Does tumor heterogeneity limit the use of the Weiss criteria in the evaluation of adrenocortical tumors? – a clinicopathological report of a 52 year-old man

Adrenal incidentalomas are detected more frequently with high-resolution imaging modalities. Even postoperatively it is difficult to distinguish between benign and malignant lesions despite the so-called histologic Weiss criteria. We here present a 52 year-old man who was found to have an adrenal incidentaloma on an annual check-up at his urologist. A 8cm large adrenal lesion was detected on ultrasound, computed tomography and magnetic resonance imaging with imaging features suggestive of malignancy. The lesion was hormonally inactive. A left-sided adrenalectomy was performed and histologic grading revealed a Weiss score of 2, suggesting a benign tumor. However, on further follow-up, the patient developed a local recurrence and pulmonary metastases diagnosed 6 years after initial presentation. After repeat left-sided adrenalectomy, adrenocortical tumor tissue had a Weiss score of 8, clearly suggesting histologic malignancy. The patient received adjuvant mitotane therapy. This case suggests that adrenal incidentalomas larger than 6cm with imaging features such as intratumoral necrosis suggestive of malignancy, should be managed as potential cancers independent of the so-called Weiss criteria. In such patients, close follow-up examinations including high-resolution imaging (preferably 3 monthly) are needed and should be carried out by a physician familiar/specialized in endocrine oncology.