A rare tumor in the adrenal region: neuron-specific enolase (NSE)-producing leiomyosarcoma in an elderly hypertensive patient

Challenges in the diagnosis of the enigmatic primary adrenal leiomyosarcoma: two case reports and review of the literature

BACKGROUND

Primary adrenal leiomyosarcoma is a rare and aggressive mesenchymal tumor derived from the smooth muscle wall of a central adrenal vein or its tributaries; therefore, tumors tend to invade the inferior vena cava and cause thrombosis. The great majority of tumors grow rapidly, which makes the disease difficult to diagnose in its early clinical stages and needs differentiation from adrenocortical carcinomas for the selection of chemotherapy including mitotane which causes adrenal insufficiency.

CASE PRESENTATION

We presented two patients with adrenal leiomyosarcoma who were referred to our hospital with abdominal pain and harboring large adrenal tumors and inferior vena cava thrombosis. The endocrine findings, including serum catecholamine levels, were unremarkable. These two patients were considered clinically inoperable, and CT-guided core needle biopsy was performed to obtain the definitive histopathological diagnosis and determine the modes of therapy. The masses were subsequently diagnosed as primary adrenal leiomyosarcoma based on the histological features and positive immunoreactivity for SMA (smooth muscle actin), desmin, and vimentin.

CONCLUSIONS

Adrenal leiomyosarcoma derived from the smooth muscle wall of a central adrenal vein or its tributaries is rare but should be considered a differential diagnosis in the case of nonfunctioning adrenal tumors extending directly to the inferior vena cava. CT-guided biopsy is considered useful for histopathological diagnosis and clinical management of patients with inoperable advanced adrenal tumors without any hormone excess.

Review of the Literature on Leiomyoma and Leiomyosarcoma of the Adrenal Gland: A Systematic Analysis of Case Reports

BACKGROUND/AIM

To date few cases of smooth muscle-derived tumors of the adrenal gland have been reported and their treatment remains a medical challenge. The aim of this manuscript was to systematically review the literature and present the tumor characteristics and their management in order to provide a standardized approach to their diagnosis and management.

MATERIALS AND METHODS

We searched five databases (PubMed, Scopus, Elsevier, ResearchGate, Google scholar) for relevant articles published until March 2020.

RESULTS

Twenty-two cases of adrenal leiomyoma, four cases of adrenal smooth muscle tumor and forty-five cases of adrenal leiomyosarcoma were included.

CONCLUSION

We present the demographic, clinical, radiological, pathological and oncological characteristics and prognosis of tumors of the adrenal gland arising from smooth muscle cells, as well as describe the common clinical investigations and therapeutic modalities that have been reported as part of their management.

Pleomorphic Leiomyosarcoma of the Adrenal Gland in a Young Woman: A Case Report and Review of the Literature

Leiomyosarcoma usually arises in the uterus, abdominal and urologic viscera, and walls of large and small blood vessels. However, primary adrenal leiomyosarcoma is extremely rare with only 39 cases previously reported in English-language literature. We report a case of a 29-year-old previously healthy woman with an incidentally found right adrenal-occupying lesion. CT scan revealed a right adrenal mass measuring 3.3×3.4 cm in size. The tumor was successfully removed by laparoscopic adrenalectomy. Postoperative histopathologic examination showed spindle cells arranged in interlacing fascicles with pleomorphism and a high mitotic rate. An immunohistochemical examination showed positive staining for SMA, desmin, vimentin and H-caldesmon, and the diagnosis of a well-differentiated adrenal leiomyosarcoma was established. The patient received no other oncological treatment after surgery and currently has no evidence of residual disease or tumor recurrence according to imaging follow-up.

Primary Adrenal Leiomyosarcoma: Clinical, Radiological, and Histopathological Characteristics

Primary adrenal leiomyosarcoma (PAL) is a rare, high-grade proliferating mesenchymal tumor with a considerable risk of metastasis, deriving from the smooth muscle wall of a central adrenal vein, or its tributaries. Roughly 40 patients with PAL have been reported in the literature. Herein, we present 3 patients with incidentally discovered PAL, along with an overview of the current knowledge on the clinical, radiological, and histopathological characteristics of PAL.

Primary adrenal leiomyosarcoma with inferior vena cava extension in a 70-year-old man

Primary adrenal leiomyosarcoma, a malignant soft tissue tumour originating from the smooth muscle of the inferior vena cava and adrenal vein, is rarely described in the literature. Cases are often diagnosed at an advanced stage as the tumour is not hormone-producing. We describe a 70-year-old man who presented with lower extremity swelling and abdominal varices and was subsequently found to have a large adrenal mass on imaging. Our case is among the few reported primary adrenal leiomyosarcomas in which a CT-guided biopsy was used to aid in diagnosis.

Primary adrenal leiomyosarcoma: case report and review of the literature

Primary adrenal leiomyosarcoma is a very rare tumor with an unusual location; the diagnosis is based entirely on histological and immunohistochemical evaluations. We report a primary adrenal leiomyosarcoma in a 57-year-old woman who was incidentally found to have an adrenal-occupying lesion during a routine medical examination. Computed tomography revealed a 64 mm × 77 mm soft tissue mass in the left adrenal gland. The patient underwent left radical nephroadrenalectomy. Histological examination of the tumor showed malignant spindle cells in interlacing fasicles and whorls. Nuclear pleomorphism, tumor giant cells, necrosis, and abnormal mitotic figures were present. On immunohistochemistry, the tumor cells were strongly positive for smooth muscle actin, desmin, and vimentin expression, but negative for cytokeratin, CD117, CD34, CD68, Myoglobin, S100, and HMB-45.The final histopathological diagnosis was primary adrenal leiomyosarcoma.

Bilateral adrenal leiomyosarcoma treated with multiple local therapies

A 62-year-old woman presented with right flank pain, and computed tomography (CT) showed bilateral adrenal tumors (right, 8 cm; left, 4 cm). There were no abnormal findings on physical examination, and adrenal hormone levels in serum and urine were within normal limits. Radiological studies showed a right adrenal tumor with intratumoral hemorrhage, a cystic tumor in the left adrenal gland, and no sign of distant metastasis. Because laboratory tests showed normal levels of adrenal hormones, we considered the tumors to be nonfunctioning adrenal tumors. The right adrenal tumor was surgically removed because it was thought to be malignant, and histological examination revealed that it was a leiomyosarcoma. Postoperative CT showed a pleural metastasis in the right chest wall. The patient received combination chemotherapy with cyclophosphamide, vincristine, adriamycin, and dacarbazine. The metastasis was also treated with radiofrequency ablation (RFA). Because the left adrenal tumor grew rapidly despite two courses of the chemotherapy, it too was surgically removed. After the operation, metastasis in the right iliac bone was treated with RFA and radiotherapy. Positron emission tomography detected bilateral femoral metastases, and these were treated with radiotherapy in combination with a low dose of cisplatin. A liver metastasis and a small metastasis in the left kidney were treated with RFA and a metastasis in the pancreatic tail was removed surgically. Sixteen months after the right adrenalectomy, the patient died due to systemic spread of the disease. Multiple local treatments including RFA, radiotherapy, and resection were effective for the local control of metastatic lesions of adrenal leiomyosarcoma.

Leiomiossarcoma primário de adrenal

O leiomiossarcoma da glândula adrenal é uma neoplasia extremamente rara, cuja origem provém da veia central da adrenal ou de suas tributárias. Estes tumores são vistos com incidência aumentada em pacientes infectados pelo vírus da imunodeficiência humana adquirida (HIV) e também pelo vírus Epstein-Barr (EBV). Relata-se o caso de uma paciente de 48 anos diagnosticada, por meio de exames de imagem, massa ocupando loja adrenal esquerda, próxima ao pâncreas. Foi submetida à ressecção cirúrgica com achados histopatológicos e imunohistoquímico compatíveis com leiomiossarcoma primário de adrenal. A paciente foi a óbito após 53 meses da adrenalectomia. Concluiu-se que, não obstante a raridade desta neoplasia, sabe-se que, bem como os demais sarcomas de partes moles, o leiomiossarcoma de adrenal se comporta de maneira agressiva e tem na adrenalectomia o tratamento de escolha, não sendo necessário o emprego de quimio ou radioterapias de rotina, exceto em doença metastática ou irressecável.