特異なリンパ節転移の形態をとった肺癌副腎転移と腎細胞癌の重複癌の1例

Abstract

58歳男。易疲労感の自覚と体重減少で受診し、腹部CTで右副腎の腫瘤性病変の指摘で当院入院となり、炎症反応、貧血を認め内分泌学的検査での異常はないが腫瘍マーカーの上昇を認めた。CTより右副腎に径8×5cm大の内部不均一な腫瘤と左腎中極に径2cm大の腫瘤を認め、MRIで右副腎腫瘍はT1強調画像で低信号、T2強調画像で不均一な高信号を呈した。右副腎腫瘍が大きく近傍のリンパ節の腫脹が顕著なため副腎癌で左腎病変は転移の可能性が高いと考え、経皮的腎生検よりrenal cell carcinomaで右副腎癌と左腎細胞癌の重複癌と術前診断した。癒着の剥離で右腎の温存ができたため左腎摘除を行い左副腎は温存した。右副腎腫瘍の病理所見より、metastatic adenocarcinomaであったが腎細胞癌や副腎癌と一致しない組織像で術後腺癌腫瘍マーカーCEAが高値を示した。PET施行で左鎖骨上と縦隔に集積を認め肺腺癌の右副腎転移、リンパ節転移と臨床診断した。その後、頸部リンパ節と縦隔リンパ節転移の腫脹に化学療法、副腎転移摘除部の局所再発に放射線療法を行ったが頸部、縦隔、腹部リンパ節転移の増大と多発骨転移を認め術後9ヵ月で死亡した。

A 58-year-old male presented to a clinic with general weakness. Right adrenal tumor was found by computed tomography and he was referred to our hospital. Imaging studies revealed right adrenal tumor (8 cm) with marked swelling of surrounding lymph nodes and synchronous left renal tumor (2 cm) that was weakly enhanced by contrast media. Needle biopsy of the left kidney proved to be clear cell type renal cell carcinoma (RCC) and the preoperative diagnosis was left RCC and right primary adrenal cancer with lymph node metastasis. We performed right adrenalectomy, lymph node dissection and left radical nephrectomy. Pathological findings of right adrenal tumor and lymph nodes were both metastatic adenocarcinoma, which was not consistent with RCC or adrenal-derived carcinoma. Then, we extensively reviewed preoperative radiological examinations and found a small lesion in the left upper lung. This lesion was attached to the mediastinal shadow and there was no obvious lymph node swelling around this lesion. According to pathological findings and an elevation of carcinoembryogenic antigen, the adrenal lesion was diagnosed as adrenal metastasis of lung adenocarcinoma.