Evolution of small (=4 cm) adrenal lesions diagnosed as adrenocortical carcinomas: a5 multicenter retrospective cohort study

Villavicencio Torres Camila A.; Kai Yu; Farida Eid; Vania Balderrama-Brondani; Habra Mouhammed Amir; Sanan Mahrokhian; Anand Vaidya; Nekić Anja Barač; Darko Kastelan; Barisson Villares Fragoso Maria Candida; Henrik Falhammar; Urzula Ambroziak; Irina Bancos

doi:10.1530/endoabs.110.P458

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Endocrine Abstracts (2025) 110 P458 | DOI: 10.1530/endoabs.110.P458

ECEESPE2025 Poster Presentations Endocrine Related Cancer (76 abstracts)

Evolution of small (=4 cm) adrenal lesions diagnosed as adrenocortical carcinomas: a5 multicenter retrospective cohort study

Camila A. Villavicencio Torres ¹ , Kai Yu ¹ , Farida Eid ² , Vania Balderrama-Brondani ² , Mouhammed Amir Habra ² , Sanan Mahrokhian ³ , Anand Vaidya ³ , Anja Barač Nekić ⁴ , Darko Kastelan ⁴ , Maria Candida Barisson Villares Fragoso ⁵ , 6 , Henrik Falhammar ⁷ , 8 , Urzula Ambroziak ⁹ & Irina Bancos ¹

Author affiliations

¹Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, United States; ²Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, United States; ³Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital and Harvard Medical School, Boston, United States; ⁴Department of Endocrinology, University Hospital Center Zagreb, Zagreb, Croatia; ⁵Unidade de Suprarrenal, Disciplina de Endocrinologia e Metabologia, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo (HCFMUSP), Sao Paulo, Brazil; ⁶Instituto do Cancer do Estado de Sao Paulo (ICESP), Sao Paulo, Brazil; ⁷Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden; ⁸Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; ⁹Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland

JOINT191

Background: Adrenocortical carcinomas (ACC) are rarely diagnosed in patients with adrenal tumors ≤4 cm, potentially representing a missed opportunity for an earlier intervention.

Aims: We aimed to characterize clinical, biochemical, and imaging presentation of patients with adrenal lesions ≤4cm eventually diagnosed as ACC.

Methodology: We present an interim analysis of an ongoing A5 multicenter retrospective cohort study (1998-2024) that included adults with adrenal tumors ≤4 cm, subsequently diagnosed as ACC. We evaluated clinical and hormonal presentation, imaging characteristics at initial and latest imaging prior to ACC diagnosis, and staging at the time of ACC diagnosis. Reference standard was histopathology after adrenalectomy or biopsy, or imaging of metastatic adrenal mass with biochemical evidence of hormone excess.

Results: At the time of interim analysis, 118 patients (65% women) with ACC diagnosed at a median age of 52 years (range, 19-83) were included. Reasons for initial imaging were unrelated to adrenal mass (70, 59%), hormone excess (19, 16%), extra-adrenal malignancy staging (19, 16%), compressive symptoms (5, 4%), and genetic screening (3, 3%). At initial imaging, median tumor size was 25 mm (range 4-40), with unenhanced mass attenuation of 31 (range 17-95). Among 33 patients (28%) suspected of having ACC, 25 (21%) underwent adrenalectomy shortly thereafter. Meanwhile, 71 patients (60%) had follow-up imaging at a median of 21 months (range 0. 9-149) showing a median tumor growth rate of 13 mm/year (range 0-198), a median tumor size of 44 mm (range 10-270), and unenhanced mass attenuation of 31 HU (18-50). At the time of ACC diagnosis, 61 patients (52%) had stage I, 21 (18%) stage II, 19 (16%) stage III, and 3 (3%) stage IV disease. Clinical features of overt hormone excess were observed in 40 patients (34%), 50% presenting with Cushing syndrome, 37% with hyperandrogenism, 30% with mineralocorticoid excess, and hyperestrogenism in 2. 5%. Biochemical hormone excess was present in 62 patients (52%) including hypercortisolism in 28 (45%), combined hypercortisolism-hyperandrogenism in 19 (31%), hyperandrogenism in 7 (11%), mineralocorticoid excess in 7 (11%), combined hypercortisolism-mineralocorticoid excess in 1 (2%), and isolated hyperestrogenism in 1 (2%).

Conclusion: We show that ACC was suspected only in 28% at the time of initial imaging, despite indeterminate imaging characteristics, potentially because of false reassurance of smaller tumor size. We further show a variable tumor growth rate, with a median of 13 mm/year. Clinicians need to be aware of the possibility of ACC in smaller indeterminate adrenal tumors.