open access

Ahead of print
Clinical vignette
Published online: 2021-04-19
Submitted: 2021-02-15
Accepted: 2021-02-18
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Metastasis of adrenocortical carcinoma to the heart: a case vignette

Monika Kamilla Skrzypiec-Spring, Justyna Kuliczkowska-Płaksej, Barbara Stachowska, Adam Szeląg, Wojciech Kustrzycki, Marek Bolanowski
DOI: 10.5603/EP.a2021.0043

open access

Ahead of print
Clinical Vignette
Published online: 2021-04-19
Submitted: 2021-02-15
Accepted: 2021-02-18

Abstract

A 32-year-old female patient was referred to the endocrine department from a gynecology and obstetrics department of a district hospital to which she was presented on the 4th day of childbed with severe headache, hypertension and bilateral leg edema and lumbar pain. Abdominal sonography taken there revealed a heterogeneous hypoechogenic mass in the the upper pole of the right kidney. This was confirmed by computed tomography. On admission the patient demonstrated elevated blood pressure, headache, hypertension, bilateral leg edema and severe abdominal and lumbar pain. Laboratory findings revealed leucocytosis 11.7 g% (normal range 4-10 K/µL), elevated levels of CRP 38.6 mg/l (normal range 0-3 mg/l), alanine aminotransferase 78 U/L (normal range 5-37 U/L), fibrinogen 800 mg% (normal range 200-450 mg%) and D-dimer 6950 ng/ml (normal range 70-490 ng/ml) and thrombocytopenia 91 K/µL (normal range 130-400 K/µL). Urine test revealed proteinuria and erythrocyturia in urine sediment. Hormonal study revealed elevated serum levels of cortisol 316.3 ng/ml at 8 a.m. (normal range 94-260 ng/ml) and 355.9 ng/ml at 12 p.m. (normal range 18-127 ng/ml) as well as decreased serum renin activity during recumbency 0.15 ng/ml/h (normal range 0,51-2,64 ng/ml/h) and 120 minutes of upright posture 0.39 ng/ml/h (normal range 0,98-4,18 ng/ml/h) and aldosterone levels during recumbency 21.3 pg/ml (normal range 29,4-161,5 pg/ml) and 120 minutes of upright posture 30.6 pg/ml (normal range 38,1-313,3 pg/ml). Trans-thoracic echocardiography indicated a large (3.8/2.8 cm) immobile right atrial mass attached to the atrial roof and the upper part of the interatrial septum as well as a mobile mass, attached to the atrial side of the anterior leaflet of the tricuspid valve, prolapsing through it. On the basis of these findings, the patient underwent urgent cardiosurgery and a large intra-atrial mass and tumor thrombi in inferior vena cava were removed. Pathologic examination demonstrated an adrenocortical carcinoma cells and a large area of necrosis within the tumor. Post-operatively, the patient did well and on 19th day was referred to urological ward for further treatment.

Abstract

A 32-year-old female patient was referred to the endocrine department from a gynecology and obstetrics department of a district hospital to which she was presented on the 4th day of childbed with severe headache, hypertension and bilateral leg edema and lumbar pain. Abdominal sonography taken there revealed a heterogeneous hypoechogenic mass in the the upper pole of the right kidney. This was confirmed by computed tomography. On admission the patient demonstrated elevated blood pressure, headache, hypertension, bilateral leg edema and severe abdominal and lumbar pain. Laboratory findings revealed leucocytosis 11.7 g% (normal range 4-10 K/µL), elevated levels of CRP 38.6 mg/l (normal range 0-3 mg/l), alanine aminotransferase 78 U/L (normal range 5-37 U/L), fibrinogen 800 mg% (normal range 200-450 mg%) and D-dimer 6950 ng/ml (normal range 70-490 ng/ml) and thrombocytopenia 91 K/µL (normal range 130-400 K/µL). Urine test revealed proteinuria and erythrocyturia in urine sediment. Hormonal study revealed elevated serum levels of cortisol 316.3 ng/ml at 8 a.m. (normal range 94-260 ng/ml) and 355.9 ng/ml at 12 p.m. (normal range 18-127 ng/ml) as well as decreased serum renin activity during recumbency 0.15 ng/ml/h (normal range 0,51-2,64 ng/ml/h) and 120 minutes of upright posture 0.39 ng/ml/h (normal range 0,98-4,18 ng/ml/h) and aldosterone levels during recumbency 21.3 pg/ml (normal range 29,4-161,5 pg/ml) and 120 minutes of upright posture 30.6 pg/ml (normal range 38,1-313,3 pg/ml). Trans-thoracic echocardiography indicated a large (3.8/2.8 cm) immobile right atrial mass attached to the atrial roof and the upper part of the interatrial septum as well as a mobile mass, attached to the atrial side of the anterior leaflet of the tricuspid valve, prolapsing through it. On the basis of these findings, the patient underwent urgent cardiosurgery and a large intra-atrial mass and tumor thrombi in inferior vena cava were removed. Pathologic examination demonstrated an adrenocortical carcinoma cells and a large area of necrosis within the tumor. Post-operatively, the patient did well and on 19th day was referred to urological ward for further treatment.

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Keywords

adrenocortical carcinoma, metastasis, heart

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About this article
Title

Metastasis of adrenocortical carcinoma to the heart: a case vignette

Journal

Endokrynologia Polska

Issue

Ahead of print

Article type

Clinical vignette

Published online

2021-04-19

DOI

10.5603/EP.a2021.0043

Keywords

adrenocortical carcinoma
metastasis
heart

Authors

Monika Kamilla Skrzypiec-Spring
Justyna Kuliczkowska-Płaksej
Barbara Stachowska
Adam Szeląg
Wojciech Kustrzycki
Marek Bolanowski

References (5)
  1. Goldberg AD, Blankstein R, Padera RF. Tumors metastatic to the heart. Circulation. 2013; 128(16): 1790–1794.
  2. Iezzi F, Quarti A, Surace C, et al. Paediatric Nonfunctioning Adrenocortical Carcinoma with Extension up to Right-Side Heart: Cardiac Surgery Approach. Case Rep Cardiol. 2016; 2016: 2321017.
  3. Kim KH, Park JC, Lim SY, et al. A case of non-functioning huge adrenocortical carcinoma extending into inferior vena cava and right atrium. J Korean Med Sci. 2006; 21(3): 572–576.
  4. Chesson JP, Theodorescu D. Adrenal tumor with caval extension--case report and review of the literature. Scand J Urol Nephrol. 2002; 36(1): 71–73.
  5. Luton JP, Cerdas S, Billaud L, et al. Clinical features of adrenocortical carcinoma, prognostic factors, and the effect of mitotane therapy. N Engl J Med. 1990; 322(17): 1195–1201.

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