Description
A 58-year-old man, a farmer, who was a known hypertensive poorly controlled on metoprolol, amlodipine and enalapril, presented with sweating and giddiness for 10 months and pedal oedema for 3 months. On ultrasonography, a heteroechoic mass was found near the upper pole of his left kidney. Multidetector CT of the abdomen showed an 11×8×5 cm heterogeneous mass arising from the left adrenal gland, with an attenuation of 28 HU on non-contrast CT and 35% absolute washout on delayed film. The venous thrombus extended from left adrenal vein into the infradiaphragmatic inferior vena cava (IVC), extending 2.5 cm above the hepatic vein confluence (figures 1 and 2). Urinary normetanephrines were 889 µg/24 h, urinary metanephrine was 107 µg/24 h and serum cortisol level was 800 nmol/L. The patient underwent left open adrenalectomy with IVC thrombectomy. At 2-year follow-up, he was normotensive without any signs of residual/recurrent disease.
Figure 1.
Post-contrast axial CT scan showing enhancing left adrenal mass with thrombus in the left renal vein extending into the inferior vena cava.
Figure 2.
Coronal section of post-contrast CT scan showing the venous thrombus extending up to the infradiaphragmatic inferior vena cava.
Adrenocortical carcinoma is infrequently associated with venous tumour thrombus (2.9%).1 Venous involvement occurs earlier in right-sided tumours due to the renal vein on the left side. CT washout studies are the gold standard for differentiating adenoma from carcinoma, the former suggested by absolute percentage washout >60% or relative percentage washout >40%. Hypersecretion of adrenal hormones is found in 50–80% of patients, the most common being cortisol. Catecholamines are typically normal, although false elevation is seen with use of β-blockers to control hypertension.2
With IVC tumour thrombus, survival is 25% at 5 years in absence of metastatic disease and only 20% at 2 years in presence of metastasis.3
Learning points.
Adrenocortical carcinoma is a rare cause of inferior vena cava (IVC) tumour thrombus.
Management of IVC tumour thrombus is similar to that for renal cell carcinoma.
Despite aggressive surgical efforts, prognosis is dismal.
Footnotes
Twitter: Follow Sohrab Arora at @drsohrab
Competing interests: None declared.
Patient consent: Obtained.
Provenance and peer review: Not commissioned; externally peer reviewed.
References
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