Case 2

A 62-year-old Caucasian female presented with postmenopausal bleeding. An endometrial biopsy showed well-to-moderately differentiated adenocarcinoma with mucinous and squamous differentiation. The patient underwent a laparoscopic-assisted hysterectomy, bilateral salpingo-oophorectomy, and bilateral pelvic and paraaortic lymphadenectomy. Pathologic evaluation showed moderate-to-poorly differentiated adenocarcinoma of the uterus. The left ovary and 1 of 47 lymph nodes were also positive for metastasis. The tumor was positive for estrogen and progesterone receptors, and stage T3aN1. Adjuvant chemotherapy with 6 cycles of cisplatinum, which has well documented results for recurrent endometrial cancer, was undertaken.

Surveillance PET/CT scan performed 10 months after surgery detected an isolated 6 cm hypermetabolic mass in the left adrenal gland (SUV 18) with no signs of local invasion. A CT-guided needle biopsy of the left adrenal mass was performed, which was positive for metastatic adenocarcinoma, with positive staining for CA-125, CK7, CK20 and Vimentin, consistent with an endometrial primary. The patient underwent a laparoscopic left adrenalectomy. Pathologic examination confirmed metastatic adenocarcinoma. Several months later, she developed a new liver lesion on CT scan, with a complete response to doxorubicin. She is currently 35 months post-adrenalectomy, and remains well with no radiographic evidence of disease.

Both adrenalectomies were performed by general surgeons with laparoscopic expertise.

Discussion

Metastatic spread of cervical carcinoma to the adrenal gland is exceedingly rare. To our knowledge, we present only the second case of adrenal metastasis from cervical squamous cell carcinoma, with Baron et al. reporting a case of metachronous adrenal metastases in 2008 treated by unilateral open adrenalectomy. The contralateral adrenal gland metastasized 6 months later, and was also treated by open adrenalectomy, followed by chemotherapy. The patient expired 6 months later [1].

Solitary adrenal metastasis from endometrial adenocarcinoma is similarly rare. The most recently reported case was treated with laparoscopic adrenalectomy, followed by 3 cycles of paclitaxel and carboplatin. 5 years and 7 months after surgery, patient is still alive with no evidence of disease [2].

Surgical intervention is indicated only if the adrenal gland is the isolated site of metastasis. Aggressive surgical intervention appears to yield improved 5 and 10 year survival rates in metastatic disease to non-adrenal sites so it is reasonable to assume that the same would apply to adrenal metastasis [3]. While laparoscopic adrenalectomy has become the gold standard for the surgical treatment of most primary adrenal tumors, its use in the setting of metastatic disease remains a topic of debate. Local recurrence and peritoneal metastases raised concerns for inadequate resection margins and a potential for peritoneal tumor dissemination. In a recent series of 63 open adrenalectomies and 31 laparoscopic adrenalectomies performed for isolated metastasis, Strong et al. found both procedures to be equivalent for margin status, local recurrence, disease-free interval, and overall survival. Operative time, blood loss, length of hospital stay, and complication rate were significantly reduced in the laparoscopic adrenalectomy group [4]. Surgical resection may be appropriate in cases of isolated metastatic disease.

Conflict of interest statement

There are no financial disclosures or conflicts of interest for any of the authors.