Unusual cause of chronic abdominal pain in a 17-year-old female: a case report of an epithelial adrenal cyst.

Adrenal cysts are rare lesions that make up 4% of all adrenal masses. They are often found incidentally during imaging or surgery and can vary in symptoms depending on their size and location; with cysts < 10 cm often being asymptomatic. These cysts are more common in adults in their 30s or 60s and can be divided into four histological subtypes, with epithelial cysts being less common. We present a case of a 17-year-old female who experienced recurrent right flank pain for a year. Ultrasonography revealed a cystic mass on the right kidney, and computerized tomography showed a well-defined suprarenal cyst measuring ~8 cm misdiagnosed as mesenteric cyst. However, during laparoscopy, an adrenal cyst was discovered, which was excised along with the right adrenal gland. Histopathology confirmed the diagnosis of an epithelial adrenal cyst. This case highlights the occurrence of adrenal cysts in younger individuals and the uncertainty of preoperative diagnosis.

Intrahepatic Portosystemic Shunt via the Right Adrenal Vein in an Asymptomatic Cirrhotic Patient.

PURPOSE: Intrahepatic Portosystemic Shunts (PSSs) draining to the Inferior Vena Cava (IVC) via the right adrenal vein has been reported as very rare, and all the patients who have been recorded have had hepatic encephalopathy. Here, we present a patient with intrahepatic PSS via the right adrenal vein diagnosed incidentally without encephalopathy. CASE PRESENTATION: A 51-year-old patient, who was diagnosed with chronic liver parenchyma disease and a suspecting nodule on the ultrasound was examined by Computed Tomography (CT) and Magnetic Resonance Imaging (MRI). A 4 cm in diameter Hepatocellular Carcinoma (HCC) was detected. In addition to HCC, an abnormal shunt between the right posterior portal vein and the IVC via the right adrenal vein was also detected. RESULTS: To the best of our knowledge, this is the first case with intrahepatic PSS via the right adrenal vein diagnosed incidentally in the absence of encephalopathy and the fourth case with this abnormal shunt in English literature. CONCLUSION: Intrahepatic PSS via the right adrenal vein is rare. It may be asymptomatic at the time of diagnosis but has the potential to cause various problems, later on, especially hepatic encephalopathy. The radiologist must be aware of this abnormal shunt.

Impact of cone beam - CT on adrenal vein sampling in primary aldosteronism.

PURPOSE: The aim of this study in a group of patients with primary aldosteronism was to evaluate the contribution of CB-CT (cone beam CT) to the overall success rate of adrenal vein sampling (AVS), and in particular to the selective cannulation of the right adrenal vein (RAV). METHOD: This was a retrospective single-center study including 91 AVS procedures performed by our consultant radiologist between March 2011 and January 2017. Fifty cases were performed with CB-CT and 50 were performed without. Angiography with CB-CT was carried out after RAV cannulation to check the accurate catheter position. For each patient, we collected technical and biochemical success rates, as well as irradiation data. RESULTS: The overall success rate of AVS with CB-CT was 80 %, vs. 44 % without (p = 0.00046), with right-sided selectivity of 88 % vs. 49 % (p < 0.0001). There was no significant increase in radiation exposure with CB-CT (p = 0.8206). Fluoroscopy time and quantity of iodine injected were significantly lower with CB-CT than without (p = 0.0039 and p < 0.0001). CONCLUSION: CB-CT allows a better evaluation of the selectivity of right-sided adrenal catheterization and greatly increases the overall success rate of AVS.

[Clinical value of transcatheter arterial chemoembolization therapy for hepatocellular carcinoma with blood supply from right adrenal artery].

Objective: To study the clinical value of transcatheter arterial chemoembolization (TACE) therapy for hepatocellular carcinoma with blood supply from right adrenal artery. Methods: An imaging and clinical data of HCC patients with blood supply from right adrenal artery were collected from 2012 to 2016 after TACE treatment in the Second Affiliated Hospital of Chongqing Medical University and the safety and therapeutic efficacy of complete embolization therapy was analyzed retrospectively. Results: Twenty hepatocellular carcinoma patients with blood supply from right adrenal artery had received 23 times treatment. All lesions had invaded and protruded from the exogenous development of liver capsule. There were 14 cases with lesions > 5 cm in diameter. Right adrenal artery was found to be involved in the blood supply of three cases of hepatocellular carcinoma during TACE treatment for the first time. In addition, the remaining 17 cases had also received TACE treatment for the second to sixth time. The superior, middle, and inferior adrenal arteries were involved in 13, 3, and 9 cases, respectively. Twenty-four right adrenal arteries (96.0%) superselectively cannulated were successfully embolized without any serious complications. The standard method for evaluating the efficacy of liver cancer in 20 solid tumors follow-up cases showed that three cases were completely relieved, nine cases were partially relieved, two cases were stable, and six cases were progressive. The effective rate of embolization with blood supply from right adrenal artery lesions was 60.0%, and the control rate of lesion development was 70.0%. Conclusion: The right adrenal artery is mainly located in the S5-S7 segments of the liver. TACE features are obvious to ascertain its safety and effectiveness in the treatment of right adrenal artery tumors.

Clinical value of transcatheter arterial chemoembolization therapy for hepatocellular carcinoma with blood supply from right adrenal artery / 中华肝脏病杂志

Objective@#To study the clinical value of transcatheter arterial chemoembolization (TACE) therapy for hepatocellular carcinoma with blood supply from right adrenal artery.@*Methods@#An imaging and clinical data of HCC patients with blood supply from right adrenal artery were collected from 2012 to 2016 after TACE treatment in the Second Affiliated Hospital of Chongqing Medical University and the safety and therapeutic efficacy of complete embolization therapy was analyzed retrospectively.@*Results@#Twenty hepatocellular carcinoma patients with blood supply from right adrenal artery had received 23 times treatment. All lesions had invaded and protruded from the exogenous development of liver capsule. There were 14 cases with lesions > 5 cm in diameter. Right adrenal artery was found to be involved in the blood supply of three cases of hepatocellular carcinoma during TACE treatment for the first time. In addition, the remaining 17 cases had also received TACE treatment for the second to sixth time. The superior, middle, and inferior adrenal arteries were involved in 13, 3, and 9 cases, respectively. Twenty-four right adrenal arteries (96.0%) superselectively cannulated were successfully embolized without any serious complications. The standard method for evaluating the efficacy of liver cancer in 20 solid tumors follow-up cases showed that three cases were completely relieved, nine cases were partially relieved, two cases were stable, and six cases were progressive. The effective rate of embolization with blood supply from right adrenal artery lesions was 60.0%, and the control rate of lesion development was 70.0%.@*Conclusion@#The right adrenal artery is mainly located in the S5-S7 segments of the liver. TACE features are obvious to ascertain its safety and effectiveness in the treatment of right adrenal artery tumors.

Visualization of right adrenal vein: Comparison with three phase dynamic contrast-enhanced CT.

PURPOSE: To evaluate the visualization of the right adrenal vein (RAV) on dynamic contrast-enhanced computed tomography (CT) images in patients with primary aldosteronism. MATERIALS AND METHODS: We evaluated 27 consecutive patients with primary aldosteronism who underwent contrast-enhanced dynamic CT and subsequent adrenal venous sampling. Scan delays were 10-, 20- and 60-s after a bolus-tracking program detected that the threshold of a 100 Hounsfield units (HU) increase in the abdominal aorta had been achieved. RAV visualization for each phase was evaluated by two readers using a four-point scale. The Friedman and McNemar tests were employed to compare the confidence ratings and the RAV visualization rates between the three phase images. RESULTS: The RAV visualization rates were 20.4%, 83.3%, and 63.0%, for the first, second, and third phase, respectively. The RAV visualization rates were 92.6%, 83.3%, 63.0%, and 92.6% for all three phases combined, the first and second phase image combined, the first and third phase image combined, and second and third phase image combined. The combined second and third phase images had the highest RAV visualization rates compared with all other image combinations (P<0.0001). CONCLUSION: RAV visualization was significantly improved by combining the second and third phase images.

Intrahepatic portosystemic venous shunt via the right adrenal vein: treatment with vascular plug.

A 65-year-old man with hepatocellular carcinoma (HCC) due to alcohol-related liver cirrhosis had undergone transarterial chemoembolization 11 times. However, treatment for HCC was difficult to continue, due to episodic hepatic encephalopathy. He was referred to our hospital for treatment of hepatic encephalopathy, showing a Child-Pugh score of 8 despite medical therapy. Abdominal computed tomography revealed intrahepatic portosystemic venous shunt comprising two shunt tracts from the right posterior portal vein to the inferior vena cava via the right adrenal vein. The larger tract was occluded using an Amplatzer Vascular Plug (AVP) II, and the smaller tract was occluded using an original AVP. The postembolization course was uneventful. Hepatic encephalopathy improved after shunt occlusion and no recurrence had occurred as of one year after the procedure.

Does catheter shape influence the success of right adrenal venous sampling? The interaction of catheter shape to anatomical factors on CT.

PURPOSE: To evaluate the importance of selecting an appropriate catheter shape for the right adrenal vein (RAV) anatomy on CT to the success of right adrenal venous sampling (RAVS) by elucidating the interactions of anatomical factors with catheter shape. MATERIALS AND METHODS: 130 patients with enhanced CT underwent RAVS using two catheters: catheter 1 was planar and catheter 2 was a three-dimensional shape. The following anatomical factors on CT were evaluated in each patient: presence of a right adrenal tumor, presence of a common trunk with an accessory right hepatic vein, diameter of the RAV, short and long diameters of the IVC, ratio of the long to the short diameter of IVC, and the transverse, modified transverse, and vertical angles of the RAV. RAVs were classified by direction on CT as lateral-caudal, lateral-cranial, medial-caudal, or medial-cranial. The technical feasibility of each catheter was evaluated by intragroup analysis. RESULTS: 108 patients underwent technically successful RAVS with one or both catheters. Eight of the 22 patients in whom RAVS was not successfully achieved by either catheter within ten minutes required microcatheters; other catheters were used in the other 14. The factors that were found to be associated with RAVS success were the modified transverse and the vertical angles (p < 0.01) of RAV on CT. Catheters 1 and 2 provided stable sampling in the lateral-caudal and medial groups, respectively. CONCLUSION: Adapting the shape of the catheter to the anatomy of the RAV can make RAVS more feasible. The anatomical factors that were found to be associated with RAVS success were the transverse angle modified by the IVC axis as well as the vertical angle of RAV on CT.

Adrenal vein sampling: substantial need for technical improvement at regional referral centres.

OBJECT: Adrenal vein sampling (AVS) is the gold standard for localization of aldosterone producing adenoma. The anatomy of the right adrenal vein makes this procedure technically demanding and it may yield no clinical information if the adrenal veins are not adequately cannulated. Having frequently observed the technical failure of AVS, we undertook a review of 220 procedures in British Columbia, Canada. DESIGN AND METHODS: Subjects were retrospectively identified through the laboratory information system. The following were collected: demographics, screening aldosterone concentration and renin activity/mass, results of dynamic function tests, AVS aldosterone and cortisol results. Standard calculations were performed on AVS data and site-specific success rates were compared. The effect of adrenocorticotropin hormone (ACTH) stimulation on the selectivity index (SI) and lateralization index (LI) were explored. RESULTS: The overall technical success-rate of AVS procedures was only 44% in procedures where no ACTH-stimulation was used (n=200) but this rose significantly (p<0.01) to 82% for those employing ACTH (n=139). ACTH-stimulation significantly increased the median SI (left: 5.8 vs 36.7, p<0.01; right: 7.0 vs 51.2, p<0.01), and salvaged 36 procedures from yielding no information, 21 of which demonstrated lateralization of aldosterone production. In 64 cases showing lateralization both pre and post-stimulation, ACTH significantly decreased the median LI from 5.4 to 2.2, p<0.01, creating substantial risk for spurious loss of lateralization. CONCLUSIONS: The technical success of AVS is lower than reported elsewhere. Provided that effects on the LI are considered, the use of ACTH-stimulation during AVS assists in the identification of unilateral forms of PA.

Dissecting the retrohepatic inferior vena cava in right hepatectomy: an experience in 77 patients / 中华肝胆外科杂志

Objective To study the technique in isolating the retrohepatic inferior vena cava in right hepatectomy.Methods Anatomical exposure of the right lateral wall of retrohepatic inferior vena cava was performed,followed by isolating its back wall.Results Part of the right liver was rotated out of the incision.The 77 patients recovered smoothly.Conclusion Dividing the right adrenal is the key to free the retrohepatic inferior vena cava.To expose the right side of the retrohepatic inferior vena cava is a standard technique to mobilize the right liver.