Adrenal cortical carcinoma presenting as right varicocele.

A 39-year-old man was referred to us for a 3-month history of rapid onset right hemiscrotal discomfort and swelling that decreased when he was supine. Medical history included vasectomy 5 years earlier. He denied abdominal pain, flushing, headaches, weight loss or other constitutional symptoms. Physical examination of the abdomen was remarkable for fullness in the right upper quadrant and right grade III varicocele. Ultrasound demonstrated subclinical left varicocele and confirmed dilatation of the right pampiniform plexus venous channels from 1.8 to 6 mm. with a Valsalva maneuver. Computerized tomography (CT) of the abdomen and pelvis with contrast medium revealed a 12 cm. right adrenal mass. There was evidence of central necrosis with peripheral calcifications and compression of the inferior vena cava just cephalad to the right renal vein (see figure). Urinalysis, complete blood count, serum chemistry studies, liver function tests and urinary catecholamines were normal. Urinary cortisol was modestly increased at 56.7 mg./24 hours (normal less than 50). Serum dehydroepiandrosterone sulfate was increased at 562 mg./dl. (normal 88 to 305). Metastatic evaluation, including CT of the chest and a bone scan, was normal. Magnetic resonance imaging was performed to exclude thrombus involving the inferior vena cava, which was equivocal and a subsequent inferior vena caval venogram revealed external compression without evidence of thrombus. Right adrenalectomy through a thoracoabdominal approach was performed without complication. Pathological examination revealed a 730 gm. poorly differentiated adrenal cortical carcinoma with 1 focus of capsular penetration into peri-adrenal fat. Pathological stage was T3M0N0 (American Joint Committee on Cancer criteria) with greater than 6 mitoses per high power field, extensive tumor necrosis and dystrophic calcifications. DISCUSSION Varicoceles are most common as unilateral dilatation of the pampiniform plexus of veins above the left testis. Left varicoceles are present in approximately 10% to 20% of men and are believed to be secondary to the venous anatomy of the left testis. Right varicoceles usually occur as bilateral processes and are apparent in 10% of clinical cases and as many as 50% of subclinical cases. Unilateral right varicocele may be attributed to the presence of situs inversus, persistence of embryological ve