ADRENOCORTICAL CARCINOMA WITH LARGE, SOLITARY HEPATIC METASTASIS FIFTEEN YEARS AFTER RESECTION OF PRIMARY TUMOUR, A CASE REPORT

E Alhamar, W Wall, S Chakrabarti, PJ Marotta

Liver Transplant Unit, London Health Sciences Centre, University of Western Ontario, London, Ontario

Adrenocortical carcinoma (ACC) is a rare tumour with an incidence of approximately 0.5-2 cases per million per year. The overall prognosis is poor mainly due to delayed diagnosis and the presence of micrometastases. Complete surgical resection of both the tumour and metastases, when applicable, is considered the standard of care. Adjuvant chemotherapy and/or mitotane (o,p'-DDD; an adrenocorticolytic agent) can be used in non-resectable tumours with variable results.
We report a 73-year-old man who presented with an incidental finding of a liver mass on routine imaging .The mass measured 7.1cm ´ 6.5cm ´ 5.8 cm with abdominal ultrasonography. Fine- needle aspiration of the mass revealed malignant cells suggestive initially of hepatocellular carcinoma. Two experienced pathologists agreed on the diagnosis, independently. The patient was asymptomatic, had no risk factors for chronic liver disease or hepatocellular malignancy. He had normal liver enzymes and normal liver function testing. However, he had a past history of a non-functioning left adrenocortical carcinoma. This lesion, was detected during a routine physical exam fifteen years ago (1987). He underwent a left adrenalectomy and complete nephrectomy. The tumour was 20 cm in maximum diameter and was stage 2/4 with no evidence of local invasion or distant metastases. No adjuvant therapy was recommended and at 5-years follow up there was no evidence of recurrence. During his pre-operative evaluation for presumed hepatocellular cancer resection, an ultrasound-guided liver biopsy of the unaffected lobe revealed normal hepatic histology. He then underwent complete segmental resection of the right lobe of the liver successfully. The final diagnosis of the mass was a well-differentiated metastatic adrenocortical carcinoma.
The prognosis of ACC is considered extremely poor and even for stage 1 or 2 ACC the 5-year survival is approximately 20 percent. This case illustrates the potential for prolonged survival following aggressive tumour resection. In addition there has been no previous reports of solitary liver metastatic ACC so long after treatment of the primary ACC.