BILATERAL ADRENAL MALIGNANT MASSES WITH EXTENSIVE CAVO-PORTAL-MESENTERIC TUMOR THROMBUS AND RAPID FATAL OUTCOME: AN IMAGING-BASED CASE REPORT

Abstract

Background: Bilateral adrenal malignant masses are uncommon and may be diagnostically challenging, particularly when associated with hepatic invasion and extensive venous tumor thrombus. Cross-sectional imaging is pivotal for defining the site of origin, mapping vascular extension, and refining the differential diagnosis.

Case presentation: A 60-year-old man presented with epigastric pain and abdominal swelling. Initial abdominal ultrasound suggested chronic liver disease with a focal right hepatic lesion, splenomegaly, and moderate ascites. Subsequent contrast-enhanced CT abdomen demonstrated large bilateral adrenal masses with extensive local and vascular invasion. The right adrenal mass invaded the inferior vena cava (IVC), with tumor thrombus extending cranially into the chest and possible right atrial involvement, and directly invaded the right hepatic lobe. Tumor thrombus also involved the portal vein, superior mesenteric vein (SMV), and splenic vein, with associated altered hepatic enhancement. The left adrenal mass extended into the left renal vein and further into the IVC. Moderate ascites was present. The extent of vascular involvement suggested advanced-stage disease at presentation, limiting therapeutic options and precluding surgical intervention. The patient deteriorated rapidly and died within one week. Histopathologic confirmation was unavailable. This extremely short clinical course highlights the fulminant biological behavior of the underlying malignancy.

Conclusion: This case highlights an unusually aggressive imaging pattern of bilateral adrenal malignant masses with simultaneous systemic and portal venous tumor thrombus. It underscores the value of contrast-enhanced CT in correcting an initial sonographic impression favoring primary hepatic disease, establishing adrenal origin, and mapping the full extent of vascular invasion. In the absence of tissue diagnosis, the findings were most suggestive of adrenal cortical malignancy, with metastatic adrenal disease and malignant pheochromocytoma remaining differential considerations.