Gastric Metastasis of Lung Cancer Mimicking an Adrenal Tumor
A 47-year-old man with a long-term heavy smoking history presented to the emergency room with an one-month history of progressive dyspnea on exertion, productive cough, marked weight loss, profuse diaphoresis at night, neck swelling and dysphagia in early October 2008. A chest film revealed a large soft tissue density in the right upper lobe of the lung and remarkable widening of the upper mediastinum. A subsequent chest computed tomography disclosed a large space-occupying lesion in the right upper lobe of the lung encasing the superior vena cava and the right pulmonary artery (fig. ). Bronchoscopic examination revealed a picture consistent with external compression in the right trachea where the mucosa presented irregularities, narrowing of the orifice of the right upper lobe with suspicious tumor tissue. The pathological report of the tissue biopsy proved it to be small cell carcinoma of the lung. The patient was hospitalized and received radiotherapy to relieve the superior vena cava syndrome, and prophylactic whole brain radiation was undertaken as well. He favorably tolerated six successive courses of chemotherapy with VP-16 and cisplatin later on and had regular follow-ups in the outpatient clinic with a quite satisfactory general performance and relatively good control of the primary lung lesion in the following 4 years.\nIn November 2011, a follow-up chest computed tomography disclosed a small, ill-defined tumor (1.8 × 1.4 cm) in the left adrenal area (fig. ). This lesion was initially interpreted as a non-functioning adrenal incidentaloma with no remarkable clinical relevance and was left for observation. However, the patient, who was free of symptoms, underwent a new chest computed tomography follow-up 6 months later (May 2012) and surprisingly a remarkable enlargement of the previously suspected left adrenal tumor was noted (3.3 × 2.5 cm) (fig. ). A distant metastasis from the lung cancer to the left adrenal gland was then considered and the patient was hospitalized again for surgical intervention by the urologists. Retroperitoneoscopy was initially performed to localize the suspicious metastatic left adrenal tumor. Unexpectedly, the surgeons found an intact left adrenal gland, and the tumor was actually arising from the posterior wall of the gastric body and penetrating into the retroperitoneal space close to the left kidney through a defect in the posterior peritoneum, mimicking an adrenal tumor. Laparotomy was immediately undertaken instead, and wedge resection of the tumor from the stomach was performed accordingly. The pathological analysis of the resected tumor revealed identical pictures as the primary lung lesion (immunohistochemical stain positive both for TTF-1 and CD-56) (fig. ).\nAfter the operation, the patient received further chemotherapy with etoposide and cisplatin and had a relatively good general performance in the meantime. In May 2013, exactly 1 year after the abdominal surgery, a follow-up computed tomography showed several metastatic tumors in the liver and additional chemotherapy with topotecan was instituted. Although the patient underwent an eventful clinical course with several episodes of pancytopenia, the chemotherapy could be finally completed and he currently still has regular follow-ups at the outpatient clinic 15 months after excision of the metastatic tumor in the stomach.