Clinical Picture
Androgen-secreting adrenocortical carcinoma Kamal P Galketiya, Sumathi Ranjikumar, Usama Majeed
A 47-year-old woman presented with abdominal pain. She had recently noticed increased growth of facial hair and loss of scalp hair, and her menstrual cycle had become erratic. Abdominal examination revealed a right upperquadrant abdominal mass. A CT scan of the abdomen revealed a 10 cm adrenal mass (figure, A, B; green arrows) that was well encapsulated and heterogeneous. Endocrine studies were ordered to exclude a functioning adrenal neoplasm. The serum total testosterone concentration was 8·6 nmol/L (reference range 0·13–2·53 nmol/L) and the serum dehydroepiandrostenedione sulphate (DHEAS) concentration was 22 μmol/L (reference range 1·0–11·6 μmol/L). The free androgen index (ratio of testosterone to sex-hormone-binding globulin) was 30·2% (reference range 75% of tumour cells, and necrosis; figure, C [haematoxylin and eosin staining]). Immunohistochemistry was positive for melan-A, vimentin, synaptophysin, and epithelial membrane antigen. Cytoplasmic staining was positive with calretinin (figure, D) and inhibin (figure, E). The Ki-67 proliferative index was 32%. Mitotane was recommended as adjuvant therapy for 2 years. No evidence of recurrence or metastatic disease was recorded 12 months postoperatively and androgen concentrations remain suppressed. Women presenting with hirsutism or virilisation are more likely to have polycystic ovarian syndrome than an androgen-secreting adrenal neoplasm. Assessment of patients requires thorough hormonal investigation and imaging, including CT, MRI, and FDG-PET.
Lancet Diabetes Endocrinol 2013; 1: e10 Published Online January 30, 2013 http://dx.doi.org/10.1016/ S2213-8587(13)70005-6 Department of Surgery, Canberra Hospital, Garran, ACT, Australia (K P Galketiya FRACS, U Majeed FRACS); and Capital Pathology, Histology Department, Deakin, ACT, Australia (S Ranjikumar FRCPA) Correspondence to: Dr Kamal P Galketiya, Department of Surgery, Canberra Hospital, Garran, ACT 2605, Australia [email protected]
Contributors KPG: writing the report; KPG, UM: managing the patient; SR: pathology. Written consent to publish was obtained. Conflicts of interest We declare that we have no conflicts of interest.
B
C
D
100 µm
www.thelancet.com/diabetes-endocrinology Vol 1 September 2013
E
100 µm
100 µm
e10
Androgen-secreting adrenocortical carcinoma Kamal P Galketiya, Sumathi Ranjikumar, Usama Majeed
A 47-year-old woman presented with abdominal pain. She had recently noticed increased growth of facial hair and loss of scalp hair, and her menstrual cycle had become erratic. Abdominal examination revealed a right upperquadrant abdominal mass. A CT scan of the abdomen revealed a 10 cm adrenal mass (figure, A, B; green arrows) that was well encapsulated and heterogeneous. Endocrine studies were ordered to exclude a functioning adrenal neoplasm. The serum total testosterone concentration was 8·6 nmol/L (reference range 0·13–2·53 nmol/L) and the serum dehydroepiandrostenedione sulphate (DHEAS) concentration was 22 μmol/L (reference range 1·0–11·6 μmol/L). The free androgen index (ratio of testosterone to sex-hormone-binding globulin) was 30·2% (reference range 75% of tumour cells, and necrosis; figure, C [haematoxylin and eosin staining]). Immunohistochemistry was positive for melan-A, vimentin, synaptophysin, and epithelial membrane antigen. Cytoplasmic staining was positive with calretinin (figure, D) and inhibin (figure, E). The Ki-67 proliferative index was 32%. Mitotane was recommended as adjuvant therapy for 2 years. No evidence of recurrence or metastatic disease was recorded 12 months postoperatively and androgen concentrations remain suppressed. Women presenting with hirsutism or virilisation are more likely to have polycystic ovarian syndrome than an androgen-secreting adrenal neoplasm. Assessment of patients requires thorough hormonal investigation and imaging, including CT, MRI, and FDG-PET.
Lancet Diabetes Endocrinol 2013; 1: e10 Published Online January 30, 2013 http://dx.doi.org/10.1016/ S2213-8587(13)70005-6 Department of Surgery, Canberra Hospital, Garran, ACT, Australia (K P Galketiya FRACS, U Majeed FRACS); and Capital Pathology, Histology Department, Deakin, ACT, Australia (S Ranjikumar FRCPA) Correspondence to: Dr Kamal P Galketiya, Department of Surgery, Canberra Hospital, Garran, ACT 2605, Australia [email protected]
Contributors KPG: writing the report; KPG, UM: managing the patient; SR: pathology. Written consent to publish was obtained. Conflicts of interest We declare that we have no conflicts of interest.
B
C
D
100 µm
www.thelancet.com/diabetes-endocrinology Vol 1 September 2013
E
100 µm
100 µm
e10
