RUPTURE OF ADRENAL CARCINOMA AFTER BIOPSY
ABDUL HAFEEZ KARDAR
From the Department of Urology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia KEY WORDS: adrenal glands; biopsy; carcinoma, adrenal cortical
Primary adrenal carcinoma is a highly malignant tumor with an incidence of 2/1,000,000.1 At the time of diagnosis more than 80% of tumors are 6 cm. or larger and up to 40% have distant metastases, resulting in dismal prognosis. Spontaneous hemorrhage in the adrenal parenchyma can occur with metastasis, pheochromocytoma, benign masses (such as myelolipoma) and secondary to overwhelming sep- sis. However, rupture of primary adrenocortical carcinoma resulting in widespread retroperitoneal tumor seeding has not been described. We report such a complication following fine needle aspiration biopsy in an adrenal mass.
CASE REPORT
A 65-year-old man presented with a 2-month history of anorexia, weight loss and fever. On computerized tomogra- phy (CT) there was an 8 cm. mass in the right adrenal fossa with no evidence of metastases. CT guided fine needle aspi- ration revealed malignant cells. A mass developed 12 hours later in the right loin and an extensive subcutaneous hema- toma occupying the right flank extended to the external genitalia and upper thigh (fig. 1). Repeat CT showed a huge hematoma around the right kidney and along the entire course of the psoas muscle (fig. 2). The patient required 4 units of packed red cells.
At surgery a huge hematoma distended Gerota’s fascia and Accepted for publication April 27, 2001.
extended along the psoas muscle. Evacuation of the hematoma and right radical nephrectomy was performed. Histopathology showed an 8 cm. high grade primary adrenocortical adenocar- cinoma. There was focal invasion of the adrenal capsule but no tumor extension into the perirenal fat. Convalescence was un- eventful and the patient was started on chemotherapy.
At 3-month followup chest and abdominal CT demon- strated a new left adrenal mass, a metastasis at the right lung apex and a mass associated with the right psoas muscle. Biopsies of the psoas and lung lesions confirmed metastases from the adrenal carcinoma. The patient died a week later.
DISCUSSION
Rupture of a solid tumor is an uncommon but serious complication of malignancy. This complication has been most commonly described with hepatoma and certain sarcomas spontaneously or following needle biopsy.2 Imaging guided needle biopsy of adrenal mass is most commonly performed to differentiate metastasis from benign incidental adenoma in the clinical setting of primary nonadrenal malignancy. Hemorrhage and needle tract tumor seeding are 2 reported complications of adrenal biopsy.3
In our patient the needle biopsy seemed to have precipi- tated rupture of the rapidly growing tumor, leading to mas- sive retroperitoneal bleeding. The spillage of tumor material resulted in the development of subsequent metastases along the course of the psoas muscle. In a review of the literature we did not find any reported case of ruptured adrenal carci- noma. We conclude that rupture and local spread of adrenal tumor should be considered to be a possible complication when needle biopsy is performed on a large adrenal mass.
REFERENCES
1. Copeland, P. M .: The incidentally recovered adrenal mass. Ann Intern Med, 98: 940, 1983
2. Smith, E. H .: Complications of percutaneous abdominal fine- needle biopsy. Review. Radiology, 178: 253, 1991
3. Voravud, N., Shin, D. M., Dekmezian, R. H. et al: Implantation metastasis of carcinoma after percutaneous fine-needle aspi- ration biopsy. Chest, 102: 313, 1992