neoplasm consistent with pheochromocytoma. The right lower lobe lesion was found to be a 3.2-cm moderately differentiated adenocarcinoma with two hilar lymph nodes positive for metastatic disease, consistent with stage IIB disease. All surgical margins were negative. The patient’s recovery from operation was uncomplicated. Postoperatively, the he was subsequently treated with six cycles of carboplatin and taxol.
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Comment
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The adrenal gland is a frequent site of metastases from non-small cell lung cancer, and in autopsy series has been reported to occur in 18% to 42% of patients [1]. In patients with otherwise operable lung cancer, estimates of the frequency of isolated adrenal metastases range from 5% to 10% at initial presentation [4]. Other types of adrenal masses, however, including adrenocortical adenomas or other benign lesions, are also present in approximately 2% to 9% of these patients [5]. Because the presence of adrenal metastases can have significant therapeutic implications, distinguishing between these lesions and benign adrenal masses is an essential part of the diagnostic evaluation in the setting of lung carcinoma [2, 3].
In this report, a 54-year-old man was initially referred to the oncology service for medical treatment of a biopsy-proven adenocarcinoma of the right lower lobe and a synchronously present right adrenal mass with presumptive metastatic disease. Further workup of the adrenal lesion, with initial fine-needle aspiration and MRI, proved to be consistent with pheochromocytoma. Had this additional evaluation not been pursued, this patient might have received inappropriate therapy. He subsequently underwent surgical resection of both primary tumors and has been treated postoperatively with radiation and chemotherapy.
The diagnosis of an isolated adrenal lesion in the setting of non-small cell lung carcinoma has traditionally been made by needle biopsy [6], and its significance for directing appropriate therapy in this report cannot be overemphasized. Standard CT-guided needle biopsy is an accurate, albeit invasive, method for establishing a tissue diagnosis in adrenal masses [2, 3], and remains a definitive test [6]. Recently, the use of MRI has emerged as a potentially less invasive alternative to needle biopsy, however, the ultimate role of this imaging modality remains somewhat unclear.
In a prospective study designed to evaluate the accuracy of MRI in distinguishing benign from malignant adrenal masses in 27 patients with otherwise operable non-small cell lung cancer, the use of conventional spin-echo MRI did not consistently predict whether a synchronously present adrenal lesion was benign or malignant [1]. Burt and associates [1] found that although the sensitivity of spin-echo MRI in predicting a metastatic lesion was 100% and the false-negative rate 0%, the specificity rate was only 24% and the false-positive rate 67%. These data preclude the use of spin-echo MRI as a routine method for determining malignancy in adrenal lesions, and suggest that this type of MRI technology cannot replace fine-needle biopsy [1].
However, in a more recent study by Schwartz and colleagues [3] involving 42 patients with lung carcinoma and synchronously present adrenal masses, an alternative MRI imaging technique, known as chemical shift MRI, was found to be 96% sensitive and 100% specific for diagnosing adrenal adenomas. Initial use of chemical shift MRI for evaluating adrenal masses in the setting lung cancer obviated the need for needle biopsy in 55% of cases and was more cost-effective when compared with needle biopsy for diagnosing all adrenal masses [3]. Such data suggests that every patient with lung carcinoma may not initially require CT-guided needle biopsy for analysis of a synchronously present adrenal lesion [3].
In summary, successful treatment of a 54-year-old man with a rare synchronous presentation of a non-small cell lung carcinoma and right adrenal pheochromocytoma is reported. This interesting case demonstrates the importance of establishing a firm diagnosis for all synchronously present adrenal lesions that are discovered in the setting of primary lung carcinoma. Ultimately, arrival at an appropriate diagnostic algorithm is clearly essential; however, this will require further investigation and analysis of currently available modalities.
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References
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- Schwartz L.H., Ginsberg M.S., Burt M.E., Brown K.T., Getrajdman G.I., Panicek D.M. MRI as an alternative to CT-guided biopsy of adrenal masses in patients with lung cancer. Ann Thorac Surg 1998;65:193-197.[Abstract/Free Full Text]
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- McNicholas M.M., Lee M.J., Mayo-Smith W.W., Hahn P.F., Boland G.W., Mueller P.R. An imaging algorithm for the differential diagnosis of adrenal adenomas and metastases. Am J Roentgenol 1995;165:1453-1459.[Abstract/Free Full Text]
- Beitler A.L., Urschel J.D., Velagapudi S.R.C., Takita H. Surgical management of adrenal metastasis from lung cancer. J Surg Oncol 1998;69:54-57.[Medline]
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Abstract
Introduction
