A pain syndrome associated with large adrenal metastases in patients with lung cancer

Palliative Radiotherapy Provided Good Pain Relief for Painful Adrenal Metastasis

Adrenal metastases often occur in patients with metastasized lung cancer, but symptoms rarely develop. A 45-year-old man presented with right abdominal pain requiring strong opioids due to large right adrenal metastasis of lung adenocarcinoma. The tumor was 7.3 × 5.6 × 8.4 cm in size. He was treated with palliative radiotherapy (RT) up to 39 Gy in 13 fractions for this lesion without severe adverse effects. After RT, he had good pain relief, and opioids were no longer needed. Palliative RT for a large adrenal tumor can provide a good analgesic effect without relevant toxicity.

Review of Palliative Radiation Therapy Patterns of Practice for Adrenal Metastases in British Columbia

PURPOSE

The adrenal gland is a common site of metastasis in patients with advanced cancer, but it is rarely symptomatic. A subset of patients develop a complex pain syndrome with anorexia, nausea, and poorly localized visceral pain in the back, flank, or epigastric region. These symptoms can affect quality of life and are occasionally challenging to palliate. The role of palliative radiation therapy (PRT) in these patients is unclear. This population-based retrospective study evaluates PRT practices for patients with adrenal metastases and aims to describe treatment response and acute toxicity.

METHODS AND MATERIALS

Patients who received PRT to an adrenal metastasis between the years of 1985 and 2015 were identified in a provincial database. Patient demographics, tumor factors, symptom burden, radiation therapy prescriptions, and response to treatment were collected. Variables were summarized using descriptive statistics. The Kaplan-Meier test was used to assess survival. Factors associated with clinical response were evaluated using univariate and logistic regression analysis. Factors associated with survival were evaluated using univariate and Cox proportional hazards model.

RESULTS

One hundred patients who received 103 separate courses of PRT were identified. The majority had a lung primary (82%). The most common baseline symptoms were pain (90%) and gastrointestinal upset (13%). Prescriptions ranged from 600 cGy in a single fraction to 4500 cGy in 25 fractions. Seventy percent of patients experienced an improvement in pain (either a complete or partial response). Forty-three percent of patients developed acute toxicity from treatment. Median survival was 3 months.

CONCLUSIONS

Compared with other anatomic sites, conventional PRT is uncommonly delivered to adrenal metastases. Despite heterogeneity in tumor histology and radiation therapy prescriptions, treatment was associated with an overall pain response of 70%. Prophylactic antiemetics to decrease radiation-induced nausea are required before treatment. Given the poor prognosis of this population, short fractionations are indicated.

Results of adrenalectomy in lung cancer metastases

BACKGROUND

The aim of this study was to report our centre's experience over the past 15 years with patients with lung carcinoma and adrenal metastases treated sequentially with lung resection and adrenalectomy.

PATIENTS AND METHODS

We analysed a retrospective series of 19 patients who underwent adrenalectomy for lung carcinoma metastasis. All patients were operated on at the same centre, between October 2000 and October 2015. We performed a descriptive analysis and an overall survival and disease-free survival analysis.

RESULTS

The study included 13 men and 6 women. The most common primary lung tumour was adenocarcinoma, 87.5% of which were G3. In 7 patients, the adrenal metastasis was detected synchronously, and in 12 patients it was detected metachronously. The median size of the metastasis was 63mm. Twenty-one percent of the cases presented local recurrence, and 79% presented distant metastasis. The median DFS was 21.5 months, while the DFS at 5 years was calculated at 58.33%. The median overall survival was 37.3 months, while survival at 5 years was calculated at 42.86%. None of the prognostic factors evaluated were statistically significant.

CONCLUSIONS

Adrenalectomy in cases of isolated lung carcinoma metastasis can offer increased overall survival. Age and the degree of differentiation of the primary lung carcinoma are the factors that most influence poorer survival.

EUS-guided alcohol ablation of left adrenal metastasis from non-small-cell lung carcinoma

BACKGROUND

EUS presents an alternative access to the left adrenal, making it possible to perform echo-guided needle biopsies.

OBJECTIVES

We present a case of EUS-guided therapy as alcohol ablation of left adrenal metastases.

DESIGN AND PATIENT

A 52-year-old man was admitted to the hospital complaining of abdominal pain. CT scan revealed an invasive process in the left upper lobe of the lung and a mass in the left adrenal area that was considered highly suspicious for left adrenal metastases from the patient's lung carcinoma. Cytopathologic examination of EUS-guided FNA confirmed the diagnosis of left adrenal metastasis. Because the patient's main clinical symptom was disabling abdominal pain, we considered the possibility of injection of alcohol into the left adrenal metastases under EUS guidance to ablate the metastatic lesion and potentially relieve the abdominal pain. EUS-guided alcohol ablation was performed successfully. RESULTS AND MAIN OUTCOME MEASUREMENT: On follow-up 3 days after EUS-guided left adrenal ablation, the patient had no abdominal pain. He remained without abdominal pain after 30 and 60 days of follow-up.

LIMITATION

New technique with limited data.

CONCLUSION

EUS-guided alcohol ablation of left adrenal metastases in patients with non-small-cell lung cancer may provide palliation of cancer-related abdominal pain. There may be potential for combining this (minimally invasive and easily performed EUS-guided therapeutic) technique for ablation of solitary adrenal metastasis in patients with lung cancer with other modalities (e.g., surgery, radiation, or chemotherapy) directed toward the primary pulmonary malignancy and adjacent mediastinal disease.

Diagnostic investigations in cancer pain

Defining the specific cause of pain in patients with cancer often has substantial therapeutic and prognostic implications. This process often requires the use of specific diagnostic investigations. Here we critically review the diagnostic investigations used in the evaluation of common pain problems in patients with cancer. Familiarity with this information facilitates the development of efficient and rational diagnostic strategies.