A Case of Synchronous Presentation of Primary Non-Small Cell Lung Carcinoma and Pheochromocytoma
A 59-year-old woman was referred to us from the cardiology division with a radiographic abnormality on her chest X-ray. She denied any history of respiratory symptoms, including coughing, phlegm, dyspnea, chest pain, and hemoptysis. She is a current smoker who has been smoking half a pack of cigarettes per day for more than 20 years. She was diagnosed with hypertension 5 years prior and is currently on antihypertensive medications. She was otherwise healthy.\nPhysical examination did not reveal any specific findings in respiratory or non respiratory areas. Routine laboratory studies and blood tests were normal. Chest X-rays revealed a solitary pulmonary nodule with ground-glass opacity in the right upper lobe (), with an interval increase in its size compared to her 3-year-old film. A subsequent chest computed tomography (CT) scan revealed a 2.5-cm spiculated nodule with an irregular margin in the upper lobe of the lung (). The lesion was uncalcified with non-enhancing features, and no associated evidence of mediastinal lymphadenopathy. The right adrenal gland showed a 3.5-cm round mass, which measured 43 Hounsfield units (HU) on unenhanced and 125 HU on enhanced images (data not shown).\nFine-needle aspiration biopsy of the lung nodule revealed non-small cell lung carcinoma. For staging determination, 18F-fluorodeoxyglucose (18F-FDG) PET-CT was performed, which displayed a 2.3-cm intense hypermetabolic lesion in the right upper lobe with no metabolic evidence of lymph node metastases. In addition, focal increased metabolic activity was revealed in the right adrenal gland (). Her blood pressure was normal (110/70 mm Hg) on admission. She had a 5-year history of hypertension, but no tachypalpitations, headache, flushing, family history of hypertension, or other endocrine disorders. Twenty-four hour urine samples demonstrated normal ranges of metanephrine (0.6 mg/day; normal range, 0-0.8 mg/day) and vanillylmandelic acid (2.5 mg/day; normal range, 0-8.0 mg/day). Biochemical tests did not reveal any abnormalities related to other functional endocrine tumors, such as Conn's syndrome or Cushing's syndrome. Her post-bronchodilator lung function test was normal: forced expiratory volume in one second (FEV1) of 1.80 L (98% of predicted value), forced vital capacity (FVC) of 2.57 L (102% of predicted value), and FEV1/FVC of 70%.\nRobotic-assisted laparoscopic right adrenalectomy was performed. The adrenal gland measured 3.5×1.6 cm, weighed 17 g, and represented a pheochromocytoma, which was a well-circumscribed, reddish-brown solid 2.5-cm mass that did not invade the surrounding tissues (). Right upper lobectomy was performed by video-assisted thoracoscopic surgery, 10 days after the adrenalectomy. The lung tumor was found to be a 2.8×2.5-cm papillary adenocarcinoma (). The lesion was confined to the lung parenchyma with clear resection margins and no evidence of tumor involvement in the mediastinal and regional lymph nodes, consistent with stage IA disease (pT1bN0M0). Her recovery from the operation was uncomplicated. Postoperatively, she did not receive chemotherapy or radiation therapy. Two years postoperatively, there has been no tumor recurrence in the thorax and abdomen, and the patient is healthy.