Case Reports
ADRENAL CORTICAL CARCINOMA PRESENTING AS RIGHT VARICOCELE
TIMOTHY C. BRAND, TED O. MORGAN, JR., JAMES R. CHATHAM, WILLIAM G. KENNON AND BRADLEY F. SCHWARTZ*
From the Department of Urology, Tripler Army Medical Center, Honolulu, Hawaii
KEY WORDS: carcinoma, adrenal cortical; varicocele; scrotum
Right varicoceles are uncommon and may represent the presence of retroperitoneal pathology. We report a case of a large adrenal cortical carcinoma that presented as a symp- tomatic right varicocele.
CASE REPORT
A 39-year-old man was referred to us for a 3-month history of rapid onset right hemiscrotal discomfort and swelling that decreased when he was supine. Medical history included vasectomy 5 years earlier. He denied abdominal pain, flush- ing, headaches, weight loss or other constitutional symp- toms. Physical examination of the abdomen was remarkable for fullness in the right upper quadrant and right grade III varicocele. Ultrasound demonstrated subclinical left varico- cele and confirmed dilatation of the right pampiniform plexus venous channels from 1.8 to 6 mm. with a Valsalva maneuver. Computerized tomography (CT) of the abdomen and pelvis with contrast medium revealed a 12 cm. right adrenal mass. There was evidence of central necrosis with peripheral calcifications and compression of the inferior vena cava just cephalad to the right renal vein (see figure).
Urinalysis, complete blood count, serum chemistry studies, liver function tests and urinary catecholamines were normal. Urinary cortisol was modestly increased at 56.7 µg./24 hours (normal less than 50). Serum dehydroepiandrosterone sulfate
Accepted for publication September 1, 2000.
The views expressed in this article are those of the authors and do not reflect the official policy or position of the United States Army, Department of Defense or the United States government.
* Requests for reprints: Department of Urology, 1 Jarrett White Rd., Honolulu, Hawaii 96859-5000.
Contrast enhanced CT of abdomen and pelvis shows large right adrenal mass (arrows) with compression of inferior vena cava.
was increased at 562 µg./dl. (normal 88 to 305). Metastatic evaluation, including CT of the chest and a bone scan, was normal. Magnetic resonance imaging was performed to exclude thrombus involving the inferior vena cava, which was equivocal and a subsequent inferior vena caval venogram revealed exter- nal compression without evidence of thrombus.
Right adrenalectomy through a thoracoabdominal ap- proach was performed without complication. Pathological ex- amination revealed a 730 gm. poorly differentiated adrenal cortical carcinoma with 1 focus of capsular penetration into peri-adrenal fat. Pathological stage was T3MONO (American Joint Committee on Cancer criteria) with greater than 6 mitoses per high power field, extensive tumor necrosis and dystrophic calcifications.
DISCUSSION
Varicoceles are most common as unilateral dilatation of the pampiniform plexus of veins above the left testis. Left varicoce- les are present in approximately 10% to 20% of men and are believed to be secondary to the venous anatomy of the left testis. Right varicoceles usually occur as bilateral processes and are apparent in 10% of clinical cases and as many as 50% of sub- clinical cases. Unilateral right varicocele may be attributed to the presence of situs inversus, persistence of embryological ve- nous structures or retroperitoneal malignancy.1
The most common malignancy to cause this presentation is right renal cell carcinoma. However, several other tumors have been attributed to cause right varicocele, such as Burkitt’s lymphoma2 or Wilms tumor. An aortic pseudoan- eurysm presenting as right varicocele has also been de- scribed. A MEDLINE search of the literature from 1966 to the present revealed no previous documentation of an adre- nal cortical carcinoma presenting as a right varicocele.
Functioning adrenal cortical carcinomas may present with virilization or hypertension. Nonfunctioning adrenal cortical carcinomas commonly present as abdominal pain, palpable mass or constitutional symptoms. The ratio of functional-to- nonfunctional adrenal cortical carcinomas is highly dependent on the patient population but is estimated to be 55:45.3 In conclusion, we believe that the diagnosis of right varicocele necessitates evaluation of the abdomen and retroperitoneum for underlying malignancy. To our knowledge we report the first case of a large, right nonfunctioning adrenal cortical carcinoma identified on evaluation of a right varicocele.
REFERENCES
1. Grillo-Lopez, A. J .: Primary right varicocele. J Urol, 105: 540, 1971
2. Roy, C. R., II, Wilson, T., Raife, M. et al: Varicocele as the presenting sign of an abdominal mass. J Urol, 141: 597, 1989
3. Wajchenberg, B. L., Albergaria Periera, M. A., Medonca, B. B. et al .: Adrenocortical carcinoma: clinical and laboratory observa- tions. Cancer, 88: 711, 2000