Adrenocortical carcinoma misdiagnosed as hepatocellular carcinoma
CrossMark
Hao-Wei Chen, Yu-Chen Chen, Ming-Yen Hsieh, Yung-Shun Juan
A 57-year-old woman without underlying disease was referred by her family doctor to Kaohsiung Municipal Ta-Tung Hospital (Kaohsiung, Taiwan) in October, 2017, for presenting with abdominal fullness lasting for several months. A huge hetero- echoic hepatic mass was identified by abdominal ultrasound. Laboratory data revealed mildly elevated liver enzymes (glutamate-oxaloacetate transaminase 44 IU/L and glutamate-pyruvate transaminase 61 IU/L) and elevated total bilirubin (1.9 mg/dL). CT scan revealed a 20-cm tumour in the right hepatic lobe, enhanced in the arterial phase and washed out in the portal and delayed phases (figure, A).
The pathological analysis of tissue sample collected by echo-guided aspiration showed cell necrosis, suggesting possible hepatocellular carcinoma with central necrosis, an inoperable disease. However, the tumour markers showed normal levels of a-fetoprotein (1.32 ng/ml). This finding led us to re-review the abdominal CT scan. We discovered a tiny so-called fat plane between the tumour and the liver (figure, B), causing us to re-diagnose the lesion as a retroperitoneal tumor. Because adrenal tumors are a potential differential diagnosis of retro- peritoneal tumours, a hormonal workup that included an analysis of glucocorticoids, mineral- ocorticoids, sex steroids, and catecholamine was done before surgery, which showed negative findings. The tumour was excised. Pathological findings showed adrenocortical carcinoma, stage
pT3N0, with a free surgical margin. After surgery, the patient’s health improved.
Right-sided huge retroperitoneal malignancy can mimic a huge hepatocellular carcinoma when located close to the liver. Being supplied by many blood vessels, such tumours can present with early enhancement in the arterial phase and early washout in the venous phase relative to normal liver findings in abdominal CT scans. Because there is biliary tract compression, patients may have increased serum concentrations of liver enzymes and bilirubin. These findings might lead to a misdiagnosis by physicians. This incorrect diagnosis can be avoided by noticing a tiny fat plane between the tumour and liver or kidney, indicating that the lesion is in fact retroperitoneal in origin. This difference allows us to differentiate between these two difficult-to-distinguish entities. In this case, a life-saving surgical procedure could be performed.
Contributors
H-WC wrote the draft of the report, did the literature search, and contributed to data interpretation. Y-CC wrote the draft of the report, did the literature search and figure editing. M-YH contributed to data interpretation. Y-SJ contributed to data interpretation and corrections to the report. All authors were equally involved in clinical diagnosis and surgical management of the patient. All authors have approved the final version of the report. Written informed consent to publication was obtained.
Declaration of interests
We declare no competing interests.
@ 2018 Elsevier Ltd. All rights reserved.
Lancet Oncol 2018; 19: e429
Graduate Institute of Clinical Medicine (H-W Chen MD, Y-C Chen MD), Graduate Institute of Medicine (Prof Y-S Juan PhD), and Department of Urology (Prof Y-S Juan), College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Urology (H-W Chen, Y-C Chen, Prof Y-S Juan) and Hepatobiliary Division, Department of Internal Medicine (M-Y Hsieh PhD), Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; and Department of Urology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan (Prof Y-S Juan)
Correspondence to: Prof Yung-Shun Juan, Department of Urology, Kaohsiung Medical University Hospital, No. 100, Tz-You 1st Road, Kaohsiung 807, Taiwan juanuro@gmail.com
A
B