Introduction: Adrenocortical carcinomas are rare aggressive tumors. 36 % of patients with ACC have distant metastasis on presentation. Although lung metastasis are commonly seen in metastatic Adrenocortical carcinoma, cannonball pulmonary metastasis which are solid and well circumscribed parenchymal masses of variable size are rare and typically seen in Renal cell carcinoma and also in other cancers such as bone sarcomas. We report a case of functional Adrenocortical cancer with cannon ball pulmonary metastasis and primary aldosteronism.
Case: A 48 year old lady presented to the Emergency department of our hospital with nausea,vomiting and dizziness and a blood pressure of 209/95 mmHg on admission. Electrolytes revealed a hypokalaemic alkalosis. Chest X-Ray showed multiple well circumscribed soft tissue density nodules in both the lungs. A CT scan of Chest/Abdomen and Pelvis confirmed multiple lung metastases of variable sizes. It also showed a mass measuring 12 × 9 cm in the renal area which was initially thought to be arising from the Kidney raising the suspicion of Renal Cell carcinoma in presence of cannon ball metastasis, but was subsequently confirmed to be of adrenal origin on an Adrenal CT. A biopsy finally confirmed it to be a primary Adrenocortical tumor. In the presence of lung metastasis a diagnosis of stage 4 Adrenocortical cancer was made. Hormonal evaluation confirmed Cushings syndrome and primary hyperaldosteronism. Plasma metanephrines were within normal limits. The patient was started on metyrapone and underwent palliative chemotherapy along with Mitotane.
Discussion: This patient presented with cannon ball lung metastasis and was found to have a mass in the renal/suprarenal area on a plain CT Chest Abdomen and Pelvis and a possibility of Renal Cell Carcinoma was raised by the reporting Radiologist. A subsequent CT of adrenals however showed this mass to be separate from the renal cortex and confirmed its adrenal origin.If the mass had been confluent with the kidney then it was likely that a diagnosis of Renal cell carcinoma would have been pursued.
Conclusion: Adrenocortical Cancer should be considered in the differential diagnosis of pulmonary canon ball metastasis although Renal Cell Carcinoma is commonest cause of this presentation.
Declaration of interest: There is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.
Funding: No specific grant from any funding agency in the public, commercial or not-for-profit sector.