An Adrenocortical Carcinoma Evolving from A Small Adrenal Incidentaloma after Years of Latency

Abstract

Objective: Adrenal incidentalomas (AIs) are frequent clinical problems. Although most are benign and nonsecretory, the possibility of malignancy is a concern. We report here a case of adrenocortical carcinoma (ACC) evolving from a small AI, 3 years after initial detection.Methods: We report our case and review similar cases in the literature and current published guidelines for AIs.Results: A 47-year-old woman was incidentally found to have a small (13 mm maximum diameter), homogeneous, left adrenal lesion with low density on computed tomography (CT) performed for abdominal pain. Two years later, she underwent magnetic resonance imaging for back pain; the lesion then measured 20 × 15 × 17 mm and again appeared benign. Ten months later, she developed fatigue, night sweats, anorexia, and weight loss. On CT, the lesion now measured 100 × 90 × 130 mm and was heterogeneous; 18 F-fluorodeoxyglucose positron emission tomography showed intense uptake. Tests for hormone hypersecretion were negative. She underwent left adrenalectomy, with symptom resolution. Histology showed ACC with high proliferative index (Ki67 = 40%). Conclusion

An Adrenocortical Carcinoma Evolving After Nine Years of Latency From a Small Adrenal Incidentaloma

“…A few other cases [7,12], similar to our case, have been described in the literature where AI was indolent for many years but subsequently demonstrated malignancy. Such a development is rare and falls outside the purview of current guideline recommendations.…”

“…Furthermore, false-positive rates of the imaging and other studies were typically 50 times greater than true-positive rates [ 5 ]. Any strategy that includes fine-needle aspiration or needle biopsy of the adrenal gland is nonproductive and risky as it may involve such complications as seeding of malignancy along the needle track [ 5 , 12 ].…”

“…Such a development is rare and falls outside the purview of current guideline recommendations. Likely this could be due to slow-growing cancer or transformation from a benign to malignant form [ 7 , 12 ]. The latter transformation could be due to de novo idiosyncratic transformation.…”

“…The latter transformation could be due to de novo idiosyncratic transformation. Such transformation is known to occur in nature and in human beings, where benign colonic adenoma can transform into a malignant tumor [ 7 , 12 ].…”

Transformation of a Benign Adrenocortical Adenoma to a Metastatic Adrenocortical Carcinoma Is Rare But It Happens

“…All cases were initially evaluated with a CT scan, and in 3 cases an MRI was additionally performed ( 6 , 11 , 13 ). Six cases had typical characteristics of ACAs on CT scan exhibiting low unenhanced attenuation values of <10 HU ( 5 , 7 , 8 , 9 , 10 , 11 ) whereas in the remaining 3 ( 6 , 12 , 13 ), the findings were ambiguous ( Table 2 ).…”