HETEROTOPIC ADRENAL CORTICAL ADENOMA MASQUERADING AS METASTATIC RENAL CELL CARCINOMA

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It is known that a heterotopic adrenal gland may be located in the upper abdomen or anywhere along the path of descent of the gonads.'.* Such adrenal glands may undergo hyperplasia in response to increased levels of adrenocorticotropic hormone, and they may serve as a site of origin of a cortical neoplasm.3 Conceivably heterotopic adrenal cortical hyperplasia and/or adenoma may be confused with certain primary or metastatic tumors. We report a case of adrenal cortical adenoma arising from the heterotopic adrenal cortex in the gastroesophageal junction that was misdiagnosed as metastatic renal cell carcinoma before and during radical nephrectomy for primary renal cell carcinoma. To our knowledge our case represents the first report of heterotopic adrenal cortical adenoma at the gastroesophageal junction mimicking metastatic renal cell carcinoma. CASE REPORT A 60-year-old black man presented with hematuria. Subsequently excretory urography and computerized tomography (CT) revealed a 12 x 12 cm. mass in the upper pole of the right kidney consistent with renal cell carcinoma (fig. 1). In addition, CT and esophagogastroduodenoscopic ultrasound showed a solid 2 x 3 cm. lesion at the gastroesophageal junction immediately outside the gastroesophageal wall. Transgastric fine needle aspiration of the mass demonstrated clusters of epithelial cells with clear cytoplasm consistent with metastatic renal cell carcinoma. Biopsy of the gastric mucosa revealed chronic active gastritis with no evidence of tumor in the gastric wall. Therapeutic approaches were significantly complicated by these apparent gastroesophageal metastases. After considering the risks, benefits and alternatives the patient elected right radical nephrectomy followed by exploration of the lesion at the gastroesophageal junction. During surgery the 2.5 to 3.0 cm., soft, rubbery, bright yellow-orange mass was not