Role of Palliative Bronchial Stenting in Endobronchial Metastasis: An Atypical Case of Metastatic Adrenocortical Carcinoma in a Young Patient
Sushrut Ingawale1 (D | Nuthan Bhat1 | Rahul Kothari2 | Shivaji Karki3 (D | Abhiroop Verma1
1Department of Medicine, Quinnipiac University - Frank H Netter MD School of Medicine/St. Vincent’s Medical Center, Bridgeport, Connecticut,
USA | 2Department of Medicine, Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai, India | 3Department of Medicine, Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
Correspondence: Shivaji Karki (shivajikarki2@gmail.com)
Received: 30 May 2025 | Revised: 17 September 2025 | Accepted: 7 October 2025
Funding: The authors received no specific funding for this work.
Keywords: adrenocortical carcinoma | airway obstruction | bronchial stents | endobronchial metastasis | palliative care
ABSTRACT
Adrenocortical carcinoma (ACC) rarely manifests endobronchial metastases, with only two prior cases reported. We present the first known case of endobronchial ACC managed with bronchial stenting. A 21-year-old male with metastatic ACC developed acute respiratory failure due to left mainstem bronchial obstruction. Bronchoscopic tumor debulking and stenting restored air- way patency and improved ventilation. Despite initial stabilization, he could not be weaned off the ventilator and transitioned to comfort care with demise. This case highlights the potential role of bronchial stenting in malignant airway obstruction for symptom relief in palliative care.
1 Introduction
Adrenocortical carcinoma (ACC) is a rare malignancy, with an incidence of 2 cases per million. It is also notable for its poor prognosis, owing to patients typically presenting with advanced disease [1]. Even so, it has been estimated that only 30% of early cases are curable. The disease most commonly metastasizes to the liver, lungs, lymph nodes, and bones [2]. There have only been two reported cases of endobronchial metastases of ACC with hemoptysis and post-obstructive pneumonia, respectively [3, 4]. Endobronchial metastases are also a rare entity, com- monly occurring secondary to breast, colorectal, and renal carcinomas. They may present with symptoms such as cough, sputum production, dyspnoea, or hemoptysis. Management of endobronchial metastases is through various palliative modal- ities, including the placement of bronchial stents [5]. Reported
here is, to the best of our knowledge, the first case of endo- bronchial metastasis of ACC treated palliatively using a bron- chial stent.
2 Case History/Examination
A 21-year-old male with a known history of metastatic right ACC presented to the emergency department with a cough, spu- tum mixed with small blood clots, and acute-onset shortness of breath. He was previously diagnosed with Cushing’s syndrome at age 17 and underwent right adrenalectomy, confirming ACC. Over time, liver and lung metastases developed. Prior treatments included right hepatectomy, multiple chemotherapy regimens (mitotane, etoposide, cisplatin, doxorubicin), immunotherapy (Ipilimumab, Nivolumab), and palliative radiotherapy.
Abbreviations: ACC, Adrenocortical carcinoma; BiPAP, Bilevel positive airway pressure; CT, Computed tomography; CXR, Chest radiograph.
@ 2025 The Author(s). Clinical Case Reports published by John Wiley & Sons Ltd.
Summary
· This case highlights the valuable palliative role of bronchial stenting in patients with endobronchial me- tastases and the utility of interventional bronchoscopy in providing symptomatic relief for malignant airway obstruction.
· It also showcases endobronchial metastasis of adreno- cortical carcinoma-an extremely rare entity.
On presentation, he was afebrile and had hypoxia (oxygen satu- ration 83% on room air), tachypnea (38/min), tachycardia (107/ min), and severe hypertension (228/135 mmHg). He was placed on BiPAP, but worsening respiratory status necessitated intuba- tion and intensive care unit admission. Arterial blood gases con- firmed acute hypoxic hypercapnic respiratory failure. Empiric antibiotics (cefepime, vancomycin) were initiated.
2.1 | Differential Diagnosis
· Primary airway tumor
· Pulmonary embolism
· Infectious pneumonia with mucous plugging
· Endobronchial metastasis from known ACC (most likely based on history and imaging)
3 Conclusion and Results (Outcome and Follow-up)
CT chest (Figure 1) with contrast revealed compression of the left main bronchus by a mass, alongside metastatic pulmonary lesions, metastatic hilar and mediastinal lymphadenopathy, and left lower lobe consolidation. Flexible bronchoscopy further identified an obstructing mass in the left mainstem bronchus. Given the lack of therapeutic alternatives, a decision was made to perform an endobronchial tumor debulking and palliative stenting to restore left bronchus patency with the goal of extu- bating the patient.
A rigid bronchoscopy (Figure 2) was performed under general anesthesia. The right-sided airways proved to be unremark- able. The left mainstem bronchus showed a slit-like opening that was easily traversed. The distal mainstem bronchus was completely occluded by a mass, and a 1.7 mm flexible cryo- probe (ERBE) was utilized to cryo-debulk it. Following this, the left lower lobe airways could be visualized and were found to be normal. The left lower lobe of the lung itself showed post-obstructive secretions, which were therapeutically as- pirated. Additional tumor tissue was debulked from the left
A
PORTABLE SUPINE LEFT
B
C
D
A
B
C
D
upper lobe until the lingula and left upper lobe proper could be identified. Once airway patency had been restored, venti- latory parameters and oxygen demand improved. Debulking was followed by stenting.
Stenting was preceded by the placement of radiopaque markers on the patient’s chest to mark the location of the main carina under fluoroscopy. A soft-tipped guidewire was then passed through the working channel of the bronchoscope into the left lower lobe, and the scope was removed, leaving the wire in place. A 10×30mm fully covered self-expanding metal stent (AERO) was advanced over the wire and deployed, then carefully with- drawn into position. The stent was patent in the airway to keep the point of maximum obstruction in the middle of the stent. The entire procedure was concluded with minimal blood loss, no complications, and an improvement in airway ventilation parameters.
Tissue pathology confirmed metastatic ACC (Inhibin-positive epithelioid cells). The ventilation parameters improved after stenting. However, given a multifactorial etiology for respira- tory failure including pneumonia, it was difficult to wean off
the ventilator. And, given the metastatic burden, the family transitioned the patient to “Comfort Measues Only” to allow natural death and withdrawal of ventilatory support resulting in his demise.
4
Discussion I
This case underscores three important clinical takeaways.
First, endobronchial metastasis from ACC is an exceedingly rare manifestation, with only two prior cases reported in the liter- ature. While ACC commonly metastasizes to the liver, lungs, lymph nodes, and bones, airway involvement remains an un- usual presentation [1, 2]. Clinicians should maintain a high index of suspicion for airway compromise in patients with met- astatic ACC presenting with respiratory distress, hemoptysis, or persistent cough.
Second, bronchial stenting is a valuable palliative interven- tion for malignancy-related airway obstruction [5, 6]. In this case, the patient presented with acute respiratory failure due
to airway occlusion by an endobronchial tumor mass. The use of rigid bronchoscopy, cryo-debulking, and self-expanding metal stenting successfully restored airway patency, improving ventilation parameters and oxygenation. Stenting can provide immediate relief by alleviating obstruction, reducing the risk of post-obstructive pneumonia, and enhancing quality of life. However, it remains a palliative measure rather than a curative one. It may be a string of hope to prolong life for a short duration of time especially in young patients while offering symptom re- flief and improving the quality of life.
Third, despite interventional success, the prognosis of meta- static ACC remains poor, necessitating individualized goals of care discussions [2]. Although the patient initially showed clin- ical improvement following bronchial stenting, he could not be weaned off ventilatory support, ultimately leading to the tran- sition to comfort care. This highlights the aggressive nature of ACC and the importance of balancing interventional efforts with patient-centered care. Documenting and analyzing such rare cases contribute to expanding knowledge on metastatic patterns and therapeutic strategies, ultimately guiding future management approaches in advanced ACC cases.
I
5 Conclusion
This case represents the first reported instance of palliative bronchial stenting for endobronchial metastasis from ACC, highlighting both the rarity of this metastatic pattern and the potential utility of interventional bronchoscopy in such sce- narios. While bronchial stenting successfully restored airway patency and improved respiratory parameters, the overall prog- nosis remained poor due to the aggressive nature of metastatic ACC. This underscores the importance of timely palliative inter- ventions to alleviate symptoms, even in the setting of advanced disease, and reinforces the need for multidisciplinary, patient- centered decision-making in complex oncologic cases. Further reporting of such rare presentations is essential to guide future recognition and management. The potential impact of palliative stenting for malignant airway obstruction, specifically in terms of symptom relief, improved quality of remaining life, and pos- sibly reducing the need for hospitalization or critical care, re- mains an important area for further exploration.
Author Contributions
Sushrut Ingawale: conceptualization, data curation, formal analysis, investigation, project administration, resources, validation, writing - original draft, writing - review and editing. Nuthan Bhat: formal anal- ysis, investigation. Rahul Kothari: investigation, writing - original draft, writing - review and editing. Shivaji Karki: writing - original draft, writing - review and editing. Abhiroop Verma: formal analysis, investigation.
Acknowledgments
We thank The Gut Liver Pancreas (GLP) Network for supporting this collaboration.
Consent
A written informed consent was obtained from all the patient(s) to pub- lish this report in accordance with the journal’s patient consent policy.
Conflicts of Interest
The authors declare no conflicts of interest.
Data Availability Statement
Data can be made available as per your request.
References
1. K. Y. Bilimoria, W. T. Shen, D. Elaraj, et al., “Adrenocortical Carcinoma in the United States: Treatment Utilization and Prognostic Factors,” Cancer 113, no. 11 (2008): 3130-3136.
2. A. Thampi, E. Shah, G. Elshimy, and R. Correa, “Adrenocortical Carcinoma: A Literature Review,” Translational Cancer Research 9, no. 2 (2020): 1253-1264.
3. A. Douglas and R. Attanoos, “Expectorated Metastatic Adrenocortical Carcinoma: A Rare Presentation of a Rare Tumour,” BMJ Case Reports 13, no. 6 (2020): e234624.
4. K. Ota, H. Satoh, S. Y. Lin, et al., “Endobronchial Metastasis From Adrenocortical Carcinoma,” Internal Medicine 48, no. 13 (2009): 1161-1164.
5. L. Dalar, C. Özdemir, S. N. Sökücü, L. Karasulu, and S. Altın, “Bronchoscopic Palliation to Treat Endobronchial Metastasis of the Tracheobronchial Tree,” Respiratory Investigation 54, no. 2 (2016): 116-120.
6. J. H. Kim, J. H. Shin, H. Y. Song, et al., “Palliative Treatment of Inoperable Malignant Tracheobronchial Obstruction: Temporary Stenting Combined With Radiation Therapy and/or Chemotherapy,” AJR. American Journal of Roentgenology 193, no. 1 (2009): W38-W42, https://doi.org/10.2214/AJR.08.2037.