Endocrine Abstracts

Adrenocortical carcinoma (ACC) is a rare malignancy. Authors present three cases of even less commonly encountered manifestation of ACC. Case 1: A 39-year-old male, with decompensated hypertension, was admitted to Department of Endocrinology due to a large tumor of the left adrenal gland (65 mm) revealed in the CT of the abdomen. Non-contrast attenuation was 35HU. After performing MRI with chemical shift, tumor was classified as non-adenoma as there was no significant loss of signal in out-of-phase sequence. Excess of cortisol and aldosterone was excluded, but urine metoxycatecholamines remained in upper limit of the norm. Scintigraphy with iodine-123-meta-iodobenzylguanidine and somatostatin receptor revealed increased uptake of radiotracers in left adrenal gland. The patient was diagnosed with pheochromocytoma and after two weeks of alfa-blocker intake he underwent surgery. The pathology report revealed ACC. Case 2: A 54-year-old woman, with hypertension and incidentalomas of both adrenal glands diagnosed in 2011 was referred to Department of Endocrinology in 2017. In 2011, due to anaphylactic reaction to iodine in medical history, only single-phase CT was performed which revealed a tumor of left adrenal gland (25 mm) of density 16 HU. Hormonal activity was excluded and the patient was diagnosed with lipid poor adenoma. One year later, CT was repeated and there was no tumor growth so the follow-up was ended. In 2017 the tumor was classified as non-adenoma based on MRI with chemical shift (very low lipid content) and the possible autonomous cortisol secretion was revealed during hormonal work-up. There was non-specific accumulation in left adrenal gland in somatostatin receptor scintigraphy and the patient underwent adrenalectomy. The pathology report, revealed myelolipoma together with ACC infiltrating the fat tissue. Case 3. A 50-year-old male reported to the emergency room due to severe hypertension, hypokalaemia and tumor in right adrenal gland (32 mm). In CT attenuation before contrast was 29HU and absolute contrast enhancement washout was 57%, so lipid poor adenoma was diagnosed. Hormonal evaluation excluded hypercortisolemia, aldosterone concentration was 123 pg/ml, PRA 0,12 ng/ml/h, therefore ARR was high =102. The primary hyperaldosteronism was confirmed in saline infusion test and lateralization in adrenal venous sampling. Patient underwent laparoscopic adrenalectomy. The pathology report revealed ACC.

Conclusion: Though ACC is rare, it should be taken into consideration in every case of non-adenoma phenotype in imaging examinations. Thorough meticulous evaluation in imaging is necessary to identify all cases of ACC, regardless of hormonal activity.