Early radiological clues in diagnosis of adrenocortical carcinoma: lessons from a missed opportunity
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ENDOCRINE IMAGING
Early radiological clues in diagnosis of adrenocortical carcinoma: lessons from a missed opportunity Subramanian Kannan • Allan Siperstein Amir H. Hamrahian
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Received: 27 April 2013 / Accepted: 4 May 2013 Ó Springer Science+Business Media New York 2013
Case presentation
Discussion
A 54-year-old woman found to have a 2.6-cm irregularly shaped, right adrenal incidentaloma (AI) during work up for appendicitis. The mass had a non-contrast CT attenuation of 35 HU and a focal speck of calcification (Fig. 1a). A follow-up CT scan 6 months later showed a stable size adrenal mass with a delayed absolute and relative washout of 58 and 41 %, respectively. Work up was negative for hormonal hypersecretion. Patient underwent right adrenalectomy. Unfortunately the mass was not resected along with the right adrenal gland. The surgical pathology reported a normal adrenal gland with an adjacent area of mature adipose tissue consistent with a lipoma. This lipomatous tissue was assumed to be the visualized adrenocortical tumor and patient was discharged from clinical care. A repeat CT abdomen, 4 years later for unrelated reasons, showed 11 cm 9 9 cm heterogeneously enhancing mass arising from the right adrenal bed with areas of necrosis (Fig. 1a) and patient was referred to our institution. The surgical resection of this mass was aborted intraoperatively as it had invaded the aorta and vertebrae. Core biopsies confirmed the adrenocortical neoplasm (Fig. 1b) and given its clinical behavior is consistent with adrenocortical carcinoma. Pathology slides from the previous institution were reviewed and it was confirmed that the original specimen did not contain the tumor.
AI offers a rare opportunity to diagnose adrenocortical carcinoma (ACC) at an earlier stage amenable to curative resection. Radiological features of early (small) ACC are rarely reported in literature [1]. There are several important points about this case which may help clinicians appropriately refer AI to the surgeon even if it does not meet the size criteria. High pre-contrast attenuation value ([30 HU), focal calcification and irregular shape, and ill-defined borders may be clues for early diagnosis of ACC. A lack of tumor growth during a relatively short follow-up period may not rule out an underlying ACC [2]. Absolute and relative wash out greater than 60 and 40 % at 15 min are reported to differentiate between adenomas and non-adenomas [3], however, these criteria may overlap between benign adenomas and early stages of ACC as described in this case. Finally, it is important to review the pathology information with respect to the pre-operative radiological information. While the pre-operative imaging suggested a lipid poor mass, the pathology suggested a lipoma. This could have been the tip-off for the treating team to reimage the patient post-operatively and remove the actual tumor.
S. Kannan (&) A. Siperstein A. H. Hamrahian Endocrinology and Metabolism Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Desk F20, Cleveland, O
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