• Users Online:330
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
IMAGES AND VIDEOS
Year : 2017  |  Volume : 6  |  Issue : 2  |  Page : 142-144

Esophageal adenocarcinoma metastasis in the left adrenal gland diagnosed by endoscopic ultrasound-guided fine needle aspiration


1 Department of Endoscopy, Santa Casa de São Paulo Hospital and French-ian Center of Endoscopic Ultrasound, São Paulo, Brazil
2 Department of Pathology, Santa Casa de São Paulo Hospital, São Paulo, Brazil

Date of Submission25-Mar-2016
Date of Acceptance28-Aug-2016
Date of Web Publication20-Apr-2017

Correspondence Address:
Everton Hadlich
Department of Endoscopy, Santa Casa de São Paulo Hospital, Rua Dr. Cesario Mota Júnior, 112, Vila Buarque, São Paulo 01224-011
Brazil
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2303-9027.204809

Rights and Permissions

How to cite this article:
Hadlich E, Carbonari AP, Assef MS, Araki OM, Nakao FS, Saieg MT, Rossini LG. Esophageal adenocarcinoma metastasis in the left adrenal gland diagnosed by endoscopic ultrasound-guided fine needle aspiration. Endosc Ultrasound 2017;6:142-4

How to cite this URL:
Hadlich E, Carbonari AP, Assef MS, Araki OM, Nakao FS, Saieg MT, Rossini LG. Esophageal adenocarcinoma metastasis in the left adrenal gland diagnosed by endoscopic ultrasound-guided fine needle aspiration. Endosc Ultrasound [serial online] 2017 [cited 2020 Jan 24];6:142-4. Available from: http://www.eusjournal.com/text.asp?2017/6/2/142/204809

A 54-year-old man with a 2-month history of dysphagia, epigastric pain, and 15 kg weight loss was referred for upper endoscopy, which revealed a vegetative lesion in the distal part of the esophagus [Figure 1]. Endoscopic biopsies confirmed the diagnosis of esophageal adenocarcinoma.
Figure 1: Upper endoscopy image: Vegetative lesion in the distal part of the esophagus

Click here to view


Computed tomography scan showed a parietal thickness of the distal part of esophagus and some perigastric, portocaval, and periaortic lymph nodes [Figure 2]. In addition, a nonspecific small nodule in the left adrenal gland was observed [Figure 3].
Figure 2: Computed tomography image: Parietal thickness of the esophagus

Click here to view
Figure 3: Computed tomography image: Nonspecific nodule in the left adrenal gland

Click here to view


As a result of these findings, the patient was referred for EUS staging (Processor EUS SU 8000, insertion tube EG 530 UT, Fujinon Corporation, Japan) that revealed a hypoechoic and heterogeneous lesion, invading the mucosa, submucosa, muscularis propria, and adventitia of the esophagus [Figure 4].
Figure 4: Endoscopic ultrasound image: T3 esophageal cancer

Click here to view


EUS confirmed the presence of enlarged regional lymph nodes [Figure 5] and also revealed a hypoechoic heterogeneous nodule in the left adrenal gland with hyperechoic central area, measuring about 12 mm × 13 mm and with well-defined limits. EUS-guided fine needle aspiration (EUS-FNA) of the left adrenal gland was performed [Figure 6] with a 22-gauge EchoTip ® Needle (Cook Medical Inc., Limerick, Ireland). The cell block histology and immunohistochemistry (CDX2 and CD20 positive) confirmed the diagnosis of esophageal adenocarcinoma metastasis [Figure 7]. Therefore, EUS staging was concluded as T3N3M1-Stage IV and the patient was forwarded for adjuvant therapy.[1]
Figure 5: Endoscopic ultrasound images: Esophageal lymph nodes (a) and pancreatic lymph nodes (b)

Click here to view
Figure 6: Endoscopic ultrasound images: Heterogeneous nodule in the left adrenal gland (a). Endoscopic ultrasound-guided fine needle aspiration of the nodule (b)

Click here to view
Figure 7: Section of the cell block showing an epithelial glandular neoplasm, consistent with adenocarcinoma (×40) (a). Section of the cell block showing an epithelial glandular neoplasm, consistent with adenocarcinoma (×80) (b). Immunohistochemistry nuclear positivity for the CDX2 marker (×40) (c). Immunohistochemistry membrane positivity for the CK20 marker (×40) (d)

Click here to view


The majority of the patients diagnosed with esophageal cancer, unfortunately, are not candidates for surgery, because at the time of the diagnosis, they present with distant metastases and therefore forwarded for adjuvant treatment.[2] The most common sites of esophageal metastasis are the liver, lungs, and bones. The adrenal gland is the fourth most common location of metastasis, but it is usually diagnosed in the context of advanced disease in postmortem studies.[3]

The prevalence of the neoplastic dissemination to the adrenal glands varies from about 5% in clinical evaluation studies to 13.6% in autopsies studies.[2],[4] In this context, there are some isolated reports in the literature suggesting the benefit of adrenalectomy in patients with esophageal carcinoma, when the gland represents a single metastatic site, suggesting some benefits in the survival rates of these individuals.[3],[4],[5]

Asymptomatic masses found in the adrenal glands may correspond, in most cases, to a benign disease; however, in the context of cancer staging, up to 75% of the lesions may be a neoplastic dissemination.[6] It is assumed that tumor infiltration of the gland is facilitated by abundant blood supply and high local concentration of corticosteroids, which would promote the implantation.[3]

The EUS-FNA of the adrenal gland can be considered a safe procedure after several series of reports without complications.[7] Only two isolated cases of bleeding and hypertension caused by EUS-FNA have been reported in the literature.[8],[9] Both cases had favorable outcomes.

EUS-FNA of the adrenal gland has an overall accuracy rate of 92% and high negative predictive value (89%) for the diagnosis of malignancy. Some authors suggest that nondiagnostic biopsies are more frequent in cases where there is diffuse thickening of the adrenal gland compared with cases where a mass is identified. It is reported that the puncture of the right adrenal gland is technically more difficult due to its low degree of visualization (approximately 30% of cases) and the interposition of the vena cava.[7],[10],[11]

In this case report, EUS-FNA was performed without complications; it confirmed an advanced disease, allowing the appropriate treatment for the patient. Furthermore, the cost-effectiveness of this procedure was appropriate because it could avoid unnecessary surgery and other examinations. In the literature, only five cases of adrenal metastasis of esophageal tumor diagnosed by EUS-FNA could be found.[6],[10],[12]

In conclusion, we emphasize that it is very important to evaluate the left adrenal gland during EUS staging not only for lung cancer but also for all other neoplasms, including esophageal cancer.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Rice TW, Blackstone EH, Rusch VW. 7th edition of the AJCC Cancer Staging Manual: Esophagus and esophagogastric junction. Ann Surg Oncol 2010;17:1721-4.  Back to cited text no. 1
    
2.
Quint LE, Hepburn LM, Francis IR, et al. Incidence and distribution of distant metastases from newly diagnosed esophageal carcinoma. Cancer 1995;76:1120-5.  Back to cited text no. 2
    
3.
O'Sullivan KE, Moriarty AR, Larkin JO, et al. Curative surgical management of isolated adrenal recurrence of oesophageal adenocarcinoma. BMJ Case Rep 2013;2013. pii: Bcr2013009657.  Back to cited text no. 3
    
4.
Yoshizumi Y, Morisaki Y, Koike H, et al. Successful combined resection of carcinoma of the esophagus and adrenal metastasis: Report of a case. Surg Today 1997;27:330-3.  Back to cited text no. 4
    
5.
Cho MM, Kobayashi K, Aoki T, 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.
DeWitt J, Alsatie M, LeBlanc J, et al. Endoscopic ultrasound-guided fine-needle aspiration of left adrenal gland masses. Endoscopy 2007;39:65-71.  Back to cited text no. 6
    
7.
Puri R, Thandassery RB, Choudhary NS, et al. Endoscopic ultrasound-guided fine-needle aspiration of the adrenal glands: Analysis of 21 patients. Clin Endosc 2015;48:165-70.  Back to cited text no. 7
    
8.
Haseganu LE, Diehl DL. Left adrenal gland hemorrhage as a complication of EUS-FNA. Gastrointest Endosc 2009;69:e51-2.  Back to cited text no. 8
    
9.
de Vries AC, Poley JW. Hypertensive crisis after endoscopic ultrasound-guided fine-needle aspiration of the right adrenal gland. Endoscopy 2014;46:E447-8.  Back to cited text no. 9
    
10.
Martinez M, LeBlanc J, Al-Haddad M, et al. Role of endoscopic ultrasound fine-needle aspiration evaluating adrenal gland enlargement or mass. World J Nephrol 2014;3:92-100.  Back to cited text no. 10
    
11.
Yip L, Tublin ME, Falcone JA, et al. The adrenal mass: Correlation of histopathology with imaging. Ann Surg Oncol 2010;17:846-52.  Back to cited text no. 11
    
12.
Eloubeidi MA, Black KR, Tamhane A, et al. A large single-center experience of EUS-guided FNA of the left and right adrenal glands: Diagnostic utility and impact on patient management. Gastrointest Endosc 2010;71:745-53.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
   References
   Article Figures

 Article Access Statistics
    Viewed930    
    Printed9    
    Emailed0    
    PDF Downloaded110    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]