Lung adenocarcinoma first detected through an adrenal metastasis

What happened, in summary

A 60-year-old man with severe bullous emphysema was admitted with a dull ache in the left lower back. Earlier chest CT scans had shown extensive atelectasis but no lung lesion considered suspicious for cancer. Abdominal imaging revealed a 47 mm left adrenal mass with aggressive features, initially raising concern for a primary adrenal cancer. Hormonal testing showed that the mass was not secreting adrenal hormones.

Whole-body PET-CT showed strong uptake in the adrenal mass and also identified a small 15 by 8 mm nodule in the left upper lung. Because the lung nodule was difficult to biopsy in the setting of emphysema, the multidisciplinary team proceeded with resection of the adrenal mass. He underwent left open adrenalectomy with partial nephrectomy, and the mass was removed with clear margins. Histology unexpectedly showed metastatic adenocarcinoma from a lung primary.

Postoperative PET-CT then showed uptake in a mediastinal lymph node and an additional area in the right upper lung. Molecular testing identified no driver mutations. The patient therefore began palliative chemotherapy for metastatic lung adenocarcinoma. His case illustrates how an adrenal metastasis can be much more visible than the primary lung tumor and how the final pathology changed both the diagnosis and the treatment plan.