37682621

Right Adrenocortical Carcinoma Coexisting With Left Adrenal Sarcomatoid Carcinoma on FDG PET/CT

Haotian Chen, MD,* Jiaona Dai, MB,¡ Fabao Gao, MD,* and Rong Tian, MD}

Abstract: Bilateral adrenal glands synchronously involved by different types of pathologies are uncommon. An 80-year-old man underwent FDG PET/CT to evaluate bilateral adrenal masses, which were initially discovered by ultrasonography and confirmed by MRI. The images demonstrated ele- vated FDG activity in both lesions, which were subsequently diagnosed as concurrent right adrenocortical carcinoma and left adrenal sarcomatoid car- cinoma respectively by histopathological examination.

Key Words: 18F-FDG PET/CT, adrenal gland, sarcomatoid carcinoma, adrenocortical carcinoma

(Clin Nucl Med 2023;48: e503-e505)

Received for publication June 12, 2023; revision accepted June 18, 2023.

From the Departments of *Radiology, and ¡Nuclear Medicine, West China Hospital, Sichuan University, Chengdu, China.

H.C. and J.D. contributed equally to this work.

Conflicts of interest and sources of funding: This study was funded by the “1.3.5” Project for Disciplines of Excellence, West China Hospital, Sichuan University (grant ZYJC21063). The authors have no conflicts to report.

Correspondence to: Rong Tian, MD, Department of Nuclear Medicine, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu 610041, Sichuan, China. E-mail: rongtiannuclear@126.com.

Copyright @ 2023 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0363-9762/23/4810-e503

DOI: 10.1097/RLU.0000000000004797

REFERENCES

1. Zhang J, Gong W, Zhang W, et al. Primary adrenal sarcomatoid carcinoma detected by 18F-FDG PET/CT. Clin Nucl Med. 2022;47:433-434.

2. Rachh S, Nilam P. Metastatic bilateral adrenal sarcomatoid carcinoma: eval- uation by 18F-FDG PET/CT. Asia Ocean J Nucl Med Biol. 2022;10:151-154.

3. Bharwani N, Rockall AG, Sahdev A, et al. Adrenocortical carcinoma: the range of appearances on CT and MRI. AJR Am J Roentgenol. 2011;196: W706-W714.

4. Claimon A, Tantranont N, Claimon T. 18F-fluoro-2-deoxy-D-glucose pos- itron emission tomography/computed tomography for preoperative planning in a rare case of hyperfunctional bilateral adrenocortical carcinoma and re- view of literatures. World J Nucl Med. 2020;19:301-305.

5. Libe R, Pais A, Violon F, et al. Positive correlation between 18 F-FDG up- take and tumor-proliferating antigen Ki-67 expression in adrenocortical car- cinomas. Clin Nucl Med. 2023;48:381-386.

6. Kaplan I, Can C, Kepenek F, et al. Superiority of 18 F-FDG PET/CT to 68 GA-FAPI PET/CT in adrenocortical tumor imaging. Clin Nucl Med. 2023; 48:e307-e309.

7. Chen X, Chen G, Fu Z, et al. Bilateral adrenal extremely intense metabolic activity on 18F-FDG PET/CT in a patient with pheochromocytomas. Clin Nucl Med. 2019;44:748-749.

8. Evangelista L, Crimi F, Visentin A, et al. [18F]FDG PET/CT and PET/MR in patients with adrenal lymphoma: a systematic review of literature and a collection of cases. Curr Oncol. 2022;29:7887-7899.

9. Anderton J, Ghobrial M, Kosmoliaptsis V, et al. Large adrenal mass heralding the diagnosis of occult extra-adrenal malignancy in two patients. BMJ Case Rep. 2021;14:e239463.

10. Castinetti F, Verschueren A, Cassagneau P, et al. Adrenal myelolipoma: an unusual cause of bilateral highly F-FDG-avid adrenal masses. J Clin Endocrinol Metab. 2012;97:2577-2578.

11. Gorla AK, Gupta K, Sood A, et al. Adrenal tuberculosis masquerading as disseminated malignancy: a pitfall of (18)F-FDG PET/CT imaging. Rev Esp Med Nucl Imagen Mol. 2016;35:257-259.

12. Altinmakas E, Guo M, Kundu UR, et al. Computed tomography and (18) F-fluorodeoxyglucose positron emission tomography/computed tomography findings in adrenal candidiasis and histoplasmosis: two cases. Clin Imaging. 2015;39:1115-1118.

FIGURE 1. An 80-year-old man presented with intermittent abdominal discomfort and diarrhea for 2 months. Abdominal ultrasonography incidentally found bilateral adrenal masses. Laboratory tests revealed adrenocortical insufficiency. Tumor markers and liver function were unremarkable. Axial T1-weighted (A) and T2-weighted fat-suppressed (B) MRI scans showed bilateral adrenal masses with heterogeneous signal intensity, measuring 59 x 47 mm on the right (long arrow) and 37 x 25 mm on the left (short arrow). The inferior vena cava was invaded by the right adrenal lesion (arrowheads). The findings were consistent with bilateral adrenal malignancy.

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FIGURE 2. FDG PET/CT was performed for staging. The MIP image (A) revealed a large focus of intense activity in the medial right upper abdomen (long arrow) with SUVmax of 19.29 and a smaller one in the medial left upper abdomen with SUVmax of 16.48 (short arrow). No other site of abnormal tracer uptake was observed. On the axial PET image (B), the larger activity (long arrow) and smaller activity (short arrow) corresponded to the known adrenal masses on the corresponding CT (C) and fusion images (D). In addition, abnormal activity in the inferior vena cava (arrowheads) was noted. The results highly indicated primary adrenal malignancy with inferior vena cava tumor thrombus. Right adrenal biopsy and left adrenalectomy was sequentially performed. Surprisingly, the pathological findings with immunohistochemical analysis demonstrated adrenocortical carcinoma on the right side but adrenal sarcomatoid carcinoma on the left. Both the adrenocortical carcinoma and the adrenal sarcomatoid carcinoma are rare aggressive malignancies in the elderly and have a poor prognosis. Only a few cases of adrenal sarcomatoid carcinoma have been previously reported.1,2 Bilateral adrenal glands can be involved in 15% of adrenal sarcomatoid carcinomas and 2%-10% of adrenocortical carcinomas.3 Patients with adrenal sarcomatoid carcinomas often have atypical symptoms, whereas patients with adrenocortical carcinomas often present with hormone-related symptoms.4 FDG PET/CT can play important roles in the evaluation of adrenal lesions.1,2,5,6 FDG-avid bilateral adrenal masses are often indicative of the same type of diseases, including pheochromocytoma," lymphoma,8 metastases,9 myelolipoma,1º and infective diseases.11,12 Our case indicates that possibility of the coexistence of 2 different pathologies should not be ignored when bilateral hypermetabolic adrenal lesions were noted on FDG PET/CT.

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