
				 the patient is a 58 years old iraqi male that referred to our center three months after an unsuccessful operation for removing a subhepatic mass , probably adrenal mass .
he experienced general weakness , fatigue , and weight loss in the last several months .
a scar of previous surgery in the right subcostal area ( subcostal incision ) with near 15  cm length was noted . in hematological examination
, hb was 11  g / dl . in serum biochemistry , renal function tests , electrolytes , and
serum levels of cortisole and aldosterone were normal . in ct scan that was done with intravenous and oral contrast ( figure 1 ) , a large mass located in the subhepatic area and intervening with the upper pole of the right kidney was noted . in the report of previous operation that was done in iraq
, tumorectomy was failed due to severe adhesions of the mass to the peripheral tissues .
the patient scheduled for right adrenalectomy with the midline laparotomy incision . after opening the layers , the mass was located in the lodge of upper pole of the right kidney .
it was severely adherent to the peripheral tissues , due to severe adhesion of the mass to the subhepatic area , its differentiation from the kidney or adrenal was difficult . due to severe bleeding from the subhepatic bed subcapsular resection of the mass with the adherent kidney performed .
its total size was 14  cm  10  cm and it weighted 2250 grams .
the final histopathological examination of the mass revealed , renal cell carcinoma , clear cell type , fuhrman nuclear grading 2 ( figure 2 ) with invasion to gerotas fascia and involvement of ipsilateral adrenal which originated from the upper pole of the kidney as exophytic growth pattern ( t3n0m0 ) .
the postoperative course was uneventful and the patient discharged home at fourth postoperative day uneventfully .
certain anatomical structures and extra - adrenal pathological conditions may produce ct images suggesting adrenal pathology where none actually exists .
disorders of the adrenal gland result in classic endocrine syndromes such as cushing syndrome , hyperaldosteronism , and pheochromocytoma . in addition
, tumors of the adrenals may present with abdominal pain or as an abdominal mass .
the diagnosis of these disorders requires careful endocrine evaluation , and in many patients adrenal imaging studies are required to define adrenal anatomy . in our patient ,
pulse , blood pressure , renal function tests , serum cortisole , electrolytes , and urinary catecholamines were all normal .
however , the tumor located below the right adrenal gland during operation and the diagnosis of renal cell carcinoma ( rcc ) depended on the histopathological examination .
a mass arising in the upper pole of the kidney may be difficult to differentiate from an adrenal mass [ 1 , 2 ] .
additional examinations are usually necessary to confirm the nature of the lesion and to exclude the presence of life - threatening malignant disease .
only 21 of 1000 specimens submitted for frozen section diagnosis were of genitourinary origin , which reflects the relatively low incidence of kidney lesions that necessitate surgery and the limited role of frozen section in the surgical management of these lesions . with the advancements in the diagnosis and treatment of renal tumors ,
f - fluro-2-deoxy - d - glucose positron emission tomography ( fdg - pet ) has proved to be valuable in the diagnosis and management of a variety of malignancies , but is still limited in providing detailed anatomical information . according to the literature , an adrenal incidentaloma with high fdg uptake usually indicates malignancy and requires further investigation .
however , accurate localization of the adrenal gland in fdg - pet is difficult without the presence of surrounding well - visualized organs , such as the kidney or liver .
if these organs have a congenital anomaly or are altered due to a previous operation , misdiagnosis can occur .
a rare diagnosis when faced with a renal mass is that of an ectopic adrenal adenoma . distinguishing this entity from renal cell carcinoma has proven to be extremely difficult due to similarities in clinical presentation and radiologic findings
typically , the diagnosis of an ectopic adrenal adenoma is only reached after surgical excision and careful pathologic examination .
an ipsilateral adrenal mass in a patient with rcc is not uncommon and usually is a primary adrenal lesion rather than metastatic rcc . on the basis of takeda et al .  
study , i-131 cholesterol adrenocortical scintigrapgy is useful in the differentiation of adrenal and renal tumors when a large tumor occupies the upper pole of the kidney or adrenal gland . in fdg - pet ,
a normal right adrenal gland is barely visualized , whereas an adrenal lesion with intense fdg uptake usually represents malignancy [ 810 ] .
finally , possible causes of the adrenal pseudotumors   are as follows ; exophytic upper pole renal mass , abundant suprarenal fat , retroperitoneal tumor localized in the area of adrenal gland , prominent lobation of the hepatic lobe , or hepatic tumor , gastric diverticulum and redundant gastric fundus , fluid filled duodenum / colon , splenic lobulation , tortuous or dilated splenic arteries and veins , pancreatic tail in an unusual location or pancreatic tail mass , and focal thickening of adjacent diaphragmatic crus .
although some of the imaging modalities like meticulous ct technique , mri ( with emphasis on the usefulness of three - dimensional reconstructions ) or intraoperative frozen section can help in the differentiation between large masses of adrenal and/or renal tumors , but the final diagnosis depends on the histopathological examination by skilled pathologists . in these instances ,
diagnostic pitfalls did not affect patient care , because these cases generally are candidates for adrenalectomy or radical nephrectomy .
 there are a variety of causes of adrenal pseudotumors on computerized tomography ( ct ) scan , including   upper - pole renal mass , gastric diverticulum , prominent splenic lobulation , pancreatic mass , hepatic mass , and periadrenal varices . 
 we present a case of a large subhepatic mass that discrimination of its origin from neighborhood organs was difficult preoperatively . 
 our patient was a 58 years old man , that three months after an unsuccessful operation in another center for a pseudoadrenal mass underwent a very difficult subcapsular tumorectomy in our center . 
1. Case Presentation
2. Discussion
3. Conclusion