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Presented by Peter Illei, M.D. and prepared by Shien Micchelli, M.D.
Case 1: This 47 years old male patient has a history of leiomyosarcoma in his left calf in 1994.
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1. Question
Week 304: Case 1
This 47 years old male patient has a history of leiomyosarcoma in his left calf in 1994 and recent metastasis to his right lung with two wedge resections in 2005. Surveillance CT demonstrated a mass in his right adrenal gland and a lesion in his liver that was thought to be a hemangioma. A right adrenalectomy was performed.images/3_12_07_1a.jpg
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Answer: Metastatic leiomyosarcoma
Histology: The adrenal gland is enlarged and distorted by a predominantly cortical 1.5 cm spindle cell neoplasm. The tumor has a minimally infiltrating rounded border and is composed of streaming spindle cells with elongated (cigar shaped) nuclei, some with perinuclear vacuoles. Scattered lymphocytic infiltrates are also noted. Mitotic figures can be readily identified. No necrosis or pigment is identified. These features are consistent with metastatic leiomyosarcoma involving the adrenal gland.
Discussion: In the adrenal gland, metastatic tumors are more common than primary tumors. The adrenal is the fourth most frequent site for distant metastasis following the lungs, liver and bone. The frequency is increased with age and peaks in the sixth to eighth decade. The majority of metastases (~90%) are carcinomas (breast, lung, kidney, upper GI tract, pancreas, ovary and colonic origin). Non-epithelial tumors include malignant melanoma, malignant lymphoma and certain sarcomas (angiosarcoma and Kaposi sarcoma usually in HIV positive patients). Rare cases of metastatic leiomyosarcoma and malignant peripheral nerve sheath tumors have also been described.
Incorrect
Answer: Metastatic leiomyosarcoma
Histology: The adrenal gland is enlarged and distorted by a predominantly cortical 1.5 cm spindle cell neoplasm. The tumor has a minimally infiltrating rounded border and is composed of streaming spindle cells with elongated (cigar shaped) nuclei, some with perinuclear vacuoles. Scattered lymphocytic infiltrates are also noted. Mitotic figures can be readily identified. No necrosis or pigment is identified. These features are consistent with metastatic leiomyosarcoma involving the adrenal gland.
Discussion: In the adrenal gland, metastatic tumors are more common than primary tumors. The adrenal is the fourth most frequent site for distant metastasis following the lungs, liver and bone. The frequency is increased with age and peaks in the sixth to eighth decade. The majority of metastases (~90%) are carcinomas (breast, lung, kidney, upper GI tract, pancreas, ovary and colonic origin). Non-epithelial tumors include malignant melanoma, malignant lymphoma and certain sarcomas (angiosarcoma and Kaposi sarcoma usually in HIV positive patients). Rare cases of metastatic leiomyosarcoma and malignant peripheral nerve sheath tumors have also been described.
