case_images: PMC11788011_01
case_images: Initial computed tomography (CT) of the abdomen/pelvis. (a) 7 mm bleb in the right lower lobe most probably the origin of the tumor. (b) Large, heterogenous retroperitoneal mass arising from the left adrenal gland, measuring 14 x 9 cm in axial representation. (c) Large, heterogenous retroperitoneal mass arising from the left adrenal gland, measuring 14 x 9 cm and a controlateral 2 cm tumor arising from the right adrenal in axial representation. No magnification of any of the images was done. They were copied as they appeared on the viewer.
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case_images: A contrast-enhanced total body computed tomography (CT) scan was then performed to rule out hepato-splenomegaly and has led to the incidental finding of a 14 x 9 cm mass arising from the left adrenal gland with extensive necrosis (Figure 1).
case_images: Cytopathology from core biopsy of left adrenal gland mass. (a) Tumor cells exhibit characteristic features of carcinoma. The tumor is composed of large neoplastic cells with necrotic foci (bar = 200 mum). (b) Adrenal cortex show carcinoma (bar = 100 mum). (c) The number of positively Ki-67 stained nuclei in the tumor. The Ki-67 index of proliferation was up to 25% (bar = 200 mum). (d) Tumor cells show positivity for chromogranin A (bar = 200 mum). (e) Tumor cells show positivity for cytokeratin (bar = 200 mum).
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case_images: TTF1, CDX2, and PAX8. These features were consistent with a diagnosis of high-grade poorly differentiated NEC of the adrenal gland (Figure 2).
case_images: FDG-PET/CT. (a) Initial FDG-PET/CT revealed increased activity in the right adrenal mass with no additional site of uptake in coronal representation. (b) Follow-up FDG-PET/CT performed 3 months after the completion of immunotherapy showed a mild interval increase in the nodularity of the remaining part of the right adrenal gland with moderate uptake and interval increase in mediastinal nodal disease in coronal representation. (c) Follow-up FDG-PET/CT performed 3 months later showed complete resolution of mediastinal lymph nodes and a right adrenal showing normal physiological activity in coronal representation. No magnification of any of the images was done.
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case_images: It revealed accumulation of 18-FDG in the right adrenal gland and ruled out other sites of distant and locoregional metastases (Figure 3). A follow-up FDG-PET scan performed 3 months after the completion of a whole year of maintenance Atezolizumab showed new progressive lymphadenopathy in the left hilum of the lung reaching 1.5 cm and in the subcarinal region reaching 2.8 cm (Figure 3). Adrenal activity detected was most likely physiological, and no tumoral enlargement was seen (Figure 3). An FDG-PET scan performed 3 months later showed complete resolution of the mediastinal nodal disease, and no abnormal activity was detected anywhere in the body (Figure 3).
case_images: Brain MRI. (a) 1.2 cm lesion in the left inferior parietal lobe misinterpreted as a scar from an old stroke when first worked up in 2022 in axial representation. (b) Brain MRI performed 3 months after completion of an entire year of immunotherapy: a 3.3 x 2.8 cm lesion in the left inferior parietal lobe in axial representation. (c) Brain MRI performed 3 months after completion of an entire year of immunotherapy showed a small tumor measuring 1.5 cm in the right frontal lateral cortical area in axial representation. (d) Follow-up brain MRI performed 3 months later: two brain lesions significantly decreased in size. Now measuring 2 cm versus 3 cm for the mass in the left inferior parietal lobe; and 4 x 8 mm versus 1.5 x 0.8 cm for the lesion in the right frontal lateral cortical area in axial representation. No magnification of any of the images was done. They were copied as they appeared on the viewer. The two images of the brain MRI labeled (b) and (c) were slightly modified by few millimeters in width to fit on the page.
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case_images: In fact it was a brain metastases measuring initially 1.2 cm and was at present on repeat imaging measuring 3.3 x 2.8 cm, on top of an additional smaller tumor of 1.5 cm in the right frontal lateral cortical area (Figure 4). The tumors significantly decreased in size (Figure 4).