Fine needle aspiration cytology of adrenocortical carcinoma--case report

A 49-year-old woman presented for hirsutism, deep voice and hypertension. Ultrasonography (US) revealed a solitary tumor mass, eight cm in size, of the right adrenal gland. Laboratory tests showed it to be a hormonally active, androgen secreting tumor (elevated testosterone level), which was consistent with the clinical picture of the disease. After histopathological analysis tumor was signed out as adrenocortical carcinoma, a low risk carcinoma according to Weiss' classification. One year later on regular follow up, US revealed a suspicious growth measuring 65 x 43 mm in the projection of the lower pole of the right kidney. The finding was verified by computerized tomography and the patient was reoperated on. Exploration revealed secondary growth in the region of greater omentum, without infiltration of adjacent organs. Histopathologic analysis confirmed metastatic ACC. 8 months after the second operation and after 6 chemotherapy cycles according to EAP protocol, control CT showed enlarged para-aortic lymph nodes and a node along the upper pole of the right kidney. Cytologic puncture was performed. Cytologic opinion was recidive of primary malignant disease. ACC is a rare malignant epithelial tumor of adrenal cortical cells, with high malignant potential. Morphologically (histopathology and cytology), differential diagnosis includes adenoma on the one hand, and renal cell carcinoma (RCC) and hepatocellular carcinoma (HCC) on the other hand. A combined evaluation of clinical features, size or weight, microscopic appearance, immunohistochemical and molecular genetic data is necessary to ensure a correct diagnosis. The purpose of this case report is to present clinical and cytomorphologic features of our case of adrenocortical carcinoma which is very rare in cytology practice.