Synchronous isolated adrenal metastasis from rectum adenocarcinoma

Abstract

The treatment of adjuvant metastatic colorectal cancer (MCRC) is protocolised in national and international treatment guidelines [1, 2]. A treatment consensus has been reached for liver metastases of colorectal cancer [3]. Protocolisation of the treatment of extrahepatic localisations such as the lung, peritoneum or adrenal glands will prove much more difficult.Adrenal metastases mainly appear in patients with lung, kidney, breast, colon and rectum cancers [4]. Colorectal cancer is frequently present in the context of a disease disseminated to various organs and isolated adrenal metastases are infrequent [5,6].In MCRC, surgical resection should be considered, as it is the only possible curative option. One third of patients with radically resected hepatic metastasis will have longer survival and be considered cured [7]. Similar survival rates are achieved when a hepatectomy and resection of adrenal metastasis are performed [8].We found no reference to the therapeutic approach to rectal disease with synchronous isolated adrenal metastasis and we want to discuss this point with a clinical case. A 61-year-old female patient, with no particular antecedents, presented in January 2003 with rectorrhagia. Exploration revealed a fixed and non-obstructive lesion and fibrocolonoscopy showed a lesion 8 cm from anal verge. Biopsy was positive for moderately differentiated adenocarcinoma. The determination of carcinoembryonic antigen (CEA) at diagnosis was 513.7 ng/ml. Further studies were performed: thorax X-ray was normal, endoscopic rectal ultrasound evidenced a uT3N1 tumour and abdominal computed tomography (CT) (Fig. 1) and magnetic resonance (MR) evidenced a rectal tumour and a 6-cm mass in the right adrenal gland, suggestive of metastasis. Fine-needle aspiration biopsy (FNAB) of the adrenal mass confirmed histological diagnosis of metastasis of colon adenocarcinoma. Positron emission tomography (PET) did not show any new metastatic lesions besides the already known suprarenal lesion.The patient was diagnosed with locally advanced rectal neoplasia with an isolated right adrenal metastasis, both lesions being resectable. Preoperative chemotherapy was initiated with 5-FU continuous infusion chemotherapy and concomitant radiotherapy on the primary Fig. 1 Abdominal enhanced CT scan, obtained 90 s after intravenous administration of contrast material, demonstrates a large, heterogenous, mostly hypodense mass affecting the right adrenal gland, highly suspicious of malignancy