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Adrenal cortical carcinoma is a rare, but highly malignant tumour with a short life expectancy, the 5 year survival varying from 16 to 30 per cent's'. It generally presents late in its course with flank pain and a palpable mass3.Pre-operative localization of an adrenal tumour and its extension is important from both therapeutic and prognostic standpoints. Most adrenal cortical carcinomas cannot be radically excised because of local invasion, lymph node metastases or distant metastases, most commonly to the lungs and l i~e r~.~.We report a case of an adrenal cortical carcinoma with preoperative ultrasonic demonstration of a tumour thrombus in the inferior vena cava, propagated via the adrenal vein. Case reportA 72-year-old woman was admitted to the surgical department complaining of right upper quadrant pain, loss of weight and slight swelling of both legs. On clinical examination a right subcostal mass was palpated. The patient was normotensive and, except for a slight elevation of DHEAS (dihydroepiandrosterone sulphate) in plasma, the hormonal and general blood status were normal.An abdominal ultrasound scan demonstrated a 5 x 2 cm thrombus in the inferior vena cava up to the level of the diaphragm. In addition a 6 x 5 cm solid mass was found just above the upper pole of the right kidney.The tumour was clearly outlined by computed tomography, and hepatic metastases were not demonstrated. The retrohepatic portion of the inferior vena cava was not visualized, indicating caval involvement.The presence of the thrombus was confirmed by cavography ( Figure I ) .The tumour and caval thrombus were removed by a combined thoraco-abdominal approach. The caval thrombus was seen propagating into the inferior vena cava from the adrenal vein.The histological examination revealed an adrenal cortical carcinoma. A repeat ultrasound examination 1 week postoperatively demonstrated a small thrombus (2 x 1 cm) in the inferior vena cava just below the diaphragm.The patient died 3 months later from extensive thrombosis of the inferior vena cava. At autopsy pulmonary metastases were demonstrated. DiscussionComputed tomography and ultrasonography represent first line diagnostic methods for evaluating suprarenal masses. Ultrasonic evaluation of the adrenals has been advocated as an accurate, simple and rapid diagnostic procedure6. Fine needle aspiration biopsy is widely used in abdominal pathology, and confirmation of an adrenal mass by ultrasound guided biopsy has been reported very helpful and safe'. To our knowledge only seven cases have previously been reported with a pre-operative demonstration of caval invasion in adrenal cortical carcinomas (Table 1).Park et d . I 2 evaluated inferior vena caval obstruction caused by hepatomas, hypernephromas and adrenal cortical carcinomas performing both cavography and ultrasonography. They concluded that ultrasonography is more advantageous in delineation of the cephalad extent of the thrombus, dynamic evaluation of the inferior vena cava below the obstruction and simultaneous evaluation of adj...
Adrenal cortical carcinoma is a rare, but highly malignant tumour with a short life expectancy, the 5 year survival varying from 16 to 30 per cent's'. It generally presents late in its course with flank pain and a palpable mass3.Pre-operative localization of an adrenal tumour and its extension is important from both therapeutic and prognostic standpoints. Most adrenal cortical carcinomas cannot be radically excised because of local invasion, lymph node metastases or distant metastases, most commonly to the lungs and l i~e r~.~.We report a case of an adrenal cortical carcinoma with preoperative ultrasonic demonstration of a tumour thrombus in the inferior vena cava, propagated via the adrenal vein. Case reportA 72-year-old woman was admitted to the surgical department complaining of right upper quadrant pain, loss of weight and slight swelling of both legs. On clinical examination a right subcostal mass was palpated. The patient was normotensive and, except for a slight elevation of DHEAS (dihydroepiandrosterone sulphate) in plasma, the hormonal and general blood status were normal.An abdominal ultrasound scan demonstrated a 5 x 2 cm thrombus in the inferior vena cava up to the level of the diaphragm. In addition a 6 x 5 cm solid mass was found just above the upper pole of the right kidney.The tumour was clearly outlined by computed tomography, and hepatic metastases were not demonstrated. The retrohepatic portion of the inferior vena cava was not visualized, indicating caval involvement.The presence of the thrombus was confirmed by cavography ( Figure I ) .The tumour and caval thrombus were removed by a combined thoraco-abdominal approach. The caval thrombus was seen propagating into the inferior vena cava from the adrenal vein.The histological examination revealed an adrenal cortical carcinoma. A repeat ultrasound examination 1 week postoperatively demonstrated a small thrombus (2 x 1 cm) in the inferior vena cava just below the diaphragm.The patient died 3 months later from extensive thrombosis of the inferior vena cava. At autopsy pulmonary metastases were demonstrated. DiscussionComputed tomography and ultrasonography represent first line diagnostic methods for evaluating suprarenal masses. Ultrasonic evaluation of the adrenals has been advocated as an accurate, simple and rapid diagnostic procedure6. Fine needle aspiration biopsy is widely used in abdominal pathology, and confirmation of an adrenal mass by ultrasound guided biopsy has been reported very helpful and safe'. To our knowledge only seven cases have previously been reported with a pre-operative demonstration of caval invasion in adrenal cortical carcinomas (Table 1).Park et d . I 2 evaluated inferior vena caval obstruction caused by hepatomas, hypernephromas and adrenal cortical carcinomas performing both cavography and ultrasonography. They concluded that ultrasonography is more advantageous in delineation of the cephalad extent of the thrombus, dynamic evaluation of the inferior vena cava below the obstruction and simultaneous evaluation of adj...
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