Session: MON 1-36-Adrenal Incidentaloma & Carcinoma
Poster Board MON-32
Clinical case: A 54 year old woman underwent emergent appendectomy in Jan 2008. Pre-operative CT abdomen revealed a well defined, 2.6 cm irregularly shaped, right adrenal incidentaloma with a non-contrast CT attenuation of 35 HU and a focal speck of calcification. A follow up CT scan six months later showed stable size of the mass along with a 58% absolute and 41% relative delayed washout percentage. Work up for pheochromocytoma and Cushing syndrome was negative. In April 2009, she underwent a laparoscopic right adrenalectomy. Surgical pathology reported a normal adrenal gland with an adjacent area of mature adipose tissue consistent with a lipoma but did not recognize any adrenocortical tumors. A repeat CT abdomen performed in Oct 2012 for abdominal pain showed a 11 X 9 cm heterogeneously enhancing mass arising from the right adrenal bed with splaying the aorta and IVC with areas of necrosis. A CT guided core biopsy could not differentiate between benign and malignant adrenal neoplasm. Immunohistochemical stains of the tissue fragment was positive for inhibin, calretinin, vimentin and Melan-A, and negative for smooth muscle antigen or CD99 confirming the adreno-cortical origin of the tumor. On subsequent referral to our institution, surgical resection of the adrenal mass was aborted intra-operatively as the mass had invaded into the aorta and vertebrae. Patient is currently undergoing chemotherapy.
Clinical lessons: High pre-contrast attenuation value (>30 HU), focal calcification and irregular shape may be clues for an early underlying ACC. A lack of tumor growth during a short follow up period should not be used as an absolute evidence against an underlying ACC. CT guided biopsy may not differentiate between benign adenoma and ACC.
Nothing to Disclose: SK, AS, KP, EB, CP, AES, AHH
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