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Mass-Effect and Incidental Discovery in ACC

Clinical Presentation

Adrenocortical carcinoma (ACC) may come to clinical attention through local mass effect, acute mechanical or hemorrhagic complications, or incidental imaging discovery rather than through a classic hormone-excess syndrome.12 Within the broader hierarchy of ACC presentation, this pattern is most often associated with clinically nonfunctioning or clinically silent tumors, although hormonally active cancers may also initially present because tumor bulk, invasion, or bleeding is more apparent than endocrine manifestations.21

This mode of presentation reflects the retroperitoneal location of the adrenal gland and the tendency of ACC to remain occult until lesions become large, heterogeneous, invasive, or are detected during imaging performed for unrelated reasons.345 Symptoms are usually nonspecific, including abdominal, flank, back, or chest pain, abdominal fullness, edema from venous obstruction, or symptoms related to hemorrhage or metastatic spread.678 Even when discovered incidentally, ACC is often already sizable, and incidental detection does not reliably indicate indolent biology.91011

The evidence base is limited. Most data derive from retrospective surgical cohorts, referral-center series, and case reports that overrepresent striking or advanced presentations.12108 As a result, the literature is more reliable for describing recurring clinical patterns than for estimating their true frequency or independent prognostic significance. Presentation and imaging findings alone also cannot definitively distinguish ACC from benign adrenal incidentaloma, hemorrhagic adrenal lesions, renal malignancy, or other retroperitoneal tumors, so these findings mainly guide suspicion and triage rather than establish diagnosis.13128

Diagnostic context

Mass-effect and incidental presentations are most relevant when ACC lacks an obvious endocrine syndrome at bedside assessment. Older and contemporary series alike suggest that nonfunctioning or clinically silent tumors are often recognized later, after substantial growth or local spread, because early symptoms are absent or vague.14151 However, clinically silent tumors are not necessarily biochemically inactive: steroid excess or precursor secretion may be detectable even when classic Cushingoid, virilizing, or feminizing features are not prominent.162

In practice, these tumors often enter care pathways through abdominal imaging, vascular evaluation, chest symptom workup, or investigation of unrelated complaints. This broadens the differential diagnosis to include benign adrenal incidentaloma, adrenal hemorrhage, renal cell carcinoma, retroperitoneal sarcoma, abscess, hematoma, and metastatic disease.131712 The most reproducible warning features are large size, heterogeneity, necrosis or hemorrhage, local invasion, and venous extension, but none is specific for ACC in isolation.58 The practical implication is that absence of overt hormone symptoms should not reassure against malignancy when structural features are concerning.

Major presentation patterns

Local pain, fullness, and palpable mass

The most commonly described mass-effect phenotype is nonspecific abdominal, flank, epigastric, or back pain, sometimes accompanied by abdominal fullness, weight loss, weakness, or a palpable mass.3418 Historical reports frequently emphasize palpable tumors, likely reflecting delayed recognition before modern cross-sectional imaging became routine.1516 Very large tumors may occasionally mimic an acute abdominal process even without frank rupture.1920

This pattern is consistently described across case series and reviews and is therefore a reliable general feature of clinically silent ACC.112 It is not diagnostically specific, however, because the same symptom complex overlaps with more common renal, gastrointestinal, and retroperitoneal disorders. Clinically, persistent pain or fullness associated with a large adrenal-region mass should prompt malignant adrenal evaluation rather than symptom-based observation alone.

Venous obstruction and locally invasive mechanical syndromes

As tumors enlarge or invade locally, ACC may present through compression of the inferior vena cava or direct tumor thrombus, producing lower-extremity edema, dyspnea, pulmonary embolic phenomena, or an isolated right-sided varicocele.212257 Extension into the right atrium has also been described and generally indicates advanced locoregional disease rather than a primary cardiologic disorder.2324

These manifestations are clinically important because they may initially trigger vascular, cardiopulmonary, or urologic evaluation before the adrenal primary is recognized. The literature reliably shows that venous involvement can be part of the presenting phenotype, but available evidence is too sparse and selective to define its frequency or independent prognostic value.237 The practical implication is that unexplained venous obstruction with a right adrenal mass should raise suspicion for locally advanced ACC and influence staging and surgical planning.

Transitioning from chronic compressive symptoms to more abrupt presentations, a smaller body of literature describes ACC first recognized because of hemorrhage or rupture.

Incidental adrenal mass discovery

Some ACCs are discovered as adrenal incidentalomas during imaging for unrelated disease or nonspecific symptoms.13925 Retrospective surgical data suggest that incidentally detected ACC may sometimes be identified at a more localized stage and may have somewhat better outcomes than symptom-detected disease, but these findings are inconsistent and vulnerable to referral and selection bias.910

The more dependable conclusion is that incidental discovery may create an opportunity for earlier diagnosis in a subset of patients, but incidental status should not be equated with benign behavior.1011 Large size, local invasion, and occult steroid secretion may still be present, so standard adrenal incidentaloma assessment remains necessary, including biochemical evaluation and malignancy-focused imaging review.25

Acute hemorrhagic and rupture presentations

Spontaneous intratumoral or retroperitoneal hemorrhage is an uncommon but repeatedly reported presentation of ACC. Patients may present with sudden abdominal, flank, chest, or back pain, anemia, falling hematocrit, hemodynamic instability, or hemorrhagic shock.26272829 Hemorrhage may obscure the adrenal origin of the lesion on initial imaging and complicate characterization of the underlying mass.308

This presentation is well documented as a real but rare event, whereas its prognostic meaning remains uncertain because reported cases are few and usually advanced.313233 The practical implication is that ACC belongs in the differential diagnosis of spontaneous retroperitoneal hematoma or apparent adrenal hemorrhage, especially when imaging shows a large heterogeneous adrenal lesion.278

Unusual metastatic or secondary mechanical presentations

Case reports describe uncommon first manifestations caused by metastatic spread or secondary obstruction, including pathologic fracture, pancreatitis from pancreatic metastasis, bowel obstruction, pericardial disease, and mandibular lesions.3435113637 These are best understood as rare consequences of advanced disease rather than common presentation phenotypes.

Because the evidence is almost entirely case-based, it is useful mainly for broadening differential diagnosis and illustrating the range of possible presentations. Such reports do not reliably inform prognosis or screening strategy, but they support considering an adrenal primary when metastatic or obstructive syndromes lack an obvious source.

Pitfalls and limitations

The main diagnostic pitfall is misclassifying clinically silent ACC as a benign incidentaloma or as a nonadrenal retroperitoneal process.1213 Hemorrhagic, cystic, or pseudocystic appearances can be particularly misleading, and necrosis or degeneration may conceal the underlying carcinoma.388 Rare abscess-like presentation or bilateral disease with adrenal insufficiency further illustrates that ACC can mimic infectious, inflammatory, or other adrenal disorders.1739

Another recurring limitation is underrecognition of subtle hormone excess when mass effect dominates the presentation. Retrospective and prospective data suggest that biochemical abnormalities may be present despite an apparently nonfunctioning clinical picture, with implications for perioperative management and tumor characterization.162 This is a reasonably reliable practical point, although the exact prevalence of occult secretion remains uncertain across cohorts.

Role in management and research

From a management perspective, this presentation category underscores that ACC may enter care as an anatomic, radiographic, vascular, or hemorrhagic problem rather than a primarily endocrine one.15 Compared with endocrine-driven presentations, these cases often require broader differential diagnosis and closer coordination among radiology, endocrinology, surgery, and oncology. What appears reliable is the need for expedited specialist assessment when pain, hemorrhage, venous obstruction, or invasive imaging features accompany an adrenal mass; what is less reliable is any attempt to infer prognosis from presentation pattern alone.108

Research remains limited by fragmented retrospective data and heavy dependence on case reports. Better multicenter datasets are needed to determine whether incidental discovery truly shifts stage distribution, how often clinically silent tumors have occult steroid secretion, and whether hemorrhagic or venous-obstructive presentations carry outcome implications beyond stage and resectability.101 Pending such data, the most defensible conclusion is descriptive: ACC may present through mass effect, invasion, or incidental imaging discovery as well as through overt endocrinology, and the absence of a classic hormonal syndrome does not exclude aggressive disease.

Included Articles

  • PMID 442338: This case report describes nonfunctioning adrenocortical carcinoma as presenting insidiously without endocrine syndromes, with symptoms driven by tumor enlargement such as flank or epigastric pain, weight loss, and a palpable abdominal mass. The authors emphasize that absence of hormonal manifestations can delay recognition.3
  • PMID 3071946: This case report describes a nonfunctioning, asymptomatic adrenocortical carcinoma discovered incidentally during evaluation of gross hematuria from synchronous ureteral transitional cell carcinoma. The review notes that nonfunctioning ACC may lack adrenal-specific symptoms and is increasingly identified incidentally with imaging.13
  • PMID 3446461: This case series describes nonfunctioning adrenocortical carcinoma as an insidious, often late-presenting disease marked by abdominal mass, pain, weight loss or weakness, and sometimes fever, without overt endocrine syndromes. Delayed recognition was common, with frequent local invasion and very poor short-term outcomes.14
  • PMID 4475307: This case report and literature summary describe non-functioning adrenocortical carcinoma as often presenting with nonspecific abdominal or flank pain and a palpable mass despite normal endocrinologic testing, which can delay recognition until surgery, metastasis, or autopsy. The reported patient had a large left upper abdominal mass without hormonal manifestations.15
  • PMID 4815581: This series characterizes clinically non-overtly hormonal adrenocortical tumors as usually presenting in later adulthood with abdominal or flank pain and a palpable mass, often with weight loss or metastatic disease. Although lacking classic endocrine syndromes, some tumors showed steroid precursor production without overt hormonal manifestations.16
  • PMID 5247971: This case report and literature summary describe feminizing ACC as a rare endocrine presentation in men, most often manifesting with gynecomastia and sometimes a palpable subcostal mass. Other feminizing features may be absent, making isolated gynecomastia an important clue to an estrogen-secreting adrenal cortical malignancy.40
  • PMID 6827502: This case report highlights tumor-induced hypoglycemia as an uncommon functional presentation of adrenocortical carcinoma, with severe neuroglycopenic manifestations including transient hemiparesis that resolved after glucose administration. The report also notes abdominal mass symptoms and discusses non-islet-cell tumor hypoglycemia as a possible mechanism.41
  • PMID 7431691: This case report describes feminizing ACC in a 37-year-old man presenting with progressive gynecomastia, impotence, decreased libido, and abdominal mass, with markedly elevated estrone and estradiol and low gonadotropins and testosterone. Surgical resection normalized hormonal abnormalities and reversed feminizing symptoms.42
  • PMID 8400512: This case report describes recurrent metastatic ACC presenting with massive pericardial effusion, a giant pericardial mass, and fatal cardiac tamponade. It highlights that ACC can rarely metastasize to the pericardium or epicardium and cause severe cardiopulmonary symptoms during the metastatic course.36
  • PMID 9893659: In a series of incidentally discovered adrenal tumors, ACC cases were usually hormonally inactive despite often large size, with only occasional steroid excess. Compared with clinically overt ACC, incidental cases showed fewer endocrine syndromes and somewhat more localized presentation at diagnosis.9
  • PMID 11176405: This case report describes adrenocortical carcinoma presenting as a symptomatic unilateral right varicocele caused by inferior vena cava compression from a large right adrenal mass. It highlights retroperitoneal malignancy as an important consideration when evaluating an isolated right varicocele.21
  • PMID 11898793: This case report describes nonfunctional adrenocortical carcinoma initially presenting with a lytic pathologic fracture from radius metastasis, alongside vague abdominal pain. The excerpt emphasizes that pain may arise from metastatic disease or a large abdominal mass and that advanced metastatic presentation is common.34
  • PMID 12441958: This case report highlights spontaneous rupture of primary adrenocortical carcinoma as a rare presentation, causing acute severe abdominal pain, shock, and retroperitoneal hemorrhage. CT showed a mixed-density hemorrhagic adrenal mass, and metastatic liver nodules were identified at surgery.26
  • PMID 15154587: This case report describes adrenocortical carcinoma presenting unusually with spontaneous tumor rupture, massive retroperitoneal hemorrhage, and hemorrhagic shock rather than typical endocrine or mass-effect symptoms. It highlights that ACC should be considered in the differential diagnosis of retroperitoneal hematoma associated with an abdominal or renal-space mass.27
  • PMID 15593464: In this prospective single-center ACC cohort, 63.6% had overt adrenocortical hyperactivity at diagnosis, while the remainder still showed biochemical steroid secretion abnormalities despite lacking obvious hormonal symptoms. Recently diagnosed moderate-to-severe, treatment-resistant hypertension was the most common presenting feature, alongside Cushingoid, virilizing, abdominal pain, and palpable-mass presentations.2
  • PMID 15964108: A case report describes very late metastatic recurrence of adrenocortical adenocarcinoma presenting 9 years after initial tumor resection as a mandibular lytic mass with lower-lip anesthesia. The report highlights an unusual metastatic presentation in the jaw rather than a typical local endocrine or abdominal manifestation.37
  • PMID 17560914: This case report highlights spontaneous rupture with intratumoral and peritumoral hemorrhage as a rare acute-abdomen presentation of adrenocortical carcinoma. In a large nonfunctional adrenal tumor, sudden severe abdominal pain and hemorrhagic enlargement prompted emergency adrenalectomy.31
  • PMID 17576894: This case report describes ACC presenting in a 26-year-old postpartum woman with persistent severe hypertension and hyperglycemia that began during pregnancy and was initially attributed to preeclampsia. MRI showed a right adrenal mass with possible liver invasion before surgical resection.43
  • PMID 17872359: This case report describes nonfunctioning adrenocortical carcinoma presenting unusually as a retroperitoneal abscess with fever, sweats, anorexia, pain, and an abscessed necrotic adrenal mass. It highlights that ACC can rarely mimic intra-abdominal infection rather than a typical endocrine syndrome.17
  • PMID 18880458: This case report emphasizes that nonhormonal adrenocortical carcinoma may present insidiously as a large palpable abdominal or flank mass with vague pain and little endocrine symptomatology, leading to late discovery and frequent metastatic spread. The reported patient was initially mistaken for having a renal neoplasm because hormonal features were absent.12
  • PMID 19926942: This case report describes adrenocortical carcinoma presenting with acute left chest and back pain due to intratumoral hemorrhage in a 6 cm adrenal mass. The report notes that hemorrhagic adrenal tumors of this size can suggest ACC and may be associated with aggressive clinical behavior.28
  • PMID 20734420: In this surgical series, some ACCs were discovered as adrenal incidentalomas rather than through symptomatic or functioning presentation. Incidentally detected ACCs were nonfunctioning and showed a trend toward lower Weiss scores and better survival than symptomatic ACC, though statistical significance was not reached.10
  • PMID 20879070: This case report highlights spontaneous rupture with retroperitoneal hemorrhage as a rare presentation of functioning ACC. During diagnostic work-up, new or changing abdominal pain in a patient with a large hormonally active adrenal mass may signal tumor rupture.32
  • PMID 22495043: This case report highlights spontaneous retroperitoneal hemorrhage from ruptured ACC as a rare presenting manifestation, initially obscuring the bleeding source and later revealing a 7 cm adrenal mass. The patient presented with flank pain and had largely nonfunctional endocrine testing despite aggressive subsequent recurrence and metastasis.30
  • PMID 23675071: This case series describes retroperitoneal hemorrhage from ruptured ACC as a rare but life-threatening initial presentation marked by sudden lumbar or abdominal pain, falling hematocrit or anemia, and shock. The authors report emergency surgery as life-saving and suggest this presentation is associated with aggressive disease and poor prognosis.29
  • PMID 25361816: This case report and literature review emphasizes that nonfunctioning ACC often lacks endocrine manifestations and therefore presents later with mass effect or metastatic disease. The reported patient presented with flank pain, weight loss, a palpable abdominal mass, and suspected lung lesions despite a normal hormonal work-up.4
  • PMID 25927963: This case report highlights that nonfunctional adrenocortical carcinoma can rarely present with spontaneous rupture causing acute massive retroperitoneal hemorrhage and severe back pain rather than endocrine symptoms. It underscores hemorrhagic presentation as an unusual but important clinical manifestation of ACC.33
  • PMID 26163636: In this 10-year Iranian adrenal tumor series, adrenocortical carcinoma accounted for 6 of 71 resected adrenal tumors and was usually larger than 4 cm and more often functional than nonfunctional. Reported ACC presentations were dominated by abdominal pain and weight loss rather than classic endocrine syndromes.18
  • PMID 28065533: This case report describes a giant nonfunctional adrenocortical carcinoma in a 64-year-old patient presenting with 3 months of abdominal pain and right upper quadrant mass effect, without other symptoms. The tumor was identified as a large retroperitoneal adrenal mass and confirmed after surgery.6
  • PMID 29147395: This case report describes a nonfunctional stage III adrenocortical carcinoma initially detected after pulmonary embolism, highlighting venous thromboembolism as an unusual presenting circumstance. The tumor lacked overt hormone-excess symptoms despite elevated urinary steroid metabolites and was otherwise found as a large flank mass.22
  • PMID 29265216: Feminizing adrenocortical carcinoma may present with bilateral gynecomastia, sometimes as the only obvious feminizing feature, and a palpable subcostal mass is present in about half of reported cases. The review notes frequent late diagnosis, large tumors, and common metastatic spread to liver, lungs, and regional lymph nodes.44
  • PMID 30413177: This review emphasizes that nonfunctioning ACC often lacks endocrine symptoms and is therefore detected late through mass effect, incidental imaging, or metastatic presentation. It highlights epigastric discomfort, abdominal compression symptoms, and the association of nonsecretory tumors with more advanced disease and poorer prognosis.1
  • PMID 31178487: This case report describes metastatic ACC presenting with recurrent acute pancreatitis due to a small pancreatic metastasis obstructing the main pancreatic duct, a highly unusual manifestation. It highlights that metastatic ACC can rarely present through pancreatitis rather than classic endocrine or mass-effect symptoms.35
  • PMID 31765326: This case report highlights a rare presentation of adrenocortical carcinoma with venous tumor thrombus extending through the inferior vena cava into the right atrium, causing pulmonary embolism. It also notes that nonfunctional ACC may present with abdominal pain or incidental discovery rather than overt hormone excess.23
  • PMID 33117452: This case report highlights an exceptionally rare presentation of ACC as bilateral adrenal masses with acute adrenal insufficiency and nonsecretory disease, accompanied by hypotension, electrolyte abnormalities, and distant metastases. It emphasizes that ACC can mimic more common causes of bilateral adrenal enlargement and should remain in the differential diagnosis.39
  • PMID 34010448: This case report describes a hormonally active ACC presenting postpartum with headache, hypertension, edema, abdominal and lumbar pain, and exceptionally rare cardiac involvement through inferior vena cava extension into the right atrium, including an intra-atrial mass and tricuspid valve lesion.24
  • PMID 34156349: This case report describes an unusual ACC presentation in a 30-year-old man whose testicular swelling led to imaging that identified a large nonfunctional adrenal mass. The report emphasizes that ACC may be discovered incidentally during evaluation of unrelated symptoms and can coexist with other rare conditions that complicate presentation.25
  • PMID 34584815: This case report describes ACC presenting through an adrenal incidentaloma with bilateral lower limb edema and dyspnea, attributed to inferior vena cava invasion impairing venous return. The patient also had biochemical hypercortisolism with subtle clinical features obscured by obesity and metastatic hepatic and pulmonary disease.5
  • PMID 35725572: This case report describes an unusual presentation of hormonally active stage III adrenocortical carcinoma with progressive bilateral peripheral edema and paroxysmal dyspnea caused by inferior vena cava compression from a massive right adrenal tumor. It highlights venous outflow obstruction as a rare mass-effect presentation when routine cardiac, hepatic, and renal evaluation is unrevealing.7
  • PMID 37903692: This case report describes a giant functional ACC in a 64-year-old woman presenting with abdominal pain, palpable mass, hirsutism, deep voice, acne, and markedly elevated testosterone with otherwise normal hormonal tests. It highlights virilization as a presentation of androgen-secreting ACC.45
  • PMID 39138988: In this single-center adrenal hemorrhage series, ACC was identified as one of the tumor types associated with hemorrhagic presentation, sometimes as the first manifestation of disease. The report emphasizes that adrenal hemorrhage can produce nonspecific flank, back, or abdominal pain and may obscure preoperative lesion characterization.8
  • PMID 41614720: This case report describes metastatic ACC initially presenting as mechanical small bowel obstruction from terminal ileal metastasis in an elderly man with a large nonfunctional adrenal incidentaloma. It highlights intestinal obstruction as an exceptionally rare presenting manifestation that can occur despite benign-appearing adrenal imaging and absence of hormone excess.11
  • PMID 41641019: This case report highlights that adrenocortical carcinoma can rarely present as acute abdomen from extreme mass effect without radiologic or operative evidence of tumor rupture. The tumor was non-functioning, very large, and associated with abdominal pain and a palpable mass rather than endocrine symptoms.20
  • PMID 22679267: A 2011 case report described adrenocortical carcinoma presenting within a giant adrenal pseudocyst, illustrating that ACC can rarely mimic a benign cystic adrenal lesion. The report mainly adds a cautionary diagnostic nuance about pseudocystic presentation rather than changing the broader presentation framework.38
  • PMID 11547736: A 2001 case report described a giant nonfunctioning adrenocortical carcinoma, supporting the note’s framing that ACC may first come to attention through tumor bulk in the absence of overt hormone-excess features.19
  • PMID 37734721: A veterinary multi-institutional retrospective study of spontaneously ruptured adrenal tumors found high short-term perioperative risk but overall survivorship among cases reaching adrenalectomy, with better short-term outcomes after stabilization and delayed rather than emergent surgery. Because the cohort included mixed adrenal tumor types in dogs and cats, it provides only indirect comparative context for hemorrhagic ACC presentations.46
  • PMID 4350184: A 1973 case report and review described Addison’s disease caused by bilateral adrenal replacement from metastatic carcinoma, noting that adrenal insufficiency is rare despite common adrenal metastases because most of the cortex must be destroyed before failure becomes clinically evident. Although not an ACC study, it adds indirect context on underrecognized adrenal failure as a cancer-related diagnostic pitfall.47
  • PMID 28781295: A veterinary case report described bilateral incidental adrenocortical carcinomas with normal cortisol testing and delayed recognition of metastatic disease. Its relevance to human ACC is indirect, but it supports caution that incidental, apparently nonfunctioning adrenal masses can still represent malignant cortical tumors.48

References

Footnotes

  1. Giant nonfunctioning adrenal tumors: two case reports and review of the literature.. J Med Case Rep. 2018. PMID: 30413177. Local full text: 30413177.md ↩ ↩2 ↩3 ↩4 ↩5 ↩6 ↩7

  2. Andrenocortical carcinomas: twelve-year prospective experience.. World J Surg. 2004. PMID: 15593464. Local full text: 15593464.md ↩ ↩2 ↩3 ↩4 ↩5 ↩6

  3. Primary nonfunctioning carcinoma of adrenal cortex.. Urology. 1979. PMID: 442338. Local full text: 442338.md ↩ ↩2 ↩3

  4. Giant nonfunctioning adrenocortical carcinoma: a case report and review of the literature.. BMC Res Notes. 2014. PMID: 25361816. Local full text: 25361816.md ↩ ↩2 ↩3

  5. A Rare Presentation of Adrenocortical Carcinoma.. Cureus. 2021. PMID: 34584815. Local full text: 34584815.md ↩ ↩2 ↩3 ↩4 ↩5 ↩6

  6. Giant adrenal cortical carcinoma.. Cir Esp. 2017. PMID: 28065533. Local full text: 28065533.md ↩ ↩2

  7. Massive adrenocortical carcinoma presenting as peripheral edema: a case report.. J Med Case Rep. 2022. PMID: 35725572. Local full text: 35725572.md ↩ ↩2 ↩3 ↩4

  8. Characteristics of Adrenal Hemorrhage: A Single Clinic’s Experience.. Pol Przegl Chir. 2024. PMID: 39138988. Local full text: 39138988.md ↩ ↩2 ↩3 ↩4 ↩5 ↩6 ↩7 ↩8 ↩9

  9. Incidentally found adrenocortical carcinoma. A study of 21 patients.. Eur J Cancer. 1998. PMID: 9893659. Local full text: 9893659.md ↩ ↩2 ↩3 ↩4

  10. Adrenal incidentalomas: risk of adrenocortical carcinoma and clinical outcomes.. J Surg Oncol. 2010. PMID: 20734420. Local full text: 20734420.md ↩ ↩2 ↩3 ↩4 ↩5 ↩6 ↩7

  11. A nonfunctional adrenal incidentaloma revealed by intestinal obstruction: metastatic adrenocortical carcinoma diagnosed by surgery.. Endocrinol Diabetes Metab Case Rep. 2026. PMID: 41614720. Local full text: 41614720.md ↩ ↩2 ↩3 ↩4

  12. Nonhormonal adrenal cortical carcinoma; report of case with 5 year survival and relief of hypertension.. J Urol. 1948. PMID: 18880458. Local full text: 18880458.md ↩ ↩2 ↩3 ↩4 ↩5 ↩6

  13. [Synchronously occurring transitional cell carcinoma of the ureter with adrenocortical carcinoma].. Hinyokika Kiyo. 1988. PMID: 3071946. Local full text: 3071946.md ↩ ↩2 ↩3 ↩4 ↩5

  14. [Non-functioning adrenocortical carcinoma: report of 3 cases].. Zhonghua Wai Ke Za Zhi. 1987. PMID: 3446461. Local full text: 3446461.md ↩ ↩2

  15. [A case of non-functioning adrenocortical carcinoma (author’s transl)].. Nihon Hinyokika Gakkai Zasshi. 1974. PMID: 4475307. Local full text: 4475307.md ↩ ↩2 ↩3

  16. The clinical and pathologic features of “non-hormonal” adrenocortical tumors. Report of twenty new cases and review of the literature.. Cancer. 1974. PMID: 4815581. Local full text: 4815581.md ↩ ↩2 ↩3 ↩4

  17. Adrenocortical carcinoma presenting as a retroperitoneal abscess: an unusual presentation of a rare tumor.. Endocr Pract. 2007. PMID: 17872359. Local full text: 17872359.md ↩ ↩2 ↩3

  18. Clinicopathological Features of Adrenal Tumors: a Ten-year Study in Yazd, Iran.. Asian Pac J Cancer Prev. 2015. PMID: 26163636. Local full text: 26163636.md ↩ ↩2

  19. Giant, nonfunctioning carcinoma of the adrenal cortex.. N Engl J Med. 2001. PMID: 11547736. Local full text: 11547736.md ↩ ↩2

  20. Massive non-functioning Adrenocortical carcinoma presenting as acute abdomen without rupture: A case report.. Urol Case Rep. 2026. PMID: 41641019. Local full text: 41641019.md ↩ ↩2

  21. Adrenal cortical carcinoma presenting as right varicocele.. J Urol. 2001. PMID: 11176405. Local full text: 11176405.md ↩ ↩2

  22. Pulmonary Embolism as an Initial Presentation of Adrenocortical Carcinoma.. World J Oncol. 2014. PMID: 29147395. Local full text: 29147395.md ↩ ↩2

  23. Adrenocortical carcinoma and pulmonary embolism from tumoral extension.. Endocrinol Diabetes Metab Case Rep. 2019. PMID: 31765326. Local full text: 31765326.md ↩ ↩2 ↩3

  24. Metastasis of adrenocortical carcinoma to the heart.. Endokrynol Pol. 2021. PMID: 34010448. Local full text: 34010448.md ↩ ↩2

  25. Testicular swelling leading to a diagnosis of adrenocortical carcinoma - co-incidence or causation?. Endocrinol Diabetes Metab Case Rep. 2021. PMID: 34156349. Local full text: 34156349.md ↩ ↩2

  26. Spontaneous rupture of adrenocortical carcinoma.. J Urol. 2002. PMID: 12441958. Local full text: 12441958.md ↩ ↩2

  27. Haemorrhagic shock from the spontaneous rupture of an adrenal cortical carcinoma. A case report.. Acta Chir Belg. 2004. PMID: 15154587. Local full text: 15154587.md ↩ ↩2 ↩3

  28. [Adrenocortical carcinoma with intratumoral hemorrhage detected from chest and back pain: a case report].. Hinyokika Kiyo. 2009. PMID: 19926942. Local full text: 19926942.md ↩ ↩2

  29. Retroperitoneal hemorrhage from adrenocortical carcinoma as a poor prognostic factor.. Int J Biomed Sci. 2008. PMID: 23675071. Local full text: 23675071.md ↩ ↩2

  30. [Adrenocortical carcinoma detected by retroperitoneal hemorrhage : a case report].. Hinyokika Kiyo. 2012. PMID: 22495043. Local full text: 22495043.md ↩ ↩2

  31. Spontaneous rupture of adrenocortical carcinoma.. Am J Surg. 2007. PMID: 17560914. Local full text: 17560914.md ↩ ↩2

  32. Spontaneous rupture of a functioning adrenocortical carcinoma.. Yonsei Med J. 2010. PMID: 20879070. Local full text: 20879070.md ↩ ↩2

  33. Nonfunctional adrenocortical carcinoma initially presenting as retroperitoneal hemorrhage.. BMC Surg. 2015. PMID: 25927963. Local full text: 25927963.md ↩ ↩2

  34. Adrenal cortical carcinoma presenting initially with radius metastasis.. Clin Oncol (R Coll Radiol). 2002. PMID: 11898793. Local full text: 11898793.md ↩ ↩2

  35. Endoscopic Ultrasonography-guided Fine-needle Aspiration Revealed Metastasis-induced Acute Pancreatitis in a Patient with Adrenocortical Carcinoma.. Intern Med. 2019. PMID: 31178487. Local full text: 31178487.md ↩ ↩2

  36. Adrenocortical carcinoma with a giant pericardial mass.. Intern Med. 1993. PMID: 8400512. Local full text: 8400512.md ↩ ↩2

  37. Interesting case: Metastatic adrenal adenocarcinoma of the mandible.. Br J Oral Maxillofac Surg. 2006. PMID: 15964108. Local full text: 15964108.md ↩ ↩2

  38. Giant adrenal pseudocyst harbouring adrenocortical cancer.. BMJ Case Rep. 2011. PMID: 22679267. Local full text: 22679267.md ↩ ↩2

  39. Bilateral Adrenocortical Carcinoma Presenting as Acute Adrenal Insufficiency.. Eur Endocrinol. 2020. PMID: 33117452. Local full text: 33117452.md ↩ ↩2

  40. Feminizing adreno-cortical carcinoma: report of a case.. Aust N Z J Surg. 1968. PMID: 5247971. Local full text: 5247971.md ↩

  41. Adrenocortical carcinoma with tumour-induced hypoglycaemia.. J R Soc Med. 1983. PMID: 6827502. Local full text: 6827502.md ↩

  42. Feminizing adrenocortical carcinoma in man.. Jpn J Surg. 1980. PMID: 7431691. Local full text: 7431691.md ↩

  43. Image of the month—adrenocortical carcinoma.. Arch Surg. 2007. PMID: 17576894. Local full text: 17576894.md ↩

  44. Feminizing Adreno-Cortical Carcinoma: Report of a Case.. Aust N Z J Surg. 1971. PMID: 29265216. Local full text: 29265216.md ↩

  45. Giant androgen-producing adrenocortical carcinoma causing male characteristics.. Asian J Surg. 2024. PMID: 37903692. Local full text: 37903692.md ↩

  46. Adrenal tumors treated by adrenalectomy following spontaneous rupture carry an overall favorable prognosis: retrospective evaluation of outcomes in 59 dogs and 3 cats (2000-2021).. J Am Vet Med Assoc. 2023. PMID: 37734721. Local full text: 37734721.md ↩

  47. Addison’s disease secondary to metastatic carcinoma: an example of adrenocortical and adrenomedullary insuffiency.. Cancer. 1973. PMID: 4350184. Local full text: 4350184.md ↩

  48. Clinical and pathological features and outcome of bilateral incidental adrenocortical carcinomas in a dog.. J Vet Med Sci. 2017. PMID: 28781295. Local full text: 28781295.md ↩

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