Adrenocortical carcinomas are extremely, rare, heterogeneous malignancies that arise from adrenal cortical cells and carries poor prognosis. We are presenting a case of highly progressive, metastatic adrenocortical carcinoma diagnosed incidentally during routine investigation procedure as a mass in right suprarenal gland .After thorough clinical, biochemical and radiological examination patient diagnosed as a case of Nonfunctioning Adrenal Cortical carcinoma of right adrenal gland with extension to renal parenchyma and peritoneal dissemination. Patient underwent surgical excision of mass, histopathology of the mass confirmed adrenocortical carcinoma. Patient was planned for combination chemotherapy with carboplatin, etoposide and adriamycin three weekly up to six courses. Introduction Adrenal cortical carcinomas (AC) are rare malignant tumor with an annual incidence of about 0.6-1.67 cases per million persons per year. 1 Overall, these tumors accounts for only 0.2% of the causes of deaths from cancer and due to this extremely low incidence rate, it is considered rare. 2 Clinically silent or biochemically and clinically asymptomatic adrenal masses also known as incidentaloma are incidentally discovered lesions, when noninvasive imaging methods such as USG, CT, MRI scan are performed for reasons other than known or suspected adrenal disease. 3 The detect ability of adrenal incidentaloma estimated in whole population at 0.1%; 0.41% in non – endocrine patients and at 4.3% in oncologically diagnosed ones. 4 The prevalence of tumors with a diameter > 1.5 cm is 1.8 % and with diameter > 6 cm is 0.025 %. 5 Case Report A 39 year old male patient underwent ultrasound examination of abdomen for routine investigation procedure while complaining of weakness and loss of weight, diagnosed having a mass in right adrenal gland. Ultrasound (USG) examination showed a heterogeneous mass of size 4.1x 3.1 cm in relation to upper pole of right kidney posterior to inferior vena cava, suggestive of adrenal mass. Detailed history of the patient was taken and found there was no significant history of pain abdomen, diarrhea, vomiting, urinary incontinence, frequency, fever. There was no hypertension, diabetes mellitus, asthma and tuberculosis. No family history of malignancies detected. General and physical examination of the patient was normal. On local examination there was no mass detected in lumber region except tenderness. Blood investigations, liver function and renal function tests were within normal limits. Urine complete and microscopic examination was negative for albumin and sugar. Urinary vanillyl mandelic acid was 2.20 mg%. Serum aldosterone was 23.4 units. The results of pheochromocytoma work up were negative. On CECT scan a small enhancing (2x2.2 cm) lesion seen at the right suprarenal gland. A 3x4 cm enhancing mass lesion was seen to the midpole of the right kidney extending into the renal parenchyma and pushing vessels at the renal hilum, enhancing lesion with surrounding fluid 2.2x2.3 cm seen intraperitoneally into right iliac fossa. (Fig 1) The patient underwent exploratory lapratomy with excision of the mass. Perioperative findings was 3 cm size adrenal tumor. Histopathological examination revealed a tumor measuring 3 cm weighing 200gm, adrenocortical carcinoma, revealing extensive areas of necrosis, high mitotic rate, and capsule invasion. (Fig 2) Peritoneal seedling also revealed infiltration by tumor. Diagnosis was made a tumor of adrenal cortex with metastases.
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