Primary Hyperaldostronisim as Initial Presentation of Adrenal Cortical Carcinoma with Liver Metastasis: A Case Report
A 22-year-old female patient with a 4-month history of weakness and tachycardia referred to Imam Reza hospital in Tabriz because of intensity of symptoms and loss of consciousness. The blood examination revealed decreased levels of potassium; 2.7 mEq/L and her blood pressure was 190/100 mmHg, she just received emergency agents as outpatient. After three months, symptoms flared up and the patient was admitted to the department of internal medicine. A detailed past medical history of the patient was taken; hypertension during last six months and preeclampsia in her prior pregnancy were detected. No family history of malignancies found. In her review of systems; weight loss (7kg during last four months), weakness, headache, tachycardia, nocturia, polyuria, polydipsia and frequency were found and there was no significant history of abdominal pain, vomiting, urinary incontinence or fever. Mucosal dehydration and positive trousseau test were points in general and physical examination. Before hospitalization she obtained atenolol 50mg/24h for hypertension. Liver and renal function tests, complete blood count and urine 24h analysis were within normal limits. Urine complete examination was negative for albumin and sugar, and in microscopic analysis; WBC: 15-16 and epithelial cell: 27-28 was reported, No crystals or casts were detected and urine culture was negative. Serum potassium was 2.9mEq/L and serum Ca ion was 0.87mmol/L. Arterial blood gas examination indicated metabolic alkalosis (PH = 7.54, PCO2 = 34.7, HCO3 = 29). ECG and chest x-ray were normal. Blood measurements of plasma aldostron and rennin after one hour upright standing posture in the morning were: aldostron = 350 units, rennin = 0.9 units. A captopril Suppression Test (CST) did not result in aldostron suppression. In order to confirm the first diagnosis, an abdominal spiral computed tomography was performed but there was no evidence of any lesions in liver, kidneys and adrenal glands. Despite the previous oral and later intravenous potassium supplementation of up to 40mEq/24h, potassium level was low and on the 10th day of hospitalization it was 3.2mEq/L. Calcium channel blockers, β-blockers and potassium sparing diuretics were added to the treatment and resulted in blood pressure decrease to 140/80mmHg on the last day of hospitalization. The patient was discharged from hospital but symptoms recurred after a week. In magnetic resonance imaging (MRI) of adrenal glands with IV contrast, a mass measuring 53×25×46 mm in size at the posterior aspect of inferior vena cava and medial side of liver just above right adrenal gland confirmed an adrenal gland tumor (). The patient underwent exploratory laparotomy with excision of right adrenal gland. The tumor had extended behind IVC, no invasion to adjacent organs or metastasis to lymph nodes was noted during the operation. Per-operative finding was a mass of about 6×5.5×1.5 cm.\nHistopathological examination revealed adrenal tissue with a cortical adenoma with areas of hemorrhage and necrosis, composed of cells with granular cytoplasm, mild and focal nuclear pleomorphism and occasional mitosis. After the surgical intervention, she was discharged uneventfully. Then she was followed-up irregularly due to pregnancy. Signs and symptoms have been revealed for six months, until the end of her first trimester (16th week), meanwhile she had flaring of hypertension and hypokalemia during anesthesia for McDonald's operation. Followed-up MRI showed no evidence of recurrent tumor at right side, even size or configuration of left side adrenal gland was normal. Her poor follow-up during pregnancy resulted in recurring hypertension and hypokalemia during cesarean section. On post operative control MRI of abdomen one year after right adrenalectomy, a round solid mass at the site of removed adrenal gland measuring 56×53 mm on diameter was seen. The mass involved the inferior aspect of the liver and probably superior anterior aspect of the right kidney. These findings indicated relapse of the removed adrenal tumor (). Liver needle biopsy was performed and proved liver tissue with relatively normal parenchymal cells and small focus of atypical cells. Primary surgery's slides reviewed; pathological examination revealed a cream-brown mass about 3.5×3 cm with hemorrhagic and necrotic areas. On microscopic assessment, neoplastic proliferation of adrenocortical cells in a diffuse pattern sometimes with severe pleomorphism, tumor cell necrosis with occasionally mitoses more than 5/50HPF was seen.\nTumoral cells also invaded the capsule, so according to Weiss criteria for malignancy, (Nine histological criteria of Adrenal Cortical Carcinoma: 1. Nuclear grade C Fuhrman III/I 2. Mitotic rate 5/50 hpf. 3. Abnormal mitosis 4. <25% clear cells 5. 1/3 diffuse architecture 6. Necrosis 7. Venous invasion 8. Sinusoidal invasion 9. Capsular invasion), this neoplasm had five of nine criteria which was compatible with adrenal cortical carcinoma ( and ).\nThe patient was discussed in tumor board and surgery planned for her followed by adjuvant treatment; surgery versus chemotherapy with mitotane. The Patient underwent surgery again with resection of right recurring adrenal tumor, liver right lobe segmental lobectomy, cholecystectomy and resection of retroperitoneal mass was done under general anesthesia. Histopathologic assessment of second surgical specimens showed segmental lobectomy of right hepatic lobe (14×12×12 cm) and retroperitoneal mass resection (5×5×4 cm) also showed the same microscopic features of primary adrenal cortical tumor composed of large eosinophilic cells with highly atypical nuclei arranged in peritheliomatous and diffuse pattern with extensive necrosis ( and ).