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case_images: Unenhanced axial CT from 2017 demonstrates a 42-mm right adrenal mass with attenuation of 32 HU (A). Homogenous enhancement was demonstrated on portal venous phase CT (B) with marked washout on delayed 15-minute imaging (C). Absolute contrast washout of adrenal mass is 78% and relative contrast washout is 36%.
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case_images: Hounsfield units (HU). However, contrast washout characteristics were reassuring, with the absolute washout of 78% and relative washout of 36% (Fig. 1).
case_images: Axial chemical shift MRI demonstrates minimal reduction in signal from in-phase (A) to out-of-phase phase imaging (B), consistent with a lipid-poor indeterminate right adrenal mass.
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case_images: On the magnetic resonance imaging (MRI), imaging characteristics were indeterminate with absence of chemical shift (Fig. 2).
case_images: Unenhanced CT through the chest demonstrates bilateral gynecomastia (arrows).
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case_images: Contrast-enhanced axial CT from 2022 demonstrates enhancing soft-tissue nodules in the left upper quadrant measuring up to 6.7 cm and associated with the gallbladder wall (arrows) and right subdiaphragmatic and periportal nodules A). Axial fused 18fluorine fluorodeoxyglucose positron emission tomography-computed tomography demonstrates mild to moderate avidity in the left upper quadrant mass (SUVmax, 9.8) and in the gallbladder wall lesions (SUVmax, 4.2).
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case_images: Imaging included abdominal CT, MRI, and positron emission tomography CT (Fig. 4).
case_images: Histology from the gallbladder wall metastasis, hematoxylin and eosin stain shown with original magnification x 4 (A) and x 20 (B) demonstrates that adrenocortical carcinoma undermines the normal appearing gallbladder mucosa. Staining was positive for SF1, Melan A, synaptophysin, and inhibin, and was negative for CK7, CK20, CDX2, and chromogranin.
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case_images: Metastatic ACC was suspected, and the ultrasound-guided left upper quadrant mesenteric mass biopsy confirmed ACC (Fig. 5).
case_images: Histology from the adrenal mass removed in 2017, hematoxylin and eosin stain shown with original magnification x 4 (A) and x 20 (B) demonstrates irregular nodular growth pattern consistent with capsular invasion and enlarged pleomorphic hyperchromatic nuclei and mitotic activity.
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case_images: This review confirmed that the initial adrenal mass from 2017 was misinterpreted as benign and was in fact ACC, Fig. 6, reporting foci suspicious for capsular invasion, marked cytological atypia, diffuse architecture, < 25% clear cells, and increased mitoses of 23/50 high power fields, with a Weiss score of 4 of 9.