Adrenocarical carcinoma

Mrs Premamma, 56yrs old lady got admitted with c/o of fatigue and early satiety since one month. There was no h/o loss of appetite, vomiting, weight loss, malena, hematuria or back pain.
No h/o hypertension, diabetes mellitus, tuberculosis or bronchial asthma.
Underwent hysterectomy 15 yrs ago for DUB.
On examination- no pallor, icterus, oedema, right supraclavicular hard node
Vitals normal.
P/a- mobile mass right lumbar region, hepatomegaly.

Investigations-

Chest x-ray – unremarkable
CT neck, chest and abdomen pelvis- neoplastic left renal mass with extensive nodal and hepatic metastasis. There is metastasis in right adrenal and left iliac bone. No lung nodule seen.
USG guided liver FNAC- smear shows fibrin and leucocytes. No malignant cells seen.
FNAC right supraclavicular node- smear shows cellular aspirate with clumps of small cells with round nucleus. Mild nuclear pleomorphism noted. No nuclear grooves/ nuclear inclusions seen. Possibility of a thyroid lesion suggested.
Bone scan- findings suggestive of skeletal metastases involving 3rd rib and bilateral iliac bones. There was increased uptake of tracer in the left supra renal mass suggestive of extensive possible calcification? cause Left supra renal mass warrants further evaluation.

Blood reports-
Serum calcium- 8.6 mg/dl
LDH- 274 IU/ml
AFP- 2.9 ng/ml
Hb- 9.1 g/dl
CEA- 1.10 ng/ml
Alp-189 IU/ml
USG guided liver trucut biopsy- shows fragments of tumour and liver tissue. Tumour shows cells with round uniform nucleus and trabecular pattern of arrangement. Cells express vimentin, pan CK is focally positive. Negative for CD10 and synaptophysin.

Impresssion- Adrenal cortical carcinoma.

COMMENTS: 56yr old lady initially was worked up as case of left renal cell carcinoma based on the CT findings as blood reports were unremarkable. Bone scan revealed a possible calcification in the left supra renal mass. It was finally confirmed by trucut biopsy as to site of primary being adrenal cortical carcinoma.