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ENICAL MAMI
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Asian Journal of Surgery
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Asian Journal of Surgery -
Letter to Editor
Scalp nodule in a patient with adrenocortical cancer
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Keywords:
Adrenocortical carcinoma Cutaneous metastases Differential diagnosis Surgery Prognosis
To the editor,
Adrenocortical carcinoma (ACC) is a rare and aggressive malig- nancy with a highly variable prognosis. About one-third of patients present with distant metastases at initial diagnosis, with the most common sites of metastases being the lung, liver, bone and local lymph nodes.1 The 5-year survival rate is even as low as 0% in met- astatic ACC patients.2
Currently, there are only isolated reports that have mentioned cutaneous metastases of ACC, the diagnosis, treatment paradigms, and survival outcomes of this disease remain elusive. Here in, we report a 68-year-old woman who presented with a nontender nodule in the scalp that was clinically diagnosed as a sebaceous glands cyst but histologically was confirmed as metastatic ACC. Her physical examination revealed a 2.5-cm soft, sharply
demarcated, round subcutaneous nodule. The routine laboratory examination was within normal range. Computed tomography (CT) scan revealed a 2.5-cm subcutaneous soft tissue mass over the left posterior parietal region (Fig. 1). The only past medical his- tory available was that she had an ACC and underwent radical left adrenalectomy, with regular follow-up after surgery, and CT scan revealed no local recurrence and distant metastasis. A surgical resection for the scalp mass was performed. Based on the morpho- logic and immunohistochemical profiles, this was diagnosed as ma- lignant tumor. Upon further obtaining and reviewing the specimen from previous adrenalectomy, the diagnosis of ACC metastases to the skin was confirmed. The patient was discharged and subse- quently declined further treatment. At follow-up three years after surgery, she had no disease recurrence and distant metastases, without any adjuvant therapy.
Cutaneous metastases are rarely considered in differential diag- nosis, if a history of ACC is not considered. Furthermore, the histo- logical criteria of adrenocortical tumors are nondescript and not fully standardized, without specific reliable markers to distinguish adrenocortical tumors from other neoplasms. However, a panel of immunohistochemical markers may be helpful in differentiating ACC from non-adrenocortical tumors with similar histological fea- tures, including steroidogenic factor-1 (SF-1), inhibin-o, melan-A and calretinin.3
Cutaneous metastases in ACC generally present in the later course of disease, despite curative resection, patients subsequently experienced disease progression and had a dismal survival (range, 2-22 months), even with aggressive therapies.4,5 For the patient we report, at 3 years of follow-up, she remained disease-free without any adjuvant therapy. Therefore, given the heterogeneity of metastatic ACC, and the lack of effective treatment regimen, we should make an individual management to avoid overtreatment and improve the quality of life of patients.
Author contributions
Kang Wu and Xiang Li conceived the idea of this manuscript. Kang Wu, Kan Wu, Mengni Zhang and Xiang Li clinically followed the patient. Kang Wu, Kan Wu, Mengni Zhang and Xiang Li collected and interpreted the patient clinical data and wrote the manuscript. All authors contributed to the article and approved the submitted version.
Data availability statement
The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.
Declaration of competing interest
The authors declare that they have nocompeting interests.
References
1. Lafemina J, Brennan MF. Adrenocortical carcinoma: past, present, and future. J
Surg Oncol. 2012;106(5):586-594.
2. Icard P, et al. Adrenocortical carcinomas: surgical trends and results of a 253- patient series from the French Association of Endocrine Surgeons study group. World J Surg. 2001;25(7):891-897.
3. Sbiera S, et al. High diagnostic and prognostic value of steroidogenic factor-1 expression in adrenal tumors. J Clin Endocrinol Metabol. 2010;95(10):E161-E171.
4. Milchgrub S, Wiley EL. Adrenal carcinoma presenting as a lesion resembling cutaneous angiosarcoma. Cancer. 1991;67:3087.
5. Dominici A, et al. Non-functioning adrenal cortical carcinoma presenting with metastasis to the tongue. J Oral Pathol Med. 2003;32(3): 185-187.
Kang Wu1, Kan Wu1
Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Sichuan, 610041, China
Mengni Zhang1 Department of Pathology, West China Hospital, Sichuan University, Sichuan, 610041, China
Xiang Li*
Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Sichuan, 610041, China
Corresponding author. Department of Urology, Institute of Urology, West China Hospital, Sichuan University, 37 Guoxue Lane, Chengdu, Sichuan, 610041, China.
E-mail address: xiangli87@hotmail.com (X. Li). 24 April 2023 Available online 26 May 2023
1 Kang Wu, Kan Wu and Mengni Zhang contributed equally to this work.