What is the likely diagnosis and treatment for a patient with a left upper lobe cavitary spiculated mass, a right upper lobe spiculated mass, ground glass opacities, and a left adrenal nodule?

Likely Diagnosis: Advanced Non-Small Cell Lung Cancer with Bilateral Pulmonary Involvement and Adrenal Metastasis

This presentation is highly suspicious for advanced stage non-small cell lung cancer (NSCLC) with bilateral pulmonary disease and adrenal metastasis, requiring urgent tissue diagnosis via biopsy of the most accessible lesion, followed by comprehensive staging and systemic therapy rather than surgical resection.

Diagnostic Interpretation

Primary Pulmonary Findings

• The bilateral spiculated masses (5.1 cm left upper lobe with cavitation, 3.4 cm right upper lobe) are highly suspicious for malignancy, as spiculation is a well-established risk factor for cancer with an odds ratio of 2.2-2.5 in detected nodules 1

• The cavitary nature of the left upper lobe mass further increases malignancy concern, as cavitation in large spiculated masses is commonly associated with squamous cell carcinoma or other aggressive histologies 1

• The multiple ground-glass opacities and semisolid nodules scattered throughout both upper lobes suggest either multifocal adenocarcinoma or intrapulmonary metastases 1

• The Fleischner Society guidelines indicate that multiple subsolid nodules with at least one suspicious lesion (large size, ground-glass appearance, and solid morphology) are most consistent with multifocal primary adenocarcinoma 1

Adrenal Nodule Assessment

• The 2.8 cm left adrenal nodule in the context of bilateral lung masses is highly suspicious for metastatic disease, as adrenal metastases occur in approximately 5-10% of clinical NSCLC cases 2, 3

• However, 40-60% of unilateral adrenal masses in patients with otherwise operable NSCLC are benign (adenomas, hyperplastic nodules, or hemorrhagic cysts), making pathologic confirmation essential 4

• The size (2.8 cm) exceeds the threshold where benign vs. malignant distinction becomes critical for staging and treatment decisions 1

Immediate Diagnostic Workup

Tissue Diagnosis (Priority #1)

• Obtain tissue diagnosis via the most accessible route: bronchoscopy with biopsy for the endobronchial component of the cavitary left upper lobe mass, or CT-guided biopsy of the larger accessible pulmonary lesion 1

• Do NOT perform fine needle biopsy of the adrenal mass first if pheochromocytoma has not been excluded, as this is contraindicated 1

• If bronchoscopy is non-diagnostic and the adrenal lesion is the most accessible, consider EUS-guided FNA of the adrenal gland after biochemical exclusion of pheochromocytoma, which has 100% accuracy for diagnosing adrenal metastasis 5

Comprehensive Staging Evaluation

• PET/CT scan to assess metabolic activity of all lesions, evaluate for additional metastatic sites, and guide biopsy decisions 1

• Brain MRI to exclude brain metastases, as this is recommended for patients with locally advanced NSCLC being considered for any curative-intent approach 1

• Invasive mediastinal staging (EBUS or mediastinoscopy) if PET/CT shows abnormal mediastinal or hilar lymph nodes, as mediastinal nodal involvement represents a contraindication to primary resection 1

Adrenal Lesion Characterization

• If PET/CT shows high FDG uptake in the adrenal mass (SUV >3.1, SUV ratio >2.5), this strongly suggests metastasis but requires pathologic confirmation given the 15% false-positive rate 6

• Obtain dedicated adrenal CT protocol (unenhanced CT to measure Hounsfield units, with 15-minute delayed contrast-enhanced CT for washout assessment) or chemical shift MRI to help distinguish benign adenoma from metastasis 1

• EUS-guided FNA of the adrenal gland provides definitive diagnosis with 100% accuracy and should be performed if imaging is indeterminate and the result would change management 5

Staging Classification

Most Likely Scenario: Stage IV Disease

• If the adrenal nodule is confirmed as metastatic, this represents M1b disease (distant metastasis to a single extrathoracic organ) 1

• The bilateral pulmonary involvement likely represents either:

  • T4 disease (separate tumor nodules in different ipsilateral lobes) if proven to be the same histologic subtype as intrapulmonary metastases 1
  • Multiple synchronous primary lung cancers if different histologic subtypes or growth patterns suggest separate primaries 1

Alternative Scenario: Multifocal Adenocarcinoma

• If the adrenal nodule is benign and the pulmonary lesions represent multifocal ground-glass/lepidic adenocarcinoma, the T stage would be determined by the highest T-lesion with notation of multifocal nature 1

• The American College of Chest Physicians suggests that multiple subsolid nodules suspected to be malignant should be classified as multifocal lung cancer (MFLC), which may be amenable to curative-intent treatment 1

Treatment Approach

If Stage IV Disease (Adrenal Metastasis Confirmed)

• Systemic therapy is the primary treatment modality, not surgical resection 1, 2

• Molecular testing of the tumor tissue is essential to guide targeted therapy selection (EGFR, ALK, ROS1, BRAF, PD-L1 expression) before initiating treatment

• Combination chemotherapy or immunotherapy based on histologic subtype and molecular profile, with consideration of local consolidative therapy to oligometastatic sites if excellent response to systemic therapy 2, 3

• Adrenalectomy may be considered only in highly selected cases of oligometastatic disease with excellent response to systemic therapy and no other sites of disease, as long-term survival can be achieved in such patients 3, 4

If Multifocal Lung Cancer (Adrenal Nodule Benign)

• Curative-intent treatment should be pursued if the patient has adequate pulmonary reserve and no mediastinal nodal involvement 1

• Sublobar resection of all lesions suspected of being malignant is suggested if feasible, rather than multiple lobectomies 1

• Distant and mediastinal staging are not routinely necessary if clinical evaluation is negative and mediastinum appears normal by CT 1

Critical Pitfalls to Avoid

• Do not assume the adrenal nodule is metastatic without pathologic confirmation, as 40-60% are benign even in the setting of lung cancer, and this distinction completely changes staging and treatment 4

• Do not proceed with surgical resection of the lung lesions without first confirming the adrenal status, as the presence of adrenal metastasis would make surgery inappropriate 4

• Do not misclassify bilateral pulmonary involvement as M1a disease without careful multidisciplinary assessment of whether these represent intrapulmonary metastases vs. synchronous primaries vs. multifocal adenocarcinoma, as this affects treatment approach 1

• Ensure adequate tissue is obtained for both histologic diagnosis and comprehensive molecular testing, as this is essential for treatment selection in advanced NSCLC

• Do not delay brain imaging, as the presence of brain metastases would further impact prognosis and treatment decisions 1