Likely lung carcinoma presenting as bilateral adrenal metastases

What happened, in summary

An 88-year-old man was evaluated after ultrasound for urinary symptoms revealed a large mass above the left kidney. CT showed a 52 by 51 mm left adrenal mass with necrotic, cystic, and enhancing areas, together with a smaller 28 by 21 mm right adrenal nodule. Hormonal testing was normal, and no extra-adrenal tumor was seen on conventional CT.

PET-CT showed intense uptake in both adrenal lesions but did not reveal a primary cancer elsewhere. Because the two adrenal masses were enlarging and appeared more consistent with metastases than with two separate primary adrenal cancers, the team performed endoscopic ultrasound-guided biopsy of the left lesion. The pathology was metastatic carcinoma of likely pulmonary origin. The lung-primary attribution remained qualified because no primary lung mass was directly visualized.

After multidisciplinary discussions, he was offered bilateral adrenalectomy, observation, or systemic chemotherapy. He chose surgery and underwent successful bilateral adrenalectomy. Steroid replacement was started because both adrenal glands had been removed. During the first three months after surgery, he continued regular oncology surveillance and had not required adjuvant chemotherapy. The case required careful shared decision-making because the metastatic pathology indicated a likely lung origin even though the primary tumor remained occult on imaging.