Tom 8, Nr 6 (2023)
Obrazy w medycynie
Opublikowany online: 2023-10-16

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The diagnostic dilemma of low-grade adrenal cortical carcinoma in a young female patient

Maciej D. Bugajski1, Agata Popow-Gierba1, Małgorzata Wysocka-Malik1
Biuletyn Polskiego Towarzystwa Onkologicznego Nowotwory 2023;8(6):486.



Obrazy w onkologii / Pictures in oncology

Biuletyn Polskiego
Towarzystwa Onkologicznego

2023, tom 8, nr 6, 486

© Polskie Towarzystwo Onkologiczne

ISSN: 2543–5248, e-ISSN: 2543–8077

The diagnostic dilemma of low-grade adrenal cortical carcinoma in a young female patient

Maciej D. Bugajski Agata Popow-GierbaMałgorzata Wysocka-Malik
Department of Radiology and Diagnostic Imaging, Maria Sklodowska-Curie Institute of Oncology, Krakow Branch, Krakow, Poland

Jak cytować / How to cite:

Bugajski MD, Popow-Gierba A, Wysocka-Malik M. The diagnostic dilemma of low-grade adrenal cortical carcinoma in a young female patient. NOWOTWORY J Oncol 2023; 73: 404.

A 33-year-old woman with hypertension and oligomenorrhea for last 6 months, with an incidentally diagnosed abdominal mass on ultrasound underwent an MRI and 18F-FDG PET-CT (fig. 1, 2). No abnormalities were seen on lab tests. Initial diagnoses were ganglioneuroma, adrenal cortical carcinoma (ACC) and pheochromocytoma. Ganglioneuroma was supported by age, normal/lower level of adrenal hormones, well-circumscribed margins, progressive enhancement and persistent in delayed phase (in T1w before and after dynamic administration of gadobutrol) and no evidence of metastasis [1, 2]. ACC was supported by haemorrhage on T1w, heterogeneous T2w signal – higher than an adjacent liver, enhanced density of periadrenal fat [1, 2]. Pheochromocytoma was less confident due to the relatively low signal on T2w. High FDG uptake (SUVmax 9.0) suggested a malignant character. For all diagnosis parameters like lesion size (11 cm), there was no presence of drop of signal during out-of-phase sequence, no evidence of IVC invasion and local compressive symptoms showed imaging overlap [1, 2]. DWI revealed a high signal within the lesion, with a low signal on ADC maps. However, DWI does not help a lot in malignant/benign adrenal lesion differentiation [2]. ACC is a very rare and aggressive malignancy, with annual incidence 0.5–2 cases/ million [2]. Excision is a primary treatment for stage I–III disease with adjuvant therapy due to high risk of recurrence even with complete resection [2]. In this case, PET-CT showed adrenal/liver SUV ratio >1.8, indicating the malignant character of the lesion [2]. On laparotomy low-grade ACC, Weiss score 5, Ki-67: 11% was confirmed.

Figure 1. MRI, T2-weighted image showing 11cm oval, well-circumscribed mass with high, heterogeneous signal, higher than the adjacent liver
Figure 2. Fluorine-18F-FDG-PET-CT PET-CT scan indicating high FDG uptake (SUV max 9.0), more than 3 times higher than the adjacent liver


  1. Shawa H, Elsayes K, Javadi S, et al. Adrenal ganglioneuroma: features and outcomes of 27 cases at a referral cancer centre. Clin Endocrinol. 2013; 80(3): 342–347, doi: 10.1111/cen.12320.
  2. Ahmed AA, Thomas AJ, Ganeshan DM, et al. Adrenal cortical carcinoma: pathology, genomics, prognosis, imaging features, and mimics with impact on management. Abdom Radiol (NY). 2020; 45(4): 945–963, doi: 10.1007/s00261-019-02371-y, indexed in Pubmed: 31894378.

Biuletyn Polskiego Towarzystwa Onkologicznego Nowotwory