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 Table of Contents     
CASE REPORT
Year : 2012  |  Volume : 27  |  Issue : 3  |  Page : 181-182  

Unusual presentation of oesophageal carcinoma with adrenal metastasis


Department of Nuclear Medicine and PET, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication31-May-2013

Correspondence Address:
Bhagwant Rai Mittal
Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh-160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-3919.112725

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   Abstract 

Adrenal gland is a common site of metastasis in many cancers but it is very rare in oesophageal carcinoma. We report one such case found to have adrenal metastasis on follow-up PET/computed tomography scan.

Keywords: Adrenal metastasis, ca oesophagus, fluorine-18 fluoro-2-deoxyglucose, positron emission tomography/computed tomography


How to cite this article:
Kashyap R, Mittal BR, Bhattacharya A, Singh B. Unusual presentation of oesophageal carcinoma with adrenal metastasis. Indian J Nucl Med 2012;27:181-2

How to cite this URL:
Kashyap R, Mittal BR, Bhattacharya A, Singh B. Unusual presentation of oesophageal carcinoma with adrenal metastasis. Indian J Nucl Med [serial online] 2012 [cited 2019 Nov 14];27:181-2. Available from: http://www.ijnm.in/text.asp?2012/27/3/181/112725


   Introduction Top


Characterization of adrenal masses in patients with known extra adrenal malignancy is critical to stage the primary disease. Several reports have documented the effectiveness of fluorine-18 fluoro-2-deoxyglucose positron emission tomography (PET) to differentiate benign from malignant adrenal disease. Malignant adrenal mass in patients having oesophageal cancer is rare though few case reports have been reported.


   Case Report Top


A 55-year-old male was diagnosed to have poorly differentiated squamous cell carcinoma of oesophagus 1 year back. An initial staging computed tomography (CT) scan showed nodal involvement in the celiac, peri-oesophageal and along the gastro-hepatic ligament. A baseline fluorine-18 fluoro-2-deoxyglucose (F-18 FDG) positron emission tomography (PET/CT) scan demonstrated hypermetabolism in the gastro-oesophageal junction growth along with focal areas of hypermetabolism in the liver and lymph nodes. The patient subsequently received six cycles of cisplatin based chemotherapy.

A repeat endoscopy done after the completion of the chemotherapy showed a small 1.0 × 1.0 cm growth at 30 cm and few small satellite nodules of 0.5 × 0.5 cm size indicating submucosal spread. A repeat PET/CT scan did not show any definite evidence of hypermetabolism in the gastro-oesophageal junction [Figure 1]a, b. However, the left adrenal gland showed a focal area of increased FDG uptake [Figure 1]c. The patient was non-compliant to another cycle of chemotherapy. Another PET/CT [Figure 2] repeated at 3 months showed definite increase in the size of the adrenal lesion [Figure 2]c, d. No FDG avidity was noticed in the image at gastro-oesophageal (GE) junction level [Figure 2]e while the endoscopy revealed subcentimetric nodule in the mucosa. The GE junction growth now showed distinct hypermetabolism [Figure 2]f. Multiple liver metastasis [Figure 2]a, b and hypermetabolic foci in the brain were also identified.
Figure 1: Maximum intensity projection (MIP) image (a), of the first follow-up fluorine-18 fluoro-2-deoxyglucose (PET/CT) scan showing focal uptake in the right hilar lymph node and left adrenal gland. Fused PET/CT representative slices demonstrating the increased uptake in the right hilar lymph node (b), and left adrenal gland (c)

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Figure 2: The CT (a) and fused images, (b) of the liver from the second follow-up fluorine-18 FDG PET/CT scan shows multiple foci of FDG uptake in hypodense lesions on the liver. Left adrenal gland is enlarged (c) and shows intense FDG uptake (d) suggestive of progression of the metastasis. The sections at gastro-oesophageal (GE) junction level show no evident uptake in the initial study (e) when the endoscopy revealed sub-centimetric nodule in the mucosa with surrounding satellite nodules. A second scan after 3 months however clearly shows intense uptake, (f) at the GE junction growth

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   Discussion Top


This report demonstrates two note-worthy aspects (1) limitation of PET in resolving sub-centimetric mucosal lesions and (2) metastasis of the oesophageal carcinoma to the adrenal gland, which is a rare entity. The first follow-up PET/CT study failed to detect any abnormality in the gastro-oesophageal junction though the endoscopy showed nodules and residual lesion which were confirmed on biopsy. This underlines the limitation of PET regarding the resolution of sub-centimetric mucosal lesions.

The adrenal gland is a common site of metastasis from primary lung cancer. Other tumours like breast, thyroid, ovary, renal cell carcinoma and lymphomas along with melanomas might also demonstrate adrenal metastasis. However, adrenal metastasis from oesophageal carcinoma is not that common though few case reports are reported. [1],[2],[3],[4],[5] One study, revealed 3% incidence of adrenal metastasis from oesophageal carcinoma [6] while another reported an incidence of 12% from autopsy series. [7] Additional value of F-18 FDG PET/CT in differentiating benign from malignant adrenal lesions in cancer patients is also described. [3],[4] SUV max of ≥ 2.5 has been reported to be 88% sensitive, 95% specific and 91% accurate. [4] Cho, et al. reported a case presenting with adrenal metastasis 8 months after esophagectomy and adrenal metastasis was also successfully resected. [5] Our case report also highlights the value of PET/CT in characterizing the adrenal metastasis, a rare entity in patients having cancer oesophagus.

 
   References Top

1.Bagwan IN, Cook G, Mudan S, Wotherspoon A. Unusual presentation of metastatic adenocarcinoma. World J Surg Oncol 2007;5:116.  Back to cited text no. 1
    
2.Bhargava N, Bhargava SK. Adenocarcinoma oesophagus with solitary, unilateral calcified adrenal metastases. Indian J Radiol Imaging 2005;15:33-4.  Back to cited text no. 2
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3.Boland GW, Blake MA, Holalkere NS, Hahn PF. PET/CT for the characterization of adrenal masses in patients with cancer: Qualitative versus quantitative accuracy in 150 consecutive patients. AJR Am J Roentgenol 2009;192:956-62.  Back to cited text no. 3
    
4.Okada M, Shimono T, Komeya Y, Ando R, Katsube T, Kuwabara M, et al. Adrenal masses: The value of additional fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) in differentiating between benign and malignant lesions. Ann Nucl Med. 2009;23:349-54.  Back to cited text no. 4
    
5.Cho MM, Kobayashi K, Aoki T, Nishioka K, Yoshida K, Hatano N, et al. Surgical resection of solitary adrenal metastasis from esophageal carcinoma following esophagectomy. Dis Esophagus 2007;20:79-81.  Back to cited text no. 5
    
6.Hess KR, Varadhachary GR, Taylor SH, Wei W, Raber MN, Lenzi R, et al. Metastatic patterns in adenocarcinoma. Cancer 2006;106:1624-33.  Back to cited text no. 6
    
7.Lam KY, Lo CY. Metastatic tumours of the adrenal glands: A 30-year experience in a teaching hospital. Clin Endocrinol (Oxf) 2002;56:95-101.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2]



 

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