PMC7085350_01
Contrast-enhanced CT abdomen, chest, and pelvis: (a) coronal image and (b) axial image showing heterogeneously enhancing left suprarenal mass (21 x 18 x 24 cm)* with central necrosis and foci of calcifications. Focal liver metastasis** is also seen.
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There were multiple liver, lymph node, and pulmonary metastasis to note (Figure 1).
CECT chest and abdomen (axial image): large liver metastasis* (largest: 12 x 11 cm in segment VII and VIII) and lung metastases**.
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Moreover, CECT chest, abdomen, and pelvis showed recurrence of the previously detected tumor (42  mm x 37  mm, 85 x 68 mm and 73 x 86 mm size tumor masses intra-abdominally) with multiple liver (largest of the metastases being 12 x 11 cm in size in segment VII and VIII), renal (40 x 62 mm), and lung metastases (Figure 2).
H&E stain (high power): solid sheets and nests of tumor cells, containing pleomorphic vesicular nuclei with coarse chromatin and eosinophilic cytoplasm.
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Histology (Figure 3) showed an encapsulated multinodular tumor composed of solid sheets and nests of tumor cells with thick fibrous bands separating them, containing pleomorphic vesicular nuclei with coarse chromatin and eosinophilic cytoplasm.
Immunohistochemical staining: (a) synaptophysin stain (patchy positivity), (b) inhibin stain (focal cytoplasmic positivity), (c) Chromogranin stain (negative), and (d) Pan CK stain (negative).
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The IHC staining profile (Figure 4) showed patchy positivity for synaptophysin and focal cytoplasmic positivity for inhibin.
ACTH Immunostaining: few scattered tumor cells showing granular cytoplasmic positivity.
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Tumor cells showed granular cytoplasmic positivity for ACTH favoring aberrant ACTH production by ACC cells (Figure 5).