Adrenocortical carcinoma (ACC) is a rare malignancy with an incidence of 0.5–2 cases/million/year [
1]. ACC can occur at any age, with a peak incidence between 40 and 60 years and women being more often affected (55–60%) [
2]. ACC may present as a functionally active adrenal gland in about 50–60% of patients. Hypercortisolism (Cushing syndrome) or mixed Cushing and virilizing syndromes are observed in the majority of these patients. Compressive symptoms such as abdominal discomfort, vomiting, and back pain may be present in 30–40%. In 10–15% of patients, the diagnosis is an incidental finding. Constitutional symptoms are rarely present [
2]. Unusual clinical manifestations reported include hematuria, lower-extremity edema, Budd–Chiari syndrome, acute abdominal pain, pelvic pain, urinary obstruction, and paraplegia [
4]. Early diagnosis is vital owing to its poor overall prognosis. Five-year survival is 60–80% for tumors confined to the adrenal space, 35–50% for locally advanced disease, and much lower in case of metastatic disease with reported percentages ranging from 0% to 28% [
2]. It is critical to know whether the adrenal mass is malignant or not. Suspicion of ACC might arise if the patients rapidly develop features of adrenocortical hormone excess such as weakness, hypokalemia, wasting and constitutional symptoms, or features of a large abdominal mass. Hirsutism or virilization in women or recent onset gynecomastia in men might be due to excess sex hormone production by an ACC. Evidence of co-secretion of different steroids raises suspicion of ACC (especially if sex hormones are involved). ACCs are usually large (> 4 cm) and of inhomogeneous appearance, and characterized by low fat content [
2]. Our patient had a lipid-poor tumor larger than 4 cm, though she did not have features of local invasion on imaging. However, definite differentiation between adenoma and carcinoma should be done after pathological assessment.
Advanced adrenal carcinomas present with vascular invasion mainly into renal vein and inferior vena cava (IVC). Since this patient had histologically proven vascular invasion, this is the most likely explanation for the hematuria. Right-sided ACC may grow into the IVC more frequently than left-sided tumors. Left-sided ACC extends into the IVC through the renal vein [
1]. There is a similar presentation of right-sided ACC without radiological evidence of local invasion reported in the literature [
5].
However, hematuria being the initial presentation of the ACC before the onset of features of hyper functioning adrenal gland is an unusual presentation.
Definitive cure requires adrenalectomy with intra- and postoperative glucocorticoid replacement in all patients with autonomous cortisol secretion followed by mitotane treatment if indicated [
2]. To date, mitotane has been the only drug that has proven effective in treating patients with metastatic adrenocortical carcinoma [
4]. Adjuvant mitotane treatment is recommended in patients without macroscopic residual tumor after surgery but who have a perceived high risk of recurrence [
2].