PMC2798106_01
Growth chart demonstrating impairment of linear growth, a classic feature of Cushing Syndrome, prior to diagnosis. After surgical removal of tumor, the patient exhibited catch-up growth during the following six months.
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Her linear growth apparently had been arrested between three and six months of age, although she gained weight at an accelerated rate (Figure 1).  Prior to referral, laboratory evaluation by her primary care physician revealed serum cortisol of 240 mcg/dl (normal, 4.5-22.7 mcg/dl);  total testosterone of 185 ng/dl (normal, 6-77ng/dl), and DHEA-S of 401 mcg/dl (normal, 16-96 mcg/dl).
Physical examination of the patient revealed features of Cushing Syndrome including round facies, acne, plethora, central obesity, and poor muscle tone; she lacked clitoromegaly, hirsutism or other signs of virilization.
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Physical examination showed Cushingoid facies, buffalo hump, facial acne, and poor muscle tone (Figure 2).
PMC2798106_02
(a) Grossly, the resected specimen showed a well-circumscribed tumor without normal adrenal gland. The tumor measured 5.2 x 4 x 3.5 cm and weighed 43 gm. (b) Adrenal cortical carcinoma with necrosis (upper field) and coarse calcifications. (c) Adrenal cortical carcinoma. Richly vascular neoplasm composed of nodules of tumor cells with lightly eosinophilic cytoplasm. The tumor contains bands of fibrous tissue and coarse calcifications (Hematoxylin and eosin, 20X).
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The adrenal mass and thrombus were removed en bloc (Figure 3(a)).  The mass showed five to ten percent necrosis of the mass with spotty calcifications (Figures 3(b) and 3(c)).
PMC2798106_03