Right adrenal metastasis from left apical non-small cell lung carcinoma with contiguous tumor thrombus extending through the inferior vena cava into the right atrium

A 76-year-old male presented to our emergency department with intermittent exertional chest pain. Computed tomography of the abdomen and pelvis demonstrated a heterogeneous right adrenal mass measuring 7.7 cm with direct tumor extension into the inferior vena cava (IVC) and right atrium; there was expansion of the IVC lumen suggestive of tumor thrombus. Magnetic resonance imaging confirmed invasion of the IVC with contiguous tumor thrombus extending into the right atrium and spanning approximately 15.5 cm craniocaudally. Image-guided biopsy of the adrenal mass confirmed metastatic poorly differentiated non-small cell lung carcinoma (NSCLC). Subsequent computed tomography of the chest demonstrated a large left apical lung mass representing the primary malignancy. After multidisciplinary evaluation, the patient elected hospice care. Adrenal metastasis from non-small cell lung carcinoma with contiguous intravascular tumor extension into the IVC and right atrium is exceedingly rare. Our case highlights this uncommon pattern of NSCLC metastasis, including incidence, clinical presentation, imaging characteristics, management, and prognosis.