Case: A 62 year old man was admitted acutely with right sided abdominal pain. A CT scan with contrast showed an acute right-sided adrenal haemorrhage with adjacent necrotic lymphadenopathy and multiple pulmonary nodules. An MRI, requested to further define the lesion, reported a malignant looking 7.4 cm right adrenal mass with direct focal invasion into the liver and inferior vena cava however no further liver lesions were identified. The images were discussed at the multi-disciplinary meeting (MDT) and it was thought that this was most likely a metastatic adrenocortico-carcinoma (ACC). Adrenal biochemical functional testing was performed which all returned normal. His lesions were not amenable to surgical treatment. Biopsies of ACC are not usually recommended due to bleeding risk and tumour cell seeding therefore a referral was made for consideration of palliative mitotane. Whilst awaiting this, an FDG-PET was performed to further define the extent of his disease. This showed more malignant deposits: multiple areas in the liver, lung, lymph nodes and possibly bone. This led us to re-think the diagnosis and, following re-discussion in the MDT, a lymph node biopsy was performed. Histology confirmed metastatic hepatocellular carcinoma (HCC) as opposed to ACC. Alpha feto-protein subsequently sent was 280Ku/l (010).
Discussion: Patients presenting with large adrenal lesions and metastatic deposits can present a diagnostic and management dilemma. Radiological investigations can be strongly suggestive of a primary adrenocortico-carcinoma however there are no clear guidelines as to when to biopsy metastatic lesions associated with large adrenal masses unless there is a known separate primary cancer, with biopsies of primary adrenal lesions discouraged entirely. However in some circumstances, a biopsy can be helpful in confirming a diagnosis to ensure correct management. This case adds to the small number of reported cases where adrenal metastatic HCC deposits have caused a diagnostic challenge.