Preoperative Detection of Liver Involvement by Right-Sided Adrenocortical Carcinoma Using CT and MRI

Abstract

The major prognosis factor of adrenocortical carcinoma (ACC) is the completeness of surgery. The aim of our study was to identify preoperative imaging features associated with direct liver involvement (DLI) by right-sided ACC. Two radiologists, blinded to the outcome, independently reviewed preoperative CT and MRI examinations for eight signs of DLI, in patients operated for right-sided ACC and retrospectively included from November 2007 to January 2020. DLI was confirmed using surgical and histopathological findings. Kappa values were calculated. Univariable and multivariable analyses were performed by using a logistic regression model. Receiver operating characteristic (ROC) curves were built for CT and MRI. Twenty-nine patients were included. Seven patients had DLI requiring en bloc resection. At multivariable analysis, focal ACC bulge was the single independent sign associated with DLI on CT (OR: 60.00; 95% CI: 4.60-782.40; p < 0.001), and ACC contour disruption was the single independent sign associated with DLI on MRI (OR: 126.00; 95% CI: 6.82-2328.21; p < 0.001). Both signs were highly reproducible, with respective kappa values of 0.85 and 0.91. The areas under ROC curves of MRI and CT models were not different (p = 0.838). Focal ACC bulge on CT and ACC contour disruption on MRI are independent and highly reproducible signs, strongly associated with DLI by right-sided ACC on preoperative imaging. MRI does not improve the preoperative assessment of DLI by comparison with CT.

Keywords: adrenocortical carcinoma; hepatectomy; liver; neoplasm; staging.

Figure 1

Flow chart of the study. ACC: adrenocortical carcinoma; MRI: magnetic resonance imaging.

Figure 2

Categorical reading criteria. (A) A 76-year-old woman with a right-sided cortisol-secreting adrenocortical carcinoma (ACC) (Weiss score = 7, Ki67 = 13%), with direct liver involvement (DLI). CT image in the transverse plane obtained during the arterial phase following intravenous administration of iodinated contrast material shows disappearance of fat border between ACC and liver (arrow). (B) A 34-year-old man with a right-sided cortisol-secreting ACC (Weiss score = 9, Ki67 = 70%), with DLI. T2-weighted BLADE fat saturated (FS) image in the transverse plane shows periadrenal fat infiltration (white arrow). (C) A 57-year-old woman with a right-sided cortisol-secreting ACC (Weiss score = 9, Ki67 = 60%), associated with DLI. T1-weighted 3D volumetric interpolated breath-hold gradient-echo (VIBE) image in the transverse plane obtained during the venous phase following intravenous administration of gadoterate meglumine shows ACC contour disruption (arrow). (D) A 23-year-old woman with a right-sided cortisol-secreting ACC (Weiss score = 8, Ki67 = 50%), without DLI. T1-weighted VIBE image in the transverse plane obtained during the venous phase after intravenous administration of gadoterate meglumine shows macroscopic mass effect on inferior vena cava (arrow). (E) A 45-year-old woman with a right-sided ACC (Weiss score = 9, Ki67 = 16%), with DLI. T1-weighted 3D VIBE image in the transverse plane obtained during the venous phase after intravenous injection of gadoterate meglumine shows macroscopic mass effect on right hepatic vein (white arrow). (F) A 36-year-old woman with a right-sided noncortisol-secreting ACC (Weiss score = 7, Ki67 = 9%) associated with DLI. CT image in the transverse plane obtained during the venous phase following intravenous administration of iodinated contrast material shows focal ACC bulge (arrow). (G) A 55-year-old woman with a right-sided cortisol-secreting ACC (Weiss score = 6, Ki67 = 7 %), with DLI. CT image in the transverse plane obtained during the venous phase after injection of iodine based intravenous contrast agent shows periadrenal hepatic parenchyma enhancement (arrow). (H) A 36-year-old woman with a right-sided noncortisol-secreting ACC (Weiss score = 7, Ki67 = 9%) associated with DLI. T1-weighted VIBE image in the transverse plane obtained during the venous phase after intravenous administration of gadoterate meglumine shows ACC inclusion by hepatic parenchyma >180° (arrow).

Figure 3

Illustration of disappearance of fat border between adrenocortical carcinoma (ACC) and liver. (A,B) A 53-year-old woman with a right-sided cortisol-secreting ACC (Weiss score = 3, Ki67 = 2%), without direct liver involvement (DLI). (A) T2-weighted half Fourier acquisition single-shot turbo spin-echo (HASTE) image in the transverse plane shows a visible and measurable fat border between ACC and liver (arrow). (B) CT image in the transverse plane obtained during the venous phase following intravenous administration of iodinated contrast material shows a visible and measurable fat border between ACC and liver (arrow). (C,D) A 57-year-old woman with a right-sided ACC (Weiss score = 7, Ki67 = 15%), with DLI. (C) T2-weighted HASTE image in the transverse plane shows a non-measurable (<1 mm) absent fat border between ACC and liver (arrow). (D) CT image in the transverse plane obtained during the venous phase following intravenous administration of iodinated contrast material shows a non-measurable (<1 mm) absent fat border between ACC and liver (white arrow). (E,F) A 73-year-old man with a right-sided ACC (Weiss score = 8, Ki67 = 20%), with DLI. (E) Unenhanced T1-weighted out-phase image in the transverse plane shows disappearance of the black boundary artifact normally visible at fat-water interfaces suggesting disappearance of fat border between ACC and liver (white arrow). (F) CT image in the transverse plane obtained during the arterial phase following intravenous administration of iodinated contrast material shows a non-measurable (<1 mm) absent fat border between ACC and liver (arrow).

Figure 4

Illustration of adrenocortical carcinoma (ACC) contour disruption. (A,B) A 53-year-old woman with a right-sided ACC (Weiss score = 9, Ki67 = 40%), without direct liver involvement (DLI). (A) T1-weighted 3D VIBE image in the transverse plane obtained during the venous phase following intravenous administration of gadoterate meglumine shows a thin marginal enhancement of the lesion suggesting an intact adrenal capsule (arrow). (B) CT image in the transverse plane obtained during the venous phase following intravenous administration of iodinated contrast material t shows a thin marginal enhancement of the lesion suggesting an intact adrenal capsule (arrow). (C,D) A 34-year-old woman with a right-sided ACC (Weiss score = 9, Ki67 = 30%), with DLI. (C) T1-weighted 3D VIBE image in the transverse plane obtained during the venous phase following intravenous administration of gadoterate meglumine shows an adrenal capsular defect without any enhancement (arrow). (D) CT image in the transverse plane obtained during the venous phase following intravenous administration of iodinated contrast material shows an adrenal capsular defect without any enhancement (arrow). (E,F) A 34-year-old man with a right-sided ACC (Weiss score = 9, Ki67 = 70%), with DLI. (E) T1-weighted 3D VIBE image in the transverse plane obtained during the late phase (5 min) following intravenous administration of gadoterate meglumine shows an adrenal capsular defect without any enhancement (arrow). (F) CT image in the transverse plane obtained during the venous phase following intravenous administration of iodinated contrast material shows an adrenal capsular defect without any enhancement (arrow).

Figure 5

Receiver operating characteristic (ROC) curves of the CT and MRI models. Focal ACC bulge on CT had an area under the ROC curves (AUROC) of 0.883 (95% CI: 0.709–0.972). ACC contour disruption on MRI had an AUROC of 0.906 (95% CI: 0.739–0.982). There was no difference between AUROC at CT and AUROC at MRI (p = 0.838).