Search for a command to run...
Abstract Disclosure: R.E. Langan: None. A. Rusz: None. M. Centeno Gavica: None. B.N. Learned: None. Background: Adrenal incidentalomas, found in 3-4% of all abdominal CT scans, affect 3-10% of the general population. Less than 3% are malignant. Adrenocortical carcinoma (ACC) is the most common primary malignant adrenal tumor with a 5-year survival rate of <30%. Guidelines consider homogeneous masses <4cm and <10 Hounsfield units (HU) to be benign, and heterogeneous masses >4cm and >20 HU to be suspicious. If immediate surgery is not offered for a suspicious mass, growth of >20% and at least 5mm in the maximum diameter in 6-12 months is concerning. We present two cases of adrenal masses with benign features and/or reassuring subsequent imaging diagnosed as ACC. Cases: Patient 1 is a 46-year-old male presenting with hypertensive emergency. CT in the ED revealed a heterogeneous 9.7x8.2cm mass with punctuate calcifications (HU not reported). This mass was known for 3 years without significant change in size (previously 9.6x7.9x7.8cm). Biochemical workup was notable for primary hyperaldosteronism and Cushing syndrome. Surgical resection revealed pT2cN0M0 ACC. Patient 2 is a 62-year-old female presenting for a 1.7x1.9cm adrenal mass (4 HU, no morphology provided), unchanged from CT 4 years prior. Dexamethasone suppression test (DST) was inconclusive due to a timing error. She was lost to follow up until 3 years later when a new, unrelated CT revealed a heterogenous 2.8x2.6x3.6cm adrenal mass (HUs not provided). DST revealed Cushing syndrome. Surgical resection revealed pT3Nx ACC. Discussion: It is unclear why patient 1 was not offered immediate surgery or why a DST was not performed. When we encountered him, his mass was stable for 3 years and would not warrant further imaging per guidelines. Some studies show that ACC has variable growth patterns. Assuming a mass benign based on stability could miss or delay a diagnosis of ACC. For Patient 2, no further imaging would have been recommended after initial presentation had her DST been negative. When she presented 3 years later, the mass had grown significantly, and repeat DST was positive, leading to resection and diagnosis of ACC. Notably, morphology was never described in the initial radiologist report. Conclusion: These cases highlight the limitations to our current adrenal incidentaloma guidelines. In addition, they highlight the importance of practicing clinical judgement while evaluating patients for adrenal masses. Adrenal imaging should be reviewed/confirmed by the endocrinologist if a radiologist with expertise in adrenal imaging is unavailable. Presentation: Sunday, July 13, 2025
Published in: Journal of the Endocrine Society
Volume 9, Issue Supplement_1