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DOI:10.2214/AJR.05.0498
AJR 2007; 188:W246-W248
© American Roentgen Ray Society

Case Report

Adrenal Cortical Adenoma in Adrenohepatic Fusion Tissue: A Mimic of Malignant Hepatic Tumor at CT

Hyoun Sik Woo1, Kyoung Ho Lee1, So Yeon Park2, Ho Seong Han3, Chang Jin Yoon1 and Young Hoon Kim1

1 Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Institute of Radiation Medicine, Seoul National University Medical Research Center, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do 463-707, South Korea.
2 Department of Pathology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Korea.
3 Department of Surgery, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Korea.

Received March 24, 2005; accepted after revision June 7, 2005.

 
Address correspondence to K. H. Lee (kholee{at}snubhrad.snu.ac.kr).

WEB This is a Web exclusive article.

Keywords: abdomen • adrenal gland • adrenohepatic fusion • CT • liver • MDCT


Introduction
Top
 Introduction
Case Report
 Discussion
 References
 
Adrenohepatic fusion is defined as adhesion of the liver and right adrenal cortex and close intermingling of the respective parenchymal cells [1], with partial or complete absence of the fibrous capsule dividing the two organs [2]. Although it is not rare at autopsy [1], the clinical significance of adrenohepatic fusion has been rarely described. We report a case of adrenal cortical adenoma that developed in adrenohepatic fusion tissue and mimicked malignant hepatic tumor at CT and angiography-assisted CT.


Case Report
Top
 Introduction
 Case Report
Discussion
 References
 
A 66-year-old woman was admitted for the treatment of rectal cancer. She had been followed up for hepatitis C-related cirrhosis of Child-Pugh class A. Her serum {alpha}-fetoprotein level was 9 ng/mL (normal value ≤ 7 ng/mL). Two-phase, hepatic artery phase and delayed phase (125-second delay), abdominal CT after IV contrast material injection was performed for staging purposes. CT revealed a primary tumor at the rectal wall, multiple enlarged lymph nodes along the inferior mesenteric artery, irregular surface of the liver, splenomegaly, and a 1.5-cm solid focal lesion at the subcapsular region of the posterior section of the right liver. The hepatic nodule appeared hyperattenuating during the hepatic artery phase and hypoattenuating (mean attenuation, 78 H) during the delayed phase (Figs. 1A and 1B). Based on this dynamic enhancement pattern at CT and the presence of cirrhosis, a tentative diagnosis of hepatocellular carcinoma, rather than metastasis from the rectal cancer, was made for the hepatic lesion.


Figure 1
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  		Fig. 1A —66-year-old woman with adrenal adenoma that developed in adrenohepatic fusion tissue. Contrast-enhanced transverse CT scans show hepatic nodule (arrows) that appears hyperattenuating during hepatic artery phase (A) and hypoattenuating during delayed phase (B).

 

Figure 2
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  		Fig. 1B —66-year-old woman with adrenal adenoma that developed in adrenohepatic fusion tissue. Contrast-enhanced transverse CT scans show hepatic nodule (arrows) that appears hyperattenuating during hepatic artery phase (A) and hypoattenuating during delayed phase (B).

 
To confirm that the hepatic lesion was a single nodular tumor and to determine the treatment plan, CT during arterial portography and CT arteriography were performed [3]. During hepatic angiography, the lesion appeared as a faint hypervascular staining. The lesion appeared as a perfusion defect area at CT during arterial portography. The lateral portion of the lesion appeared hyperattenuating at CT arteriography. The medial portion of the lesion appeared as a defect in hepatic arterial perfusion (Figs. 1C and 1D), and we interpreted this finding as a portion of tumor being supplied by the right inferior phrenic artery. Otherwise, no other solid focal lesion was found in the liver. With these clinical and radiologic findings, we concluded that the hepatic lesion was a single nodular malignant tumor that was probably hepatocellular carcinoma.


Figure 3
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  		Fig. 1C —66-year-old woman with adrenal adenoma that developed in adrenohepatic fusion tissue. At CT during arterial portography, lesion appears as perfusion defect (arrow).

 

Figure 4
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  		Fig. 1D —66-year-old woman with adrenal adenoma that developed in adrenohepatic fusion tissue. At CT arteriography, lateral portion of lesion appears hyperattenuating (arrow).

 
During surgical exploration, the surgeon found that the right adrenal gland was adherent to the subcapsular hepatic nodule and therefore performed subsegmental tumorectomy and partial resection of the adrenal gland. Low anterior resection of the rectum and sigmoid colon was performed for the rectal mass. The patient recovered uneventfully and was referred to the oncologic clinic for neoadjuvant chemotherapy after the operation.

Pathologic examination revealed a 1.5-cm yellow nodule in the resected specimen (Fig. 1F). At histopathologic examination, this lesion was found to be an adrenal cortical adenoma that developed in adrenohepatic fusion tissue (Fig. 1G).


Figure 6
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  		Fig. 1F —66-year-old woman with adrenal adenoma that developed in adrenohepatic fusion tissue. Specimen photograph shows yellow nodule (arrow) surrounded by cirrhotic hepatic parenchyma.

 

Figure 7
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  		Fig. 1G —66-year-old woman with adrenal adenoma that developed in adrenohepatic fusion tissue. Immunohistochemical staining of antihepatocyte highlights absence of intervening fibrous capsule and admixture of hepatocytes (H) and adrenal cortical cells (A) at boundary of two organs. (x200)

 

Discussion
Top
 Introduction
 Case Report
 Discussion
References
 
Normally, the entire adrenal gland is surrounded by a capsule of connective tissue. The right adrenal gland anteriorly contacts the bare area of the liver, the inferior vena cava, and the peritoneum [4].

Honma [1] reported that adrenohepatic fusion is a rather common incidental finding, seen in 9.9% of 636 autopsies. The development mechanism of adrenohepatic fusion has been proposed to be a differentiation failure of the intervening fat tissue between the two organs [5]; however, an increased incidence of adrenohepatic fusion at autopsy of older patients suggests that adrenohepatic fusion may be an acquired age-related phenomenon [1]. Adrenohepatic fusion itself is not related to the pathology of each involved organ, although it has been suggested that hepatocellular carcinoma at the right liver can metastasize to the right adrenal gland through adrenohepatic fusion [6].


Figure 5
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  		Fig. 1E —66-year-old woman with adrenal adenoma that developed in adrenohepatic fusion tissue. Double oblique multiplanar reformation image shows attachment between hepatic lesion (arrow) and right adrenal gland. Note medial and lateral limbs of right adrenal gland (arrowheads).

 
In this patient, the presence of liver cirrhosis and rectal cancer led us to make the false-positive diagnosis of malignant hepatic tumor at CT; consequently, the patient underwent unnecessary hepatic resection. The attachment between the hepatic lesion and the adrenal gland could be seen by careful retrospective review of the thin-section CT data set the with the multiplanar reformation technique (Fig. 1E), which might be a clue to the correct diagnosis. However, in our experience, the fat plane between the normal right adrenal gland and the right liver is not always visible at CT, especially in thin patients; therefore, the lack of this fat plane at CT might not necessarily suggest the presence of adrenohepatic fusion.

To our best knowledge, adrenal cortical adenoma that developed in adrenohepatic fusion tissue has not been reported in the literature. Radiologists should be aware of this potential occurrence to avoid unnecessary surgery. Visualization of the attachment between the lesion and the right adrenal gland might be helpful for the preoperative diagnosis of this rare entity.


References
Top
 Introduction
 Case Report
 Discussion
 References
 

  1. Honma K. Adreno-hepatic fusion: an autopsy study. Zentralbl Pathol 1991;137 : 117-122[Medline]
  2. Dolan MF, Janovski NA. Adreno-hepatic union (adrenal dystopia). Arch Pathol 1968;86 : 22-24[Medline]
  3. Choi D, Kim S, Lim J, et al. Preoperative detection of hepatocellular carcinoma: ferumoxides-enhanced MR imaging versus combined helical CT during arterial portography and CT hepatic arteriography. AJR 2001; 176:475 -482[Abstract/Free Full Text]
  4. O'Rahilly R. The kidneys, ureters, and suprarenal glands. In: O'Rahilly R, ed. Gardner-Gray-O'Rahilly anatomy, 5th ed. Philadelphia, PA: Saunders, 1986:423
  5. Honore LH, O'Hara KE. Combined adrenorenal fusion and adrenohepatic adhesion: a case report with review of the literature and discussion of pathogenesis. J Urol 1976;115 : 323-325[Medline]
  6. Okano K, Usuki H, Maeta H. Adrenal metastasis from hepatocellular carcinoma through an adrenohepatic fusion. J Clin Gastroenterol 2004; 38:912[CrossRef][Medline]

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