An extremely rare case of adrenocortical cancer with cannon ball pulmonary metastasis
Vito Antonio Falcone, Ilaria Nardi, Maria Mesto, Vanessa Trotta, Vito Picca Department of Intensive Respiratory Care Unit, San Paolo Hospital of Bari, Italy
Abstract
Multiple pulmonary nodules on chest X-ray, known common- ly as cannon ball secondaries, are the classical presentation of hematogenous dissemination of a malignant tumor to the lungs. This almost always indicates an advanced stage of the disease with a very grim outlook in terms of cure or survival. In this case report, we present a patient with very extensive cannon ball lung metastases due to adrenocortical carcinoma with a more favorable prognosis. This is the first case described in the literature of can- nonball lung metastases from adrenocortical tumor in a man.
Introduction
It is largely described that an adrenocortical cancer, a rare dis- ease also called cancer of the adrenal cortex, can be responsible for pulmonary metastases [1-2]. In addition, cannon ball pul-
Correspondence: Vito Antonio Falcone, Department of Intensive Respiratory Care Unit, San Paolo Hospital, via Caposcardicchio 1, 70124 Bari, Italy. Tel. +39.393.4320444. E-mail: va.falcone13@gmail.com
Key words: Cannon ball metastases; lung metastasis; malignancy; adrenocortical carcinoma.
Contributions: IN, MM, VT, data collecting and analyzing; VAF, man- uscript drafting; VP, VAF, manuscript reviewing and literature search. All authors gave substantial intellectual contribution to the study, read and approved the final version to be published.
Conflict of interest: the authors declare no potential conflict of interests.
Informed consent: obtained.
Received for publication: 31 March 2019. Accepted for publication: 12 September 2019.
@Copyright: the Author(s), 2019 Licensee PAGEPress, Italy Monaldi Archives for Chest Disease 2019; 89:1076 doi: 10.4081/monaldi.2019.1076
This article is distributed under the terms of the Creative Commons Attribution Noncommercial License (by-nc 4.0) which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.
monary metastases have been associated with a wide spectrum of neoplasms [3]. However, this is the first case described in the lit- erature of cannonball lung metastases caused by an adrenocortical tumor in a man.
Case Report
A 70-year-old man, no-smoker and no-diabetic, was taken to the Emergency Unit of the San Paolo Hospital in Bari, Italy, on August 21, 2017. His medical history reported a right adrenocor- tical carcinoma, surgically removed in 2002; in February and April 2011, respectively, the patient had been subjected to the atypical resection of the upper lobe of the left lung and to the com- plete resection of the lower lobe of the right lung. In both cases the histological diagnosis of pulmonary biopsies had concluded for secondary locations of adrenal carcinoma. No metastatic lesions were found till 2013, when the patient decided to interrupt any radiological control and any treatment but palliation.
In the last 5 days, he had developed cough, hemoptysis, pro- gressive wheezing without fever. A hypertensive crisis was detected in the emergency room. Routine blood tests revealed normal white and red blood cells, hemoglobin 14.9 g/dL (13- 17.5), PCR 12,1 mg/L (0-5), NT-PROBNP 3081 pg/ml (0-125). The physical examination revealed a respiratory rate of 30/min and the use of accessory muscles of respiration, heart rate 120/min, blood pressure 160/90 mmHg, oxygen saturation 80% in the ambient air, swelling of the foot for edema. Chest exami- nation revealed a reduction of breathing sounds in all-field and diffuse bilateral cracklings and acute on chronic global respira- tory failure thanks to a blood gas analysis performed in the ambi- ent air and a spontaneous breathing. Viral serology for hepatitis (A, B, C), respiratory syncytial virus, Epstein Barr virus, Cytomegalovirus were negative. The serum Mycoplasma and Chlamydia Pneumoniae antibodies IgM-A-G were also negative. A routine chest X-ray - posteroanterior and lateral views - showed multiple large lung masses in both fields, of which the biggest measured 11 cm, which were highly suggestive of sec- ondaries (Figure 1). A CT scan of the chest revealed more bilat- eral “cannon ball” pulmonary metastases (Figure 2). At that moment only, the family of the patient gave us the images of a CT scan of the chest taken in February 2017, which confirmed the presence of many lung masses which had increased of over 2 cm each one during the last months (Figure 3). A fiberoptic bron- choscopy showed no stenosis of bronchi, nor any endobronchial lesion. The patient died due to respiratory failure after 3 days, despite an initial clinical improvement obtained through medical cares and oxygen therapy.
Discussion
In this case, medical history, CT scan abnormalities, biochem- ical parameters were suggestive of cannonball pulmonary metas- tases from adrenocortical cancer. In addition, the histological spec- imens confirmed the diagnosis.
The adrenocortical carcinoma is an aggressive cancer originat- ing in the cortex of the adrenal gland. It is a rare tumor, with an inci- dence of 1-2 per million population/year. At the time of diagnosis, it has often invaded nearby tissues or metastasized to distant organs, and the overall 5-year survival rate is only 20-35% [4-7]. The lung is an uncommon site for metastasis from adrenal gland cancer.
On CT, cannon ball metastases refer to large, well circum- scribed, round pulmonary masses that appear like cannon balls [2]. In this regard, it should be noted that these lesions may be mim- icked by a broad range of clinical entities, including septic embolism, tuberculosis, angioinvasive aspergillosis, rheumatoid nodules, and others [8]. However, confusion between these condi- tions is rare due to differences in clinical presentation, and bio- chemical parameters, such as in the present case.
Multiple pulmonary metastases from adrenal gland cancer have been extensively described [9-10]. On the other hand, can- non ball pulmonary metastases have been classically associated to urogenital tract malignancies (renal cell carcinoma and chori- ocarcinoma), gastrointestinal tumors and sarcomas [11]. In this regard, to the best of our knowledge, this is the first case in the literature of cannon ball pulmonary metastases from adrenocorti- cal cancer in a man.
In literature, a similar case in a woman has been reported in 2012 [12]; typically, these kind of lesions are more frequent in women, especially if they are associated with endocrine syn- dromes. In addition, it is important to remark that cannon ball metastases usually indicate advanced disease and portend poor prognosis [13]; on the contrary, in this case, six years had passed since the diagnosis of pulmonary metastases to patient exitus.
Conclusions
In presence of adrenocortical tumor, it is reasonable to suspect the occurrence of cannon ball lung metastases when CT findings are suggestive of it. Although these kinds of lesions are generally related to more aggressive histotypes of cancer such as renal cell carcinoma or choriocarcinoma, this case raises the possibility of cannonball lung metastases also from a less aggressive tumor with a better outcome.
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References
1. Ammannagari N, Polu V. ‘Cannon ball’ pulmonary metastases. BMJ Case Rep 2013;2013:bcr2012008158. doi:10.1136/bcr- 2012-008158.
2. Bickle I. Cannonball metastases (lungs). [Internet] Radiopaedia.org. Available from: https://radiopaedia.org/arti- cles/cannonball-metastases-lungs?lang=gb
3. Kshatriya R, Patel V, Chaudhari S, et al. Cannon ball appear- ance on radiology in a middle-aged diabetic female. Lung India 2016;33:562-8.
4. Arkless R. Renal carcinoma: how it metastasizes. Radiology 1996;84:496-501.
5. PDQ Adult Treatment Editorial Board. Adrenocortical Carcinoma Treatment (PDQ®). [Internet]. Available from: https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0032533/
6. Brunt LM, Moley JF. Adrenal incidentaloma. World J Surg 2001;25:905-13.
a . Bel. On
7. De Vita VT, Hellman S, Rosenberg SA. Cancer: principles & practice of oncology. Philadelphia: Lippincott-Raven; 2005.
8. Buchholz S, Szawarski P, Dawson SL. An odd case of multiple “cannonball metastasis” Postgraduate Med J 2003;79:542-3.
9. Allard P, Yankaskas BC, Fletcher RH, et al. Sensitivity and specificity of computed tomography for the detection of adre- nal metastatic lesions among 91 autopsied lung cancer patients. Cancer 1990;66:457-62.
10. Karanikiotis C, Tentes AA, Markakidis S, et al. Large bilateral adrenal metastases in non-small cell lung cancer. World J Surg Oncol 2004;2:37.
11. Agarwal R, Mukhopadhyay J, Lahiri D, et al. Cannon-ball pul- monary metastases as a presenting feature of stomach cancer. Lung India 2015;32:300-2.
12. Khan M, Banerjee R. A case of adrenocortical cancer with can- non ball pulmonary metastasis and primary hyperaldostero- nism. Endocrine Abstracts 2012;28:P154.
13. Flavin R, Finn S, McErlean A, et al. Cannonball metastases with favourable prognosis. Ir J Med Sci 2005;174:61-4.
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