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case_images: CT findings at the initial examination and pathological findings at primary tumor resection. Plain CT findings of the ACC at initial examination (A). The lesion (arrow) is a 54 mm x 61 mm heterogeneous mass in the left adrenal gland with heterogeneous enhancement (B). Macroscopic findings reveal a brownish solid tumor with internal hemorrhage and necrosis (C). Microscopic findings revealed alveolar growth of tumor cells, accompanied by high-grade nuclear atypia and multiple mitotic counts. Magnification 100x (D) and 400x (E).. Abbreviations: CT, computed tomography; ACC, adrenocortical carcinoma.
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case_images: Histological examination met all the Weiss criteria   and confirmed the diagnosis of ACC (Figure 1C-E).
case_images: CT and MRI findings of the liver metastases at the initial RFA. Representative CT and Gd-EOB-DTPA MRI findings of liver metastases of ACC at the initial RFA. Plane CT reveals multiple low-density areas (arrows) in the periphery of the liver (A and B). These lesions were of relatively low density compared to the surrounding normal liver with indistinct borders on contrast-enhanced CT (C and D). In addition, a total of 11 lesions (arrows) were observed in the hepatobiliary phase of GdEOB-DTPA MRI (E and F).. Abbreviations: CT, computed tomography; MRI, magnetic resonance imaging; Gd-EOB-DTPA, gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid; ACC, adrenocortical carcinoma; RFA, radiofrequency ablation.
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case_images: Imaging using plain CT revealed the presence of multiple low-density nodules in the periphery of the liver (Figure 2A and B), and contrast-enhanced CT revealed lesions with a lower density than the surrounding normal liver tissue (Figure 2C and D). Gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid magnetic resonance imaging (Gd-EOB-DTPA MRI) revealed low-intensity lesions in the hepatobiliary phase (Figure 2E and F).
case_images: CT findings of the liver metastases at the second and third RFA. Representative CT findings at 4 months (A-D) and 6 months (E and F) after the initial RFA. New metastatic lesions (arrows) are observed in the liver (A and B). The lesions were treated with RFA (C and D). Metastatic lesions (arrows) were observed in the lungs (E, F).. Abbreviations: CT, computed tomography; RFA, radiofrequency ablation.
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case_images: Four months after the initial RFA, lesions that could only be detected on MRI became apparent on CT, and local recurrence was observed near the initial ablation site (Figure 3A and B). A second RFA was performed (Figure 3C and D). Lung metastases appeared 6 months after the initial RFA (Figure 3E and F).
case_images: Latest CT findings of liver and distant metastases. Representative CT findings at 33 months (A-C) and 36 months (D-F) after the initial RFA. Recurrence of liver metastases (A and B) and appearance of distant lymph node metastases (C) are observed (arrows). A reduction in the size of the distant lymph node metastasis was observed upon resumption of chemotherapy (D), and RFA was performed for liver metastases (E and F).. Abbreviations: CT, computed tomography; RFA, radiofrequency ablation.
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case_images: Computed tomography revealed local recurrence of liver metastases and distant lymph node metastases 33 months after the initial RFA (Figure 4A-C). Systemic chemotherapy with a combination of etoposide and cisplatin (EP) was resumed, and distant lymph node metastases showed a partial response (Figure 4D). However, as there was no effect on the liver metastases, the seventh and eighth RFA sessions were performed (Figure 4E and F).
case_images: The progress from diagnosis to the present of the patient.. Abbreviations: RFA, radiofrequency ablation; EDP, a combination of etoposide, doxorubicin, and cisplatin; EP, a combination of etoposide and cisplatin.
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case_images: The progress from diagnosis to the present is shown in Figure 5.