Benign or Malignant? Challenging Case of an Adreanal Mass!

Presentation Number: SAT 370
Date of Presentation: April 1st, 2017

Mehmet Sercan Marangoz*, Stephanie Moss, Brian Boulmay, Farah Naz Mushtaq and Taniya DeSilva
LSUHSC, New Orleans, LA

Abstract

Introduction:

Adrenocortical cancer (ACC) is a rare and aggressive malignancy with metastatic potential in 40% of patients within 2 years despite complete resection. The pathologic differentiation of ACC from benign neoplasms is challenging.

We present the case of a 49-year-old woman with recurrent masses despite complete left adrenalectomy 4 years prior for what was deemed benign adrenocortical hyperplasia.

Case report:

A 49-year-old presented in 11/2011 for evaluation of an incidental adrenal mass. She was noted to have a 6.7cm left adrenal mass with Hounsfield units<10. Hormonal evaluation was negative. She underwent left adrenalectomy in 4/2012. Pathology was notable for a modified Weiss score positive for 3/9 criteria, consistent with ACC. However, given the size of the neoplasm, mitotic activity and invasiveness, ultimately she was classified to have adrenocortical hyperplasia.

She was lost to follow up for 4 years finally returning to clinic in 6/2016. She complained of weight gain, unusual facial hair growth and constant left upper quadrant, abdominal pain. Her physical exam was negative for Cushingoid features, or hirsutism.

Her biochemical evaluation was significant for: aldosterone 8.7 (4.0-31ng/dl), renin:0.7 (0.2-1.6ng/ml/hr), DHEA-S: 94(32-240 ug/dl), 24 hr urine Cortisol: 15(0-50ug/24hr) for a creatinine of 2.2g/24h, TSH: 1.31(0.5-5 IUI/ml), 24hr urine epinephrine, norepinephrine, metanephrine were within normal limits. Repeat CT revealed new lesions in the left adrenal bed, anterior to the left kidney and adjacent to the diaphragm concerning for recurrent or metastatic disease.

CT guided FNA of the diaphragmatic lesion was performed. Cytology revealed similar features to the patient’s previously resected adrenal lesion. According to the modified Weiss score these features are consistent with a malignant lesion of uncertain potential.

Repeat CT scan in 10/2016 revealed further enlargement of patient’s left adrenalectomy bed nodule. She is awaiting surgical resection of the nodules.

Discussion:

ACC is a rare but aggressive malignancy that can lead to multiple endocrine disorders. Five-year survival is approximately 45 to 60% for early stage disease, and 10 to 25% for advanced stage disease. A modified Weiss scoring system is used for pathologic diagnosis. This case highlights the difficulties in pathologic diagnosis of ACC and the importance of strict adherence to the Weiss scoring system. Patients diagnosed with a malignant lesion or lesions with uncertain potential should be treated aggressively and followed closely.

 

Nothing to Disclose: MSM, SM, BB, FNM, TD