title: Adrenohepatic fusion: Adhesion or invasion in primary virilizant giant adrenal carcinoma? Implications for surgical resection. Two case report and review of the literature.
abstract: BACKGROUND
  Adrenohepatic fusion means union between the adrenal gland and the liver, intermingling its parenchymas. It is not possible to identify this condition by image tests. Its presence implies radical and multidisciplinar approach.
  
  
  METHODS
  We report two female cases of 45 and 50 years old with clinical virilization and palpable mass on the abdominal right upper quadrant corresponding to adrenocortical carcinoma with hepatic fusion. The contrast-enhanced tomography showed an indistinguishable mass involving the liver and the right adrenal gland. In the first case, the patient had a two-time operation, the former removing only the adrenal carcinoma, and the second performing a radical surgery after an early relapse. In the second case, a radical right en bloc adrenohepatectomy was performed. Both cases were pathologically reported as liver-infiltrating adrenal carcinoma. Only in the second case the surgery was radical effective as first intention to treat, with 3 years of disease-free survival.
  
  
  CONCLUSIONS
  ACC is a rare entity with poor prognosis. The major indicators of malignancy are tumour diameter over 6cm, local invasion or metastasis, secretion of corticosteroids, virilization and hypertension and hypokalaemia. The parenchymal fusion of the adrenal cortical layer can be misdiagnosed as hepatocellular carcinoma with adhesion with the Glisson capsule. AHF in such cases may be misinterpreted during surgery, what may impair its resectability, and therefore the survival. The surgical treatment must be performed en bloc, often using liver vascular control. Postoperative treatment must be offered immediately after surgery.
  
  
  CONCLUSIONS
  We report two consecutive rare cases of adrenohepatic fusion in giant right adrenocortical carcinoma, not detectable by imaging, what has important implications for the surgical decision-making. As radical surgery is the best choice to offer a curative treatment, it has to be performed by a multidisciplinary well-assembled team, counting with endocrine and liver surgeons, and transplant surgeons in case of vena cava involvement, in order to maximize the disease-free survival.
authors.affiliation: Deparment of General Surgery, Endocrinologyc and Hepato-Biliary-Pancreatic Units, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain. Electronic address: aalastrue.germanstrias@gencat.cat.
authors.forename: Antonio
authors.initials: A
authors.lastname: Alastrué Vidal
authors.affiliation: Deparment of General Surgery, Endocrinologyc and Hepato-Biliary-Pancreatic Units, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain. Electronic address: drnavines@gmail.com.
authors.forename: Jordi
authors.initials: J
authors.lastname: Navinés López
authors.affiliation: Deparment of General Surgery, Endocrinologyc and Hepato-Biliary-Pancreatic Units, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain. Electronic address: jfjulian.germanstrias@gencat.cat.
authors.forename: Juan Francisco
authors.initials: JF
authors.lastname: Julián Ibáñez
authors.affiliation: Deparment of Pathology, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain. Electronic address: ndelaossa.germanstrias@gencat.cat.
authors.forename: Napoleón
authors.initials: N
authors.lastname: De la Ossa Merlano
authors.affiliation: Deparment of General Surgery, Endocrinologyc and Hepato-Biliary-Pancreatic Units, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain. Electronic address: mbotey.germanstrias@gencat.cat.
authors.forename: Mireia
authors.initials: M
authors.lastname: Botey Fernandez
authors.affiliation: Deparment of Angioradiology, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain. Electronic address: jsampere.germanstrias@gencat.cat.
authors.forename: Jaume
authors.initials: J
authors.lastname: Sampere Moragues
authors.affiliation: IDI Magnetic Resonance Unit, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain. Electronic address: mcsanchez.germanstrias@gencat.cat.
authors.forename: Maria Del Carmen
authors.initials: Mdel C
authors.lastname: Sánchez Torres
authors.affiliation: Department of Radiology, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain. Electronic address: ebarluenga.germanstrias@gencat.cat.
authors.forename: Eva
authors.initials: E
authors.lastname: Barluenga Torres
authors.affiliation: Deparment of General Surgery, Endocrinologyc and Hepato-Biliary-Pancreatic Units, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain. Electronic address: jfernandezllamazares.germanstrias@gencat.cat.
authors.forename: Jaime
authors.initials: J
authors.lastname: Fernández-Llamazares Rodríguez