Virilizing Adrenocortical Carcinoma with Liver Metastases: A Case Report

Abstract

Adrenocortical carcinoma (ACC) is a rare and aggressive malignancy with an incidence of approximately 1-2 cases per million population per year. Clinical presentation varies widely and may result from hormone hypersecretion or mass effect. Virilization in women is highly suggestive of ACC. Prognosis is strongly related to tumor stage, as metastatic disease is associated with poor outcomes. We report the case of a 41-year-old woman who presented with a 10-month history of abdominal and lumbar pain, amenorrhea, hirsutism, and progressive virilization. Physical examination revealed male-pattern hair distribution and a palpable abdominal mass. Laboratory tests showed markedly elevated androgen levels, including total testosterone and dehydroepiandrosterone sulfate. Computed tomography revealed a large right adrenal mass measuring 10×16 cm with compression of adjacent structures. Positron emission tomography demonstrated intense metabolic activity and suggested hepatic invasion. After multidisciplinary discussion, the patient underwent en bloc resection including right adrenalectomy, right hepatectomy, and cholecystectomy. Histopathological examination confirmed a high-grade adrenocortical carcinoma with a Ki-67 proliferation index of approximately 40% and hepatic metastases (ENSAT stage IV). Early postoperative imaging revealed further hepatic disease progression. The patient subsequently received systemic therapy with mitotane and chemotherapy but developed treatment-related toxicity and progressive metastatic disease. She was referred to palliative care and died six months after surgery.

ACC remains a rare but highly aggressive malignancy. Although complete surgical resection is the cornerstone of treatment, patients with stage IV disease have a poor prognosis despite multimodal therapy. This case highlights the aggressive natural history of metastatic ACC and the challenges associated with its management.