Scientific letter
Adrenal metastasis as presentation of hepatocellular carcinoma
Metástasis adrenal como presentación de un hepatocarcinoma
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"identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Raquel" "apellidos" => "Ríos León" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Álvaro" "apellidos" => "Flores de Miguel" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Antonio" "apellidos" => "Guerrero García" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Héctor" "apellidos" => "Pian" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "Francisco" "apellidos" => "Gea Rodríguez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 6 => array:3 [ "nombre" => "Agustín" "apellidos" => "Albillos Martínez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Gastroenterología y Hepatología, Hospital Ramón y Cajal, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital Ramón y Cajal, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Metástasis adrenal como presentación de un hepatocarcinoma" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1221 "Ancho" => 2500 "Tamanyo" => 293802 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) MRI of metastasis in the left adrenal gland (arrow). (B) Haematoxylin–eosin staining of hepatocellular carcinoma (H) metastasis adjacent to normal adrenal tissue (AG).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Extrahepatic disease often develops during progression of hepatocellular carcinoma, but metastatic disease as an initial manifestation is rare. Our case study is a 61-year old male patient who received an orthotopic liver transplantation 10 years ago due to decompensated alcohol-related cirrhosis and hepatitis <span class="elsevierStyleSmallCaps">C</span> virus infection with no virological response to earlier therapies.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Pathology tests on the explanted liver specimen ruled out the presence of hepatocellular carcinoma. Following transplantation, immunosuppressant therapy with ciclosporin 150<span class="elsevierStyleHsp" style=""></span>mg/12<span class="elsevierStyleHsp" style=""></span>h and mycophenolate mofetil 500<span class="elsevierStyleHsp" style=""></span>mg/12<span class="elsevierStyleHsp" style=""></span>h was initiated. During the first few months following transplantation, the patient's laboratory and histology test results were suggestive of rejection, which was resolved with corticosteroid therapy. The patient was then monitored using blood tests, ultrasound and Fibroscan<span class="elsevierStyleSup">®</span>, with no evidence of significant alterations and maintaining normal liver function. Nine years after the transplantation, the patient was treated with a combination of sofosbuvir, ledipasvir and ribavirin for 12 weeks, achieving sustained virological response. One year later, elevated alpha-fetoprotein levels (111.89<span class="elsevierStyleHsp" style=""></span>IU/ml, increased from 7.6<span class="elsevierStyleHsp" style=""></span>IU/ml) were observed in a routine blood test.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A multiphase computerised axial tomography scan (CT scan) of the abdomen was performed, which showed a liver graft of normal size and morphology, and a nodule measuring 4<span class="elsevierStyleHsp" style=""></span>mm in liver segment VI with contrast uptake in the arterial phase and no evidence of washout in the venous phase, LI-RADS-3. A lobulated, solid, left adrenal mass measuring 77<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>44<span class="elsevierStyleHsp" style=""></span>mm was also described. Three months later, magnetic resonance imaging (MRI) of the abdomen showed enlargement of the adrenal lesion (88<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>66<span class="elsevierStyleHsp" style=""></span>mm) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A), which was not characterisable with this imaging method, and stability of the liver lesion. The presence of hormone hypersecretion was ruled out: thyroid function tests, cortisol, ACTH, DHEA, 17-OH progesterone, urine catecholamines and cortisol suppression following dexamethasone injection were all within the normal range. It was decided that it was best to surgically remove the lesion. Histopathology tests (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B) revealed a metastatic carcinoma with an immunohistochemical morphology and profile consistent with hepatocellular carcinoma (Hep Par-1, cytoplasmic TTF-1, CAM 5.2 and CD10). There was no infiltration of the resection margins. The size of the liver lesion had remained stable on the control CT scan. A PET/CT scan was performed, which showed no suspicious malignant lesions. Today, five months after surgical resection, the patient is stable and shows no signs of tumour recurrence on imaging scans, with alpha-fetoprotein levels of 6.7<span class="elsevierStyleHsp" style=""></span>IU/ml.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Adrenal incidentalomas are extremely common. Although the best way to manage such tumours has not been completely determined, the first step is to rule out the presence of hormone hypersecretion and the possibility of malignancy.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Some lesions may be characterisable from imaging scans. In other cases, pathology testing of the lesion may be required to determine whether it is benign or malignant.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Metastases account for 5% of adrenal incidentalomas.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> The incidence of adrenal metastasis from hepatocellular carcinoma in autopsy series ranges from 4.6% to 12.5%, and it is the fourth most common site of metastasis after the lungs, lymph nodes and bones.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> It has been suggested that the most likely mechanism of onset is arterial spread via the aorta.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">These lesions can be synchronous or metachronous, and may appear years after liver transplantation performed to treat hepatocellular carcinoma.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> However, adrenal metastasis as the first clinical manifestation is extremely rare.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> A literature review revealed a few cases in which metastasis was the initial manifestation of hepatocellular carcinoma. Bone lesions, right atrial metastases, lesions in the parotid gland, a mass in the gluteal region and adrenal metastases have been reported.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">4,5</span></a> However, in all of these cases, a primary lesion was detected during follow-up,<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">4,5</span></a> unlike the case study presented herein, in which, 9 months after initial diagnosis, there was no evidence of intrahepatic disease. Therefore, based on existing scientific evidence, this is the first ever described case of adrenal metastatic disease with no evidence of a primary liver tumour.</p><p id="par0040" class="elsevierStylePara elsevierViewall">To conclude, adrenal metastasis can be the first manifestation of the disease and must be considered if an adrenal incidentaloma is detected in patients with an increased risk of hepatocellular carcinoma.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Sánchez Rodríguez E, Ríos León R, Flores de Miguel Á, Guerrero García A, Pian H, Gea Rodríguez F, et al. Metástasis adrenal como presentación de un hepatocarcinoma. Gastroenterol Hepatol. 2019;42:171–172.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1221 "Ancho" => 2500 "Tamanyo" => 293802 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) MRI of metastasis in the left adrenal gland (arrow). 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 1 | 7 |
| 2024 October | 18 | 1 | 19 |
| 2024 September | 31 | 4 | 35 |
| 2024 August | 27 | 3 | 30 |
| 2024 July | 17 | 3 | 20 |
| 2024 June | 28 | 3 | 31 |
| 2024 May | 24 | 2 | 26 |
| 2024 April | 31 | 7 | 38 |
| 2024 March | 29 | 5 | 34 |
| 2024 February | 39 | 5 | 44 |
| 2024 January | 51 | 4 | 55 |
| 2023 December | 65 | 4 | 69 |
| 2023 November | 47 | 8 | 55 |
| 2023 October | 58 | 3 | 61 |
| 2023 September | 33 | 3 | 36 |
| 2023 August | 21 | 1 | 22 |
| 2023 July | 9 | 5 | 14 |
| 2023 June | 17 | 2 | 19 |
| 2023 May | 30 | 2 | 32 |
| 2023 April | 43 | 2 | 45 |
| 2023 March | 33 | 7 | 40 |
| 2023 February | 27 | 4 | 31 |
| 2023 January | 18 | 6 | 24 |
| 2022 December | 24 | 5 | 29 |
| 2022 November | 19 | 6 | 25 |
| 2022 October | 21 | 8 | 29 |
| 2022 September | 16 | 7 | 23 |
| 2022 August | 33 | 7 | 40 |
| 2022 July | 21 | 9 | 30 |
| 2022 June | 23 | 13 | 36 |
| 2022 May | 19 | 6 | 25 |
| 2022 April | 36 | 12 | 48 |
| 2022 March | 15 | 9 | 24 |
| 2022 February | 26 | 6 | 32 |
| 2022 January | 47 | 7 | 54 |
| 2021 December | 42 | 9 | 51 |
| 2021 November | 20 | 10 | 30 |
| 2021 October | 31 | 10 | 41 |
| 2021 September | 14 | 5 | 19 |
| 2021 August | 7 | 0 | 7 |
| 2021 July | 12 | 9 | 21 |
| 2021 June | 13 | 4 | 17 |
| 2021 May | 11 | 6 | 17 |
| 2021 April | 31 | 1 | 32 |
| 2021 March | 8 | 1 | 9 |
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