Symptomatic Large Bilateral Adrenal Metastases At Presentation In Small
Navneet Singh1, Karan Madan1, Ashutosh N. Aggarwal1, Ashim Das2
Departments of 1Pulmonary Medicine and 2Histopathology, Postgraduate Institute of Medical Education & Research , Chandigarh, India
The adrenal gland is a common site for metastasis from lung cancer. Adrenal metastases are usually solitary, asymptomatic and diagnosed incidentally during staging of patients with lung cancer. Bilateral adrenal metastases at the time of diagnosis are seen in 3% of lung cancer patients. Large symptomatic bilateral adrenal metastases at presentation are extremely rare and those occurring in the setting of small cell lung cancer have not been reported previously. Herein we describe a 46-year old male patient with SCLC who was symptomatic from large bilateral adrenal metastases at presentation. The patient was successfully treated with conventional platinum based chemotherapy and had no complications related to the large adrenal masses either at presentation or subsequently during treatment and follow up.
Keywords: Lung cancer adrenal gland metastasis mass
Submitted Aug 10, 2011. Accepted for publication Sep 20, 2011.
What Are The Symptoms Of Metastatic Cancer
Some people will have minimal or no symptoms of metastatic cancer. If symptoms are present, theyre based on the location of the metastasis.
Bone metastasis may or may not cause pain. The first sign of bone metastasis is bone breakage after a minor injury or no injury. Severe back pain accompanied by leg numbness or difficulty with bowel or bladder control must be evaluated immediately.
Cancer symptoms of lung metastasis are usually very vague. This is because they can be similar to symptoms of other health conditions. Warning signs may include a cough , coughing up blood, chest pain or shortness of breath.
Left Adrenal Gland Metastasis Of Breast Invasive Ductal Carcinoma: A Case Report
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The majority of the common primary neoplasms whichmetastasize to the adrenal gland include melanoma, lung cancer,breast carcinoma, colon malignant tumor and renal cell carcinoma. In practice, adrenal glandmetastasis normally results from systemic metastasis, particularlyin the advanced stage of the primary neoplasms like breastcarcinoma, and the most common method of metastasis is blood-borne.Breast carcinoma is the most common malignancy in females, whilethe primary histological type of the breast cancer is invasiveductal carcinoma. A report revealed that ~80% of all breast cancertypes are breast invasive ductal carcinomas , which normally metastasize to the lung,liver, bone and brain however, metastasis to the adrenal gland israre . Metastasis of breastcarcinoma often leads to a poorer prognosis and a lower 5-yearsurvival rate . Patients who havesolitary adrenal gland metastasis normally have a long-termsurvival compared with those who exhibit synchronous metastasis. Laparoscopic adrenalectomy ,the treatment of adrenal gland metastases, has become more and moreacceptable.
The patient was discharged on the 7 dayspost-operation. At the time of writing, no problems were reportedwith the patient.
Reported cases of adrenal glandmetastasis of breast invasive ductal carcinoma.
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Treatment Of The Primary Tumor
Treating stage 4 lung cancer may include chemotherapy, targeted therapies, immunotherapy, and/or radiation therapy. Some people also participate in clinical trials studying new drugs and procedures. The addition of targeted therapies and immunotherapy have changed the face of advanced lung cancer for many people in recent years.
If targetable mutations are present, targeted drugs can sometimes treat stage 4 lung cancer like a chronic disease. While drug resistance remains a concern, second- and third-line drugs are now available to extend the duration of therapy.
An example is ALK-positive lung cancer. A 2018 study found that, with appropriate treatment, the median survival of people with stage 4 disease was 6.8 years, even if they had brain metastases.
Immunotherapy, when effective, has sometimes even resulted in a “durable response,” holding lung cancer in check for a lengthy period of time. Since the first drug in this category was only approved in 2015, we have yet to know if the remissions we sometimes see will last, or what the long-term outcomes may be.
Symptoms Of Metastatic Cancer
Metastatic cancer does not always cause symptoms. When symptoms do occur, what they are like and how often you have them will depend on the size and location of the metastatic tumors. Some common signs of metastatic cancer include:
- pain and fractures, when cancer has spread to the bone
- headache, seizures, or dizziness, when cancer has spread to the brain
- shortness of breath, when cancer has spread to the lung
- jaundice or swelling in the belly, when cancer has spread to the liver
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When Metastatic Cancer Can No Longer Be Controlled
If you have been told your cancer can no longer be controlled, you and your loved ones may want to discuss end-of-life care. Whether or not you choose to continue treatment to shrink the cancer or control its growth, you can always receive palliative care to control the symptoms of cancer and the side effects of treatment. Information on coping with and planning for end-of-life care is available in the Advanced Cancer section of this site.
Origin Staging And Primary Treatment Of Extra
The extra-adrenal malignancies in patients with AM included lung , renal , colorectal , liver and gynecological cancers and lymphoma . The frequent extra-adrenal malignancies in patients with ABM comprised of thyroid , kidney , gynecological , breast , stomach , lung , and colorectal cancers. A higher percentage of patients with stage III/IV extra-adrenal tumors were found in the metastatic group and a higher percentage of those with stage I-II tumors were found in the benign group .
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Enhancing Healthcare Team Outcomes
Adrenal metastases are the most common malignant lesions involving the adrenal gland and the second most common tumor of the adrenal gland after benign adenomas. These metastases were primarily found on autopsy. However, with the increasing role of CT, MRI, and PET in diagnosing, staging, and follow-up of malignancies, adrenal metastases are increasingly found incidentally. The management of adrenal metastatic lesions is best done with an interprofessional team that includes an oncologist, a surgeon, radiologist, primary care provider, internist, and a pathologist. The key is to find out the primary. In most cases the biggest difficulty is determining if the adrenal lesion is benign or a metastatic lesion. Sometimes a biopsy or laparoscopy may be required. If the lesion is metastatic the prognosis for most patients is poor.
Treatment Of Adrenal Cancer
- If surgically resectable:open adrenalectomy and en-bloc removal of the tumor, the surrounding tissues, any invading structures and the regional lymph nodes.
- Adjuvant therapy with mitotane and possibly chemotherapy is usually recommended.
- Unresectable tumors: mitotane, chemotherapy, and clinical trials with newer biologic agents
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What Causes Adrenal Fatigue
Adrenal fatigue is rooted in your stress, especially when it is endless and becomes too much for your body to handle. Our body deals with stress by producing hormones like cortisol. Under long-term stress, the adrenal glands cannot keep up.
What are the symptoms of adrenal fatigue?
Here are a few of the symptoms. This is not an exhaustive list, and these symptoms could be a myriad of different health concerns. Talk to your doctor and/or coach about your specific symptoms.
- Pain in the lower back: Since your adrenal glands are above your kidneys, a dull ache or throb in your lower back could be caused by unhealthy adrenal glands.
- Weakened immune system: The immune system affects the secretion of hormones from the hypothalamic-pituitary-adrenal axis. Therefore a weak immune system, which can be from even emotional stress, directly impacts how the adrenals work.
- Raised heart rate: It is obvious, but adrenaline levels and heart rate are intrinsically linked. This can have disastrous consequences if you already have a heart condition.
- Fatigue: It could cause you to want to sleep more, feel lethargic all day, or crave boosting yourself up with caffeine thus continuing the cycle of bad sleep.
- Malaise: This condition is when someone experiences an impending feeling of dread. Usually, this happens when the body does not understand what is wrong with it. Depression, extreme doubt, lack of motivation, and emotional distress can take over if not quickly resolved.
Metastatic Disease To The Adrenal Gland
Certain cancers can spread from other parts of the body to the adrenal gland, including kidney cancer , melanoma , lung cancer, colon cancer, and lymphoma. The best treatment for metastatic cancer is usually systemic therapy like chemotherapy, however doctors will sometimes recommend removing the adrenal gland. Adrenalectomy may be recommended when the primary disease is well controlled and the adrenal is the only site of metastatic disease, if the patient is having significant symptoms from a large adrenal tumor, or if a diagnosis needs to be made and the adrenal is the easiest site to perform a biopsy. It is uncommon for metastatic cancer to appear in the adrenal gland before the primary site is known.
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Adrenal Cancer And Metastases To The Adrenal
Cancer in the adrenal gland is rare.
The most common cancer is a metastasis from another cancer that spread to the adrenal gland. Much less common is Adrenal Cortical Carcinoma , a rare, usually aggressive cancer that is diagnosed in 1-2% of all adrenal masses. It arises from the cortex, or outer layer of the gland and most commonly occurs in the very young or older individuals.
If Adrenal Gland Cancer Spreads
Cancer cells can spread from the adrenal gland to other parts of the body. This spread is called metastasis.
Understanding how a type of cancer usually grows and spreads helps your healthcare team plan your treatment and future care. If primary adrenal gland cancer spreads, it can spread to the following:
- regional lymph nodes
- large blood vessels
- skin this is rare
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What Is Adrenal Cancer
Cells in the body grow and divide to replace old or damaged cells. This growth is highly regulated, and once enough cells are made to replace the old ones, normal cells stop dividing. Tumors occur when there is an error in this regulation and cells continue to grow in an uncontrolled way. Tumors can either be benign or malignant. Benign tumors do not spread beyond the part of the body where they started and do not grow into nearby tissues. Malignant tumors can invade and damage other tissues around them. They also may spread to other parts of the body, usually through the bloodstream or through the lymphatic system where the lymph nodes are found.
Over time, the cells in a malignant tumor become more abnormal and look less like normal cells. This change in the appearance of cancer cells is called the tumor grade, and cancer cells are described as being well-differentiated, moderately-differentiated, poorly-differentiated, or undifferentiated. Well-differentiated cells are quite normal appearing and look like the normal cells from which they started. Undifferentiated cells are cells that have become so abnormal that often we cannot tell what types of cells they started from.
Symptoms Of Metastasis May Vary Depending On Where The Cancer Has Spread To
Here are some symptoms that vary by locations commonly associated with breast cancer metastasis.
Metastasis in the bone may cause:
- Severe, progressive pain
- Bones that are more easily fractured or broken
Metastasis to the brain may cause:
- Persistent, progressively worsening headache or pressure to the head
- Vision disturbances
- Behavioral changes or personality changes
Metastasis to the liver may cause:
- Abnormally high enzymes in the liver
- Abdominal pain, appetite loss, nausea, and vomiting
Metastasis to the lungs may cause:
- Chronic cough or inability to get a full breath
- Abnormal chest X-ray
- Other nonspecific systemic symptoms of metastatic breast cancer can include fatigue, weight loss, and poor appetite, but its important to remember these can also be caused by medication or depression.
If you notice these symptoms, be sure you talk with your physician. They could be important for getting the treatment you need.
Interested in learning more? i3Health is hosting an upcoming webinar Metastatic Triple-Negative Breast Cancer: Applying Treatment Advances to Personalized Care. Learn more here.
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Diagnostic Tests For Adrenal Cancer And Metastases
- The diagnostic workup of adrenal cancer consists of blood tests, sometimes urine tests, and imaging which determine if the adrenal mass is producing hormones and the extent of the tumor spread.
- Definitive diagnosis is only made on final pathology. However, certain characteristics of the tumor on imaging studies make it highly suspicious for ACC.
There is no role for needle biopsy unless a tumor is strongly felt to be a metastatic lesion from another cancer, and this would be done after a hormone producing tumor is ruled out.
Adrenal Health And The Breast Cancer Connection
Fatigue, emotional distress, changes in appetitebreast cancer conquerors, do these feel familiar?
For years I suffered from adrenal health issues my adrenal glands produced insufficient cortisol and adrenaline. They were burned out from a lack of sleep, and a pile of chronic stress wore heavy on me as I was burning both ends of the candle. I was literally burning out, and it was affecting my health. Staying in the stress response over the long term is one of the main factors for developing chronic dis-eases, including breast cancer. Yes, stress can directly lead to breast cancer cell growth. This is why Essential #3 is Balance Your Energy, and Essential #4 is Heal Your Emotional Wounds in my 7 Essentials System®.
To start healing my adrenals, I took Adrenal Support during the day to balance cortisol and replenish my catecholamines . Before I went to bed, I took Adrenal Calm to calm down my adrenals and rejuvenate my adrenal health. This should be done in conjunction with melatonin. Now, I take these 3 supplements every day to ensure I keep my body, adrenal health, and mind in tip-top shape!
As it turns out, the adrenals are also the production center for progesterone, a vital hormone for the reproductive system and also a strong cancer protector. Research has found that adequate amounts of progesterone in the system and functioning cellular receptors for progesterone are vital ingredients for slowing down ER+ breast cancer.
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How Is Adrenal Adenoma Treated
Adrenal adenomas should be treated only if they are causing symptoms. Otherwise, they can be followed with scheduled scans. If an adenoma needs to be treated, surgical removal is often used. In many cases, this can done with a laparoscopic procedure. A laparoscope is a small fiberoptic camera that can be placed into the abdomen through small incisions. Other small tools can also be placed through these incisions. The adrenal adenoma can be resected while inside the body, without making a large incision in the abdomen, and removed through the small holes through which the camera and other tools are placed. In some cases, because of the size or location of the adenoma, a laparoscopic procedure cannot be done and a larger incision will need to be made.
In most cases of hyperaldosteronism, symptoms go away when the adenoma is removed. Some patients will have repeat episodes of high blood pressure even after the adenoma is removed. If the adrenal adenoma makes cortisol, the patient should take steroids by mouth before and for some time after the surgery until the body is able to make these steroids on its own again.
How Do I Take Care Of Myself
Being diagnosed with metastatic cancer comes with many challenges. These challenges vary from person to person, but you might:
- Feel sad, angry or hopeless.
- Worry that treatment wont work and that your cancer will get worse quickly.
- Get tired of going to so many appointments and making so many important decisions.
- Need help with daily routines.
- Feel frustrated about the cost of your treatment.
Talking with a counselor or social worker can help you cope with these complicated emotions. Managing stress is also an important aspect of self-care. Practice meditation, mindfulness or find other ways to reduce stress and anxiety.
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How Is Adrenal Cancer Diagnosed
Functioning adrenal cortical cancers and adenomas are often diagnosed because of the symptoms from the overproduction of hormones caused by the cancer. A full workup will be done to find the cause of this overproduction and if it is related to an adrenal tumor.
Patients with Cushing’s syndrome could have a problem in the adrenal glands, the pituitary gland, or another tumor somewhere else in the body. The first step is measuring the amount of cortisol in the urine . This test is sometimes done while giving the patient an extra dose of steroids to see how the body responds. After this is done, most patients have a dexamethasone suppression test where patients are given a high dose of the steroid dexamethasone. In normal patients, and in patients with Cushing’s syndrome due to a problem in the pituitary gland, a high dose of dexamethasone will cause the levels of cortisol in the blood and urine to decrease. In patients with adrenal tumors or another tumor in the body that produces ACTH, cortisol levels remain high even after a patient receives a high dose of dexamethasone.
Patients with excess levels of aldosterone should have the blood levels of the chemical renin tested. In cases of hyperaldosteronism due to a tumor in the adrenal gland, renin levels will be low. Patients who have elevated aldosterone levels due to a problem with the blood vessels of the kidney , will have high blood levels of renin.