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Collision/Composite Tumors of the Adrenal Gland: A Pitfall of Scintigraphy Imaging and Hormone Assays in the Detection of Adrenal Metastasis

Institut National de la Santé et de la Recherche Médicale U413 (A.T.-S., H.L.), European Institute for Peptide Research (Institut Fédératif de Recherches Multidisciplinaires sur les Peptides 23), Department of Endocrinology, Diabetology, and Metabolic Diseases, and Department of Pathology (A.P.), Centre Hospitalier Universitaire of Rouen, 76031 Rouen, France; and Department of Pathology (F.T.-R.), Centre Hospitalier Universitaire Cochin, and Department of Endocrinology (L.G., X.B., J.B.), Centre Hospitalier Universitaire Cochin and Institut Cochin, Institut National de la Santé et de la Recherche Médicale U567, Centre National de la Recherche Scientifique UMR8104, IFR 116, Université Paris V-René Descartes, 75014 Paris, France

Address all correspondence and requests for reprints to: Dr. Hervé Lefebvre, Institut Fédératif de Recherche Multidisciplinaires sur les Peptides 23, Institut National de la Santé et de la Recherche Médicale U413, Department of Endocrinology, Hospital of Boisguillaume, Centre Hospitalier Universitaire of Rouen, 76031 Rouen cedex, France. E-mail: herve.lefebvre{at}chu-rouen.fr.

Context: In patients with a history of extraadrenal tumor, incidental discovery of an adrenal mass necessitates excluding the possibility of metastatic malignancy. Detection of the malignant tissue is a difficult challenge when metastasis occurs in an adrenal adenoma, forming a collision/composite tumor.

Objective, Design, and Setting: We report two patients with adrenal collision/composite tumors referred to two French university hospitals.

Patients and Results: Two patients with histories of mammary and sigmoid carcinomas, respectively, presented with adrenal mass discovered 8 and 3 yr after surgical removal of the primary tumor. In the two cases, computerized tomographic scan showed that the adrenal tumor contained two components with low and high attenuation values, respectively. Uptake of iodocholesterol by the adrenal tumor in case 1 and elevated plasma ACTH-stimulated 17-hydroxyprogesterone values in case 2 strongly argued for the diagnosis of primary adrenocortical tumors. Enlargement of the adrenal mass during follow-up in case 1 and association of the adrenal lesion with a hepatic mass in case 2 led to adrenalectomy. In both cases, histological examination of the tumor demonstrated the presence of metastatic carcinoma tissue in an adrenocortical adenoma, allowing classification of the neoplasia as a collision/composite tumor.

Conclusion: These observations show that collision/composite tumors of the adrenal gland formed by carcinoma metastasis in benign adenomas are a pitfall of iodocholesterol scintigraphy and/or plasma steroid assays to exclude the diagnosis of adrenal metastasis. Conversely, computerized tomographic scan is a useful tool for the distinction between the benign and malignant tissues in adrenal collision/composite tumors.

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