|Year : 2010 | Volume
| Issue : 1 | Page : 37-40
Adrenal sarcomatoid carcinoma: A rare case depicted on multi-detector row computed tomography
Yuan-Chun Feng1, Zhi-Gang Yang2, Tian-Wu Chen1, Xue-Ying Su3, Wen Deng1, Qi-Ling Wang1
1 Department of Radiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
2 Department of Radiology and State Key Laboratory of Biotherapy, West China Hospital of Sichuan University, Chengdu, Sichuan, China
3 Department of Pathology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
|Date of Web Publication||31-Jan-2012|
Department of Radiology, West China Hospital of Sichuan University, 37# Guo Xue Xiang, Chengdu, Sichuan – 610 041
Primary adrenal sarcomatoid carcinoma is rare malignant tumor with the characteristics of carcinoma and sarcoma. To date, only one case of primary sarcomatoid carcinoma in the adrenal gland was reported. We present here computed tomography appearance and pathological features of the case with primary adrenal sarcomatoid carcinoma confirmed by pathology. In addition, a brief review of the relevant literature is presented.
Keywords: Adrenal gland, multi-detector row CT, sarcomatoid carcinoma
|How to cite this article:|
Feng YC, Yang ZG, Chen TW, Su XY, Deng W, Wang QL. Adrenal sarcomatoid carcinoma: A rare case depicted on multi-detector row computed tomography. Indian J Med Sci 2010;64:37-40
|How to cite this URL:|
Feng YC, Yang ZG, Chen TW, Su XY, Deng W, Wang QL. Adrenal sarcomatoid carcinoma: A rare case depicted on multi-detector row computed tomography. Indian J Med Sci [serial online] 2010 [cited 2013 May 25];64:37-40. Available from: http://www.indianjmedsci.org/text.asp?2010/64/1/37/92486
| ¤ Introduction|| |
Sarcomatoid carcinoma usually occurs in the upper respiratory tract and the gastrointestinal tract in elderly men, and is rarely found in the urinary system. Primary sarcomatoid carcinoma in the adrenal gland is extremely rare.  Sarcomatoid carcinoma is characteristic with overtly carcinoma and sarcoma. To the best of our knowledge, only one case of primary sarcomatoid carcinoma was clinically reported. But imaging findings of the tumor were not reported in the literatures. Computed tomography (CT) is a reliable modality for detecting tumors in the adrenal gland. Dynamic enhanced scan with multi-detector row CT (MDCT) may show the compositions and the blood supply of a tumor. We report the appearances shown on MDCT and the pathological features of a case with sarcomatoid carcinoma in the left adrenal gland.
| ¤ Case Report|| |
A 72-year-old man presented with a 2-month history of left lumbar region pain. On physical examination, his body temperature, heart rate, respiratory rate, and blood pressure were 37.2 o C, 94 bpm, 30 breaths/min, and 117/64 mmHg, respectively. On laboratory examination, blood hydrocortisone, serum potassium, plasma norepinephrine, epinephrine, and adrenocorticotropic hormones were 766.90 nmol/L (mild elevation), 3.3 mmol/L (mild decrease), 59 ng/L (dramatic decrease), less than 50 ng/L (mild decrease), and 72.11 ng/L (within the normal range), respectively. Vanillylmandelic acid (VMA) in the urine was negative. Chest X-ray was normal, but heterogeneous parenchymal echo of a mass in the left adrenal gland was found on ultrasonography.
The patient underwent non-enhanced MDCT (16-detector row CT, Siemens Sonata, Erlangen, Germany.) in the upper and middle abdomen and the contrast-enhanced MDCT scan after injected contrast medium (Ultravist 300 iopamidol, Schering, Germany; bolus injection of 3 ml/s)) with pump injector (MEORAD-Stellant, MEORAD Company, Germany). Non-enhanced CT showed a soft tissue mass with well margin in the left adrenal gland [Figure 1]a, and the size of the mass was 7.1×6.4 cm on axial CT image. No calcifications were found in the mass. Contrast-enhanced CT showed heterogeneous enhancement with high- and low-attenuation areas within the tumor, CT values of high-attenuation areas were 55-69 HU, and those of low-attenuation regions were 28-30 HU [Figure 1]b. The left kidney, the gastric fundus, tail of pancreas, and splenic vein were compressed by the tumor. No tumor thrombus was found in the renal vein or inferior caval vein, and retroperitoneal enlarged lymph nodes were not noted.
|Figure 1: A 72-year-old male with sarcomatoid carcinoma in the left adrenal gland. (a) Non-enhanced axial CT scan demonstrates a soft tissue mass in left adrenal gland (arrow). (b) The mass is inhomogeneous attenuation on contrast-enhanced CT (arrow). (c) Photomicrography of histological specimen shows epithelium-like arrayed tumor cells within the mass. (d) Photomicrography shows the spindle-shaped cells (arrow) and necrosis foci (N) within the tumor (H and E, ×100). (e) The tumor cells are positive for pan cytokeratin in immunohistochemical staining (arrow) (H and E, ×100).|
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Subsequently, surgical therapy was performed, and the tumor was found to be soft with a complete capsule. The post-surgical pathology demonstrated that the tumor consisted of epithelioid malignant cell [Figure 1]c, spindle-like cells, interspersed necrotic foci on light microscope [Figure 1]d. Immunohistochemistry showed that pan cytokeratin (PCK) was positive [Figure 1]e, and microtubule-associated protein (MAP-1), synaptophysin (Syn), chromograin
A (CgA), smooth muscle actin (SMA), calretinin (CR), and HBME-1 were all negative. The patient was diagnosed with sarcomatoid carcinoma in the left adrenal gland.
| ¤ Discussion|| |
Sarcomatoid carcinoma mainly occurs in men aged in more than 60 years old. The tumor has been reported in relatively common organs such as the respiratory tract, gastrointestinal tract, and mammary gland.  Primary sarcomatoid carcinoma in the adrenal gland is extremely rare, and only one case has been reported in the literature. Sarcomatoid carcinoma is a highly malignant tumor originating from epithelial tissue. Regarding morphology, there are two main differentiated forms including epithelial origin and mesenchymal origin.  This type of tumor consists of carcinomatous and sarcomatous-like components with the transition zone between them. The characteristics of its immunohistochemistry are positive in cytokeratin (CK), epithelial membrane antigen (EMA), and vimentin. It is usually confirmed by immunohistochemistry.
CT is essential for the preoperative diagnosis of a tumor in the adrenal gland. , There have been no reports of primary sarcomatoid carcinoma in the adrenal gland diagnosed by MDCT. In the present case, heterogeneous enhancement were found on contrast-enhanced CT. Low-attenuation regions presumably resulted from the interspersed necrotic foci with insufficient blood supply, whereas the high-attenuation parts resulted from the preserved abundant blood supply within the tumor. CT may be helpful in detecting the spatial relationships between the tumor and the adjacent structures.
This tumor should be differentiated from other adrenal tumors such as adrenocortical carcinoma, pheochromocytoma, neuroblastoma, and primary lymphoma. Adrenocortical carcinoma is a soft tissue mass with rich blood supply. Corticosteroids are found to be increased in 40-50% of patients with adrenocortical carcinoma,  whereas the remaining with adrenocortical carcinoma with no elevated corticosteroids are difficultly differentiated from sarcomatoid carcinoma on CT. Pheochromocytomas, resulting in refractory elevated blood pressure, are frequently found in some patients. Significantly enhanced CT can be found in the mass presumably resulted from the preserved abundant blood supply within the mass.  Compared with the pheochromocytomas, the present patient with sarcomatoid carcinoma in our case had normal blood pressure. Neuroblastoma occurs commonly in children.  CT indicates heterogeneous attenuation, and necrosis and hemorrhage may be found in the lesion. Neuroblastoma is confirmed by elevated VMA in the urine. However, elevated VMA in the urine was not found in our case. Primary lymphoma rarely occurs in the adrenal gland, unilaterally or bilaterally,  and the incidence of primary lymphoma was 25%.  Contrast-enhanced CT indicates homogeneous enhancement and necrosis is seldom found in most tumors, which was different from the inhomogeneous enhancement in our case.
In conclusion, we reported a case of adrenal sarcomatoid carcinoma detected by MDCT. The correlation between MDCT appearances and pathological findings of this entity may be helpful for the diagnosis, and contrast-enhanced CT could provide sufficient information prior to making an appropriate therapeutic decision.
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