Unusual presentation of oesophageal carcinoma with adrenal metastasis

INTRODUCTION

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

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 1a, b]. However, the left adrenal gland showed a focal area of increased FDG uptake [Figure 1c]. 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 2c, d]. No FDG avidity was noticed in the image at gastro-oesophageal (GE) junction level [Figure 2e] while the endoscopy revealed subcentimetric nodule in the mucosa. The GE junction growth now showed distinct hypermetabolism [Figure 2f]. Multiple liver metastasis [Figure 2a, b] and hypermetabolic foci in the brain were also identified.

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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

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.[12345] 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.[34] 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.