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Simple Summary: Pituitary neuroendocrine tumors (PitNETs) comprise a large panel of histological types and usually require a multidisciplinary team for diagnosis and management. The most common are clinically and biochemically non-functioning PitNETs, and among them are incidentally found masses of pituitary incidentalomas (PIs), which have an increasing rate of detection currently. PIs are diagnosed in 10% of the population (up to 40% in some studies), and they may be confirmed at any age, mostly by computed tomography (CT) or magnetic resonance imaging (MRI). The rate of PIs growth varies from 5% to 50% depending on the tumor size, but micro-adenomas generally have a lower rate of enlargement. Long-term follow-up is advised, yet standard protocols are not homogenous. Overall, forestalling the tumor's spontaneous evolution is still an open issue. Non-functioning (NF) accidentally detected PitNETs (PIs) are common findings of CT/MRI scans currently. Data concerning their behavior vary, and some PIs will potentially experience a size change over time that might become clinically relevant. Objective: We aimed to evaluate CT-related PIs diameters following 3 aspects: a cross-sectional analysis based on the age' groups at first PI diagnosis and on the gender distribution and a longitudinal analysis in PIs with <0.5 cm versus ≥0.5 cm as the largest diameter at baseline. Methods: A retrospective, real-life, multi-centric study in adults with NF micro-PIs was performed. Results: 208 subjects (92.79% females) were included (average age 43.18 ± 12.58 y). The mean largest diameter (between transversal and longitudinal diameters) was 0.55 ± 0.16cm, and 44.71% of the PIs were located on the right part of the pituitary gland. The patients were divided into 10 age-groups (21 to 70 y), and no difference was observed between the mean largest diameters of these groups (p = 0.693). Females and males had a similar age at PIs diagnosis (p = 0.353), transverse diameter (p = 0.910), longitudinal diameter (p = 0.229), and PI location (p = 0.368). Serial CT scans (2 to 4 per patient) included a median (Q1–Q3) of 20 (12–36) months for the second CT scan, 58 (36–84) for the third CT scan, 78 (53–118) for the fourth CT scan, and a total follow-up between baseline and last CT scan of 40 (13–72) months. The initial largest diameter correlated with the diameter change between the baseline and the last CT (r = −0.575, p = 0.000). The largest PI diameter was similar between each serial CT scan (p = 0.840). According to the cut-off value of 0.5 cm diameter (for initial largest tumor diameter), group A (N = 78, 37.50%, <0.5 cm) and group B (N = 130, 62. 50%; ≥0.5 cm) had similar age at baseline (43.83 ± 12.72 versus 42.79 ± 12.54 y, p = 0.565) and PIs locations (right, left, median). The largest PI diameter remained smaller in group A versus B amid the second CT scan (p = 0.000) and the last CT scan (p = 0.009). The largest diameter change from the first to the last CT scan showed an increase in group A (median of +0.10 cm, p = 0.000) and a decrease in group B (median of −0.01 cm, p = 0.002); this diameter change was different in group A versus B (p = 0.000). The cumulative probability of tumor-growth-free survival showed different survival functions (log rank p = 0.000): group A exhibited a more gradual decrease versus B; at 60 months, the cumulative probability was 0.32 ± 0.08 for group A versus 0.75 ± 0.07 for B. During follow-up, all PIs remained NF, and no hypopituitarism was noted (as limits, we mention that dynamic hypopituitarism testing was selectively performed). Conclusions: NF micro-PIs in adults showed a similar age and sex distribution. During follow-up, PIs with a largest diameter < 0.5 cm increased after a median of 40 months but remained <1 cm, while in PIs with ≥0.5 cm, the largest diameter decreased. This highlights a lower predictability in tumor behavior than expected, particularly in larger micro-PIs that, overall, remained without relevant clinical implications after surveillance. [ABSTRACT FROM AUTHOR]

Background. Incidentalomas have an increasing incidence all over the world due to a larger access to imaging assessments, and endocrine incidentalomas make no exception in this matter, including pituitary incidentalomas (PIs). Objective. Our objective was to analyse the dynamic changes amid a second computed tomography (CT) scan after adult patients were initially confirmed with a PI (non-functioning micro-adenoma). Methods. This was a multi-centric, longitudinal, retrospective study in adults (aged between 20 and 70 y) amid real-world data collection. We excluded patients who experienced baseline pituitary hormonal excess or deficiency or those with tumours larger than 1 cm. Results. A total of 117 adults were included (94.02% females) with a mean age of 43.86 ± 11.99 years, followed between 6 and 156 months with a median (M) of 40 months (Q1 Q3: 13.50, 72.00). At the time of PI diagnosis, the transverse diameter had a mean value of 0.53 ± 0.16 cm, the longitudinal mean diameter was 0.41 ± 0.13 cm, and the largest diameter was 0.55 ± 0.16 cm. No PI became functioning during follow-up, neither associated hypopituitarism nor increased >1 cm diameter. A total of 46/117 (39.32%) patients had a larger diameter during follow-up (increase group = IG) versus a non-increase group (non-IG; N = 71, 60.68%) that included the subjects with stationary or decreased diameters. IG had lower initial transverse, longitudinal, and largest diameter versus non-IG: 0.45 ± 0.12 versus 0.57 ± 0.17 (p < 0.0001), 0.36 ± 0.11 versus 0.43 ± 0.13 (p = 0.004), respectively, 0.46 ± 0.12 versus 0.6 ± 0.16 (p < 0.0001). IG versus non-IG had a larger period of surveillance: M (Q1, Q3) of 48 (24, 84) versus 32.5 (12, 72) months (p = 0.045) and showed similar age, pituitary hormone profile, and tumour lateralisation at baseline and displayed a median diameter change of +0.14 cm versus −0.03 cm (p < 0.0001). To conclude, a rather high percent of patients might experience PI diameter increase during a longer period of follow-up, including those with a smaller initial size, while the age at diagnosis does not predict the tumour growth. This might help practitioners with further long-term surveillance protocols. [ABSTRACT FROM AUTHOR]

Chronic kidney disease (CKD) causes specific hormonal disturbances, such as variations in leptin and testosterone levels and function. These disturbances can promote errors in signaling interaction and cellular information processing and can be implicated in the pathogenesis of atherosclerosis. This study investigates the factors that affect leptin in CKD patients and examines how leptin is related to markers of vascular disease. We conducted a cross-sectional study of 162 patients with CKD in pre-dialysis and dialysis stages. We recorded clinical and laboratory data, including leptin, testosterone, and subclinical atherosclerosis markers like brachial–ankle pulse wave velocity (ba PWV) in pre-dialysis CKD patients and flow-mediated vasodilation (FMD) and nitroglycerin-mediated vasodilation (NMD) in hemodialysis (HD) patients. Leptin was significantly correlated with testosterone in CKD pre-dialysis stages (p < 0.001) and also in HD (p = 0.026), with adipose tissue mass in pre-dialysis stages (p < 0.001), and also in HD (p < 0.001). In women HD patients, leptin correlated with NMD (p = 0.039; r = −0.379); in all HD patients, leptin correlated with C reactive protein (p = 0.007; r = 0.28) and parathormone (p = 0.039; r = −0.220). Our research emphasizes the connection between leptin, adipose tissue, and testosterone in all stages of CKD. Leptin was associated with NMD in HD women and correlated with inflammatory syndrome and parathyroid hormone in all HD patients. [ABSTRACT FROM AUTHOR]

Petrified ear (PE), an exceptional entity, stands for the calcification ± ossification of auricular cartilage (CAC/OAC); its pathogenic traits are still an open matter. Endocrine panel represents one of the most important; yet, no standard protocol of assessments is available. Our objective was to highlight most recent PE data and associated endocrine (versus non-endocrine) ailments in terms of presentation, imagery tools, hormonal assessments, biopsy, outcome, pathogenic features. This was a comprehensive review via PubMed search (January 2000–March 2024). A total of 75 PE subjects included: 46 case reports/series (N = 49) and two imagery-based retrospective studies (N = 26) with CAC/OAC prevalence of 7–23% (N = 251) amid routine head/temporal bone CT scans. Endocrine PE (EPE): N = 23, male/female ratio = 10.5; average age = 56.78, ranges: 22–79; non-EPE cohort: N = 26; male/female ratio = 1.88, mean age = 49.44; ranges: 18–75 (+a single pediatric case).The longest post-diagnosis follow-up was of 6–7 years. The diagnosis of PE and endocrine anomalies was synchronous or not (time gap of 10–20 years). A novel case in point (calcified EPE amid autoimmune poly-endocrine syndrome type 2 with a 10-year post-diagnosis documented follow-up) was introduced. We re-analyzed EPE and re-classified another five subjects as such. Hence, the final EPE cohort (N = 50) showed: adrenal insufficiency was the most frequent endocrine condition (36%) followed by hypopituitarism (22%) and hypothyroidism (18%); 39% of the patients with adrenal failure had Addison's disease; primary type represented 72% of all cases with hypothyroidism; an endocrine autoimmune (any type) component was diagnosed in 18%. We propose the term of "endocrine petrified ear" and a workflow algorithm to assess the potential hormonal/metabolic background in PE. [ABSTRACT FROM AUTHOR]

This document is a certificate of publication for an article titled "Mineral metabolism assays and osteoporotic fracture risk evaluation in menopausal population diagnosed with adrenal incidentalomas: a sub-analysis of PRECES study." The article is authored by Alexandra-Ioana Trandafir, Mihaela Stanciu, Ana Valea, Oana-Claudia Sima, Claudiu Nistor, Mădălina Gabriela Iliescu, Ileana Ciobanu, Florina Ligia Popa, and Mara Carsote. It was published in the Balneo & PRM Research Journal in June 2024. The article focuses on evaluating the risk of osteoporotic fractures in menopausal individuals diagnosed with adrenal incidentalomas through mineral metabolism assays. The certificate includes the website of the journal and information about the editorial board. [Extracted from the article]

Vitiligo, the discoloration of the skin, has different autoimmune mechanisms reflected by many biomarkers as shown by skin histology, staining for CD4 and CD8 T lymphocytes, chemokine ligand 9 or circulating cytokines such as interleukin (IL)-1 beta, interferon (IFN)-gamma, transforming growth factor (TGF)-beta, antibodies, markers of oxidative stress, chemokines, and others. In this narrative review, we aim to overview vitiligo in relationship with chronic autoimmune thyroiditis. Regarding vitiligo, more than 50 different genetic loci have been associated with this disease, and the heritability is high. There is a 20% risk of an environmental connection which may also act as a trigger; moreover, the association with human leukocyte antigen (HLA) expression is well recognized. The specific lesions display CD8+ tissue-resident memory T cells as continuous key activators of melanocytes. The association with chronic thyroiditis is based on common autoimmune background and excessive reactive oxygen species that destroy melanocytes and thyrocytes (oxidative stress hypothesis) with thyroxine and melanin as target molecules, thus sharing a common origin: tyrosine. Moreover, common epigenetic anomalies or mutations of the Forkhead transcription factor D3 (FOXD3) have been described. Since vitiligo affects up to 1-2% of the population worldwide and 34% of patients have positive thyroid antibodies, apart from common autoimmunity background and oxidative stress toxicity, the association is clinically relevant for different practitioners. [ABSTRACT FROM AUTHOR]

Introduction. As opposed to secreting tumours, non-functioning pituitary adenomas are usually diagnosed at a later stage, when they are large enough to cause symptoms due to mass effect rather than because their associated endocrine dysfunction. We aim to introduce a case report with limited therapy options. Case presentation. We present the case of a 69 year-old male patient with a history of stroke, atrial fibrillation and type 2 diabetes, who was initially admitted to the neurology department three years ago for frontal headaches and visual disturbances. The MRI (magnetic resonance imaging) exam revealed a 15.4/26.7/19.5 mm sellar mass, with suprasellar and parasellar extension, minimal optic chiasm compression and pituitary stalk deviation. Initial pituitary hormone profile showed central hypogonadism and mild hyperprolactinemia. The patient underwent neurosurgery evaluation but at that point transsphenoidal surgery was contraindicated due to severe cardiovascular comorbidities and the patient was referred to the endocrinology department for further follow-up, where he presented a year later, after worsening of symptoms. The MRI revealed tumour enlargement (18.5/28/24.6 mm) and stationary hormonal profile. The diagnosis of nonfunctioning pituitary macroadenoma was once again confirmed, cabergoline was initiated as adjuvant therapy since surgery was still contraindicated because high cardiovascular risk. Stereotactic radiation was not an option due to tumour proximity to the optic chiasm, therefore the patient underwent conventional radiotherapy. Evaluation after 3 months showed stationary clinical picture while MRI scan 3 months revealed a mild tumour growth (4 mm in all diameters). Further cabergoline therapy 2 mg/week was prescribed and the patient needs carefull monitorization for worsening of symptoms and hypopituitarism. Conclusion. Surgery is the mainstay of therapy in case of large nonfunctioning pituitary macroadenomas. If contraindicated, the available options include radiotherapy and medical therapy like cabergoline, with varying results, mostly suboptimal. [ABSTRACT FROM AUTHOR]

Hereditary syndromes underlying neuroendocrine tumours are extremely heterogeneous and, despite the genetic background, their recognition may actually be done later in life in many cases. Our purpose is to introduce a case of neurofibromatosis type 1 -related pheocromocytoma on a patient within his six decade of life after multiple cardiovascular complications. A 53-year old male is admitted for loss of appetite with weight loss, decreased exercise tolerance, transient occipital headache, night sweats. His medical history revealed arterial hypertension, right carotid artery ischemic stroke, and a recently non-STEMI myocardial infarction diagnosed two months ago. The pathological family history illustrated mother and a brother prematurely dying of myocardial infarction (no date of skin anomalies). Clinical examination reveals café-au-lait spots, axillary freckles, skin neurofibromas and a large plexiform neurofibroma in the right thigh. Evaluation of the adrenal gland revealed highly elevated values of urinary metanephrines and normetanephrines. Computed tomography showed a left adrenal gland tumour of 31/39 mm. Thus neurofibromatosis type 1 in addition to a left pheocromocytoma was confirmed. A cardiologic examination before surgery was re-done. Given previous pathological history (cardiovascular events like stroke and nonSTEMI infarction) adrenalectomy was delayed for the moment in addition to second antiplatelet agent and the alpha blocker medication in increasing doses. The adrenal tumour removal is planned to be done as soon as cardiovascular risk is acceptable. The importance of endocrine check is seen in young patients with severe cardiovascular and neurological acute conditions that are actually caused by a hormonal excess like found in pheocromocytoma. Nevertheless, the spectrum of tumours associated with neurofibromatosis type 1 is heterogeneous and screening protocols are still a matter of debate. Delayed diagnosis worsts the overall prognosis [ABSTRACT FROM AUTHOR]

TBS (Trabecular Bone Score) is the latest tool for clinicians to evaluate bone micro-architecture based on a pixel greyscale, which is provided by lumbar dual-energy X-ray absorptiometry (DXA). Its use enhances fracture prediction in addition to DXA-BMD (Bone Mineral Density). This is independent of fracture risk assessment (FRAX) and DXA results. We present a narrative review regarding the connection between TBS and Glucocorticoids (GC), either as a drug used for different conditions or as a tumor-produced endogenous excess. TBS is a better discriminator for GC-induced vertebral fractures compared to DXA-BMD. This aspect is similarly available for patients with osteoporosis diagnosed by DXA. TBS is inversely correlated with the cumulative dose of GC (systemic or inhaled), with disease duration, and positively correlated with respiratory function in patients with asthma. Low TBS values are found in females with a T-score at the hip within the osteoporosis range, with diabetes mellitus, or who use GC. Lumbar TBS is a screening tool in menopausal women with type 2 diabetes mellitus. TBS is an independent parameter that provides information regarding skeleton deterioration in diabetic patients receiving GC therapy in a manner complementary to DXA-BMD. TBS might become an essential step regarding the adrenalectomy decision in patients with adrenal incidentaloma in whom autonomous cortisol secretion might damage bone micro-architecture. TBS currently represents a standard tool of fracture risk evaluation in patients receiving GC therapy or with endogenous Cushing's syndrome, a tool easy to be applied by different practitioners since GCs are largely used. [ABSTRACT FROM AUTHOR]

Scar is part of wound healing and hypertrophic aspects as well as keloids are pathological formation of a scar. Their appearance is seen post-operatory, post-trauma and the consequences are more than cosmetic depending on location, for instance at joins functional impotence is associated. A scar formation involves activation of matrix enzymes, matrix response, local inflammation and fibroblast intervention as well as local cytokines and growth factors action. Our purpose is to introduce to cases of females who developed hypertrophic scars after thyroidectomy in addition to local swelling as revealed by neck ultrasound. The paper is two cases series report. The hormonal assays and ultrasound aspects are provided. A 30-year female with Basedow disease had one month after thyroidectmy TRAb of 2.4 U/l while TSH was 1 of under daily 100 ìg of levothyroxine. The subject presented a post-operatory hypertrophic scar in addition to the following ultrasound aspect: right area with an inhomogeneous structure of 1/1.2/4 cm, left area of 1.4/1.7/4 cm, with multiple images with posterior echo and intense local edema. This is a 44-year female referred for total thyroidectomy (for large goiter). The subject did not develop any peri-operatory complication. The histological report showed chronic autoimmune thyoiditis background of focal type in addition to nodules of colloidal and cystic adenomatosis with hyperplasic epithelium. One month later TSH was normal under levothyroxine. The subject presented a post-operatory hypertrophic scar in addition to ultrasound aspect of edema in association with inflammatory lymph nodes at lateral cervical level of 0.6/0.2 cm maximum diameter. It is still a matter of debate to classify the high risk patients for developing post-thyroidectomy scars. [ABSTRACT FROM AUTHOR]

Hypoparathyroidism is a rare condition associating autoimmune, genetic, post-operatory (most frequent) or idiopathic causes. Low calcium causes neuromuscular irritability of chronic or acute type like muscle crample, paresthesia, tingling, cardiac rhythm anomalies, seizures, etc. Despite calcium and active vitamin D replacement, acute complications are frequently seen and generally a reduced quality of life is registered since pathogenic medication like parathormone drug substitution is not currently available in daily practice. Other complications are due to overtreatment with calcium and vitamin D like kidney stones and associated urinary infections and hypercalciuria while increased calcium-phosphor product causes calcifilaxia of different locations causing complications like skin necrosis, brain calcifications with seizures, etc. We introduce a case of hypoparathyoidism in association with other co- morbiditis and a brief discussion around the case related to bone mineral density anomalies or usefulness in general panel of investigations in this particular topic. This is a 43-year old non-smoking male coming from non-endemic area that had a small lesion of skin necrosis at left hand. He has autoimmune thyroiditis and on admission low values of calcium and PTH 2 pg/ml (normal 15-65 pg/ml) are consistent for the diagnosis of hypoparathyroidsm, probably of autoimmune cause. Central DXA shows high BMD at each site. He was offered calcium and vitamin D replacements with a mild clinical improvement. This case of autoimmune hypoparathyroidism associated with Hashimoto's thyroiditis highlights the idea of high DXA-BMD due to cortical and trabecular effects of PTH deficiency. [ABSTRACT FROM AUTHOR]

Neuroendocrine neoplasia (NEN), priory known as neuroendocrine tumours represent the modern approach of traditionally named "carcinoid" tumours. We shortly introduce benign and malign dermatological aspects that are linked to NEN field. This is a multidisciplinary perspective. The paper is a mini-review. 30 articles are included as references. NEN represents 2% of all cancers, being considered orphan disease. Skin and soft tissue are exceptional sites of NEN, the majority are actually secondary spreading of NEN of other locations. Little data have been published related to the topic. Some cases reports showed invasion of dermis and subcutis, probably more frequent in older adults. The entity has been named low-grade neuroendocrine carcinoma of the skin, also named primary cutaneous carcinoid tumour. As seen in NEN diagnosis, the immunohistochemistry is essential like chromogranin A, synaptophysin, neuron specific enolase which are classical neuroendocrine markers and non-neuroendocrine parameters are useful for differential diagnosis like estrogens, androgens and progesterone receptors, GATA3, carcinoembryonic antigen. Merkel cell carcinoma represents the high grade NEN. It has a poor prognosis, with a 30% risk of local metastasis. The risk factors are either viral infection like Merkel cell polyomavirus, either long time exposure to ultraviolet light. The prognostic is similar between the two factors. Surgical removal is the first line therapy and adjuvant treatment is radiotherapy and chemotherapy. Skin NEN represents an exceptional finding of aggressive profile. Their prompt recognition may help the prognosis. [ABSTRACT FROM AUTHOR]

Skin metastases are not typical. Malignancies like mammary cancer (most frequent in females) and pulmonary neoplasia (most frequent in males) represent the majority and exceptional findings are in those originating from thyroid, prostate, ovaries and oesophagus, usually in advanced, generally disseminated stages, with a poor prognosis. It may be found more often in elderly patients. We aim to present some practical aspects of skin metastases in thyroid cancer that originates from follicular thyroid epithelium. This is a brief literature review. The level of evidence is poor since most data is provided from cases reports. Cutaneous malignant lumps are rarely the first sign of disease, mostly associating a cancer relapse. The location varies from neck and head (majority) to exceptional sites as chest wall and of variable rate for scalp. Underling neck muscle or Meckel's cave metastasis may be associated. The lesion is usually a lump of medium to small size, sometimes of papular appearance, without local pain (but depends on the site); it may associate erythema. The diagnosis is difficult unless an index of suspicion is positive (in which case whole body radioiodine scintigram may be useful). Biopsy and histological report are essential for diagnosis especially in cases without an evident connection to a prior/synchronous thyroid malignancy. Knowing the exceptional prevalence, the need for awareness in this particular topic is connected with a multidisciplinary daily practice. [ABSTRACT FROM AUTHOR]

Breast fibroadenoma is a benign tumour that is mostly asymptomatic thus it may be detected as an incidentaloma. Typically they are diagnosed in women of reproductive age and they reduce the dimensions during menopause because of estrogens deficiency that is why in menopause are rare. The mass is elastic, mobile and it contains an epithelial part and a stromal component (so called fibroepithelial tumours). Here is the case of a 70-year old female who had done a mammogram for the first time and she was found with such a lesion of 1.5 cm. She also is confirmed with osteopenia, most probable unrelated to the breast tumour. Menopausal fibroadenoma, even at low risk of malignancy requires a good multidisciplinary team of decision. Because of the differential diagnosis with breast cancer the positive diagnostic is based on ultrasound, mammogram and even biopsy. Menopausal fibroadenoma, even at low risk of malignancy requires a good multidisciplinary team of decision. Because of the differential diagnosis with breast cancer the positive diagnostic is based on ultrasound, mammogram and even biopsy. Due to low aggressive profile, the follow-up is, however, the most rational approach. [ABSTRACT FROM AUTHOR]

Introduction. High prolactin may cause central hypogonadism including osteoporosis and breast secretion but also rare manifestations like increased androgens in females or galactocele. A part from high prolactin - related large cystic incidental mammary findings, the breast cysts may be associated with infections, local trauma and hemorrhage of priory benign cystic disease or solid tumors. Method. We introduce different clinical aspects of breast nodules with benign appearance, either symptomatic like painful large cyst with local inflammation elements or asymptomatic as an incidental finding. This is a cases series from a multidisciplinary perspective. Cases data. The patients' age is between 43 and 62 years. The youngest female presented a large left cyst after a potential local trauma with local inflammation signs which were released after liquid evacuation. The oldest patient had bilateral mammary micro-cysts with a good prognostic as incidental finding. Conclusion. Benign breast lesions of adult females may associate local skin changes as redness and increased temperature or they may be completely asymptomatic, being detected as incidental findings. Regardless the scenario, the index of malignancy suspicion is always necessary because of heterogeneous presentation and increased incidence of mammary cancer. [ABSTRACT FROM AUTHOR]

We introduce dermatological aspects from an endocrine point of view related to pituitary tumours that display active secretor activity. This is a short literature review. 40 papers are cited including narrative reviews and original studies. Acromegaly: GH overproduction causes the thickening of the skin and swelling of the soft tissues in addition to the enlargement of extremities (like nose, hands, feet, jaw), coarsening of facial features (as front head and naso-labial folds), excessive sweating, exaggerate skin wrinkles, oily skin, and acrochordons. Cushing's disease: cortisol overproduction has a severe protein catabolic effect at skin with collagen network disruption while immune effect of hypercortisolemia induces chronic skin infections and difficulties in wound healing. In females, consecutive androgens excess induces acne, hirsutism, and androgens-related alopecia. The classical phenotype includes: fragile skin or skin atrophy, red/purple striae, easy bruising, facial plethora. Skin changes represent the window to pituitary tumours for clinicians of different specialities, therefore contributing to final diagnosis of endocrinopathies. [ABSTRACT FROM AUTHOR]

Adrenal carcinoma is a complex orphan disease with a very poor prognosis. The evolution is rapid and in cases with suggestive symptoms the diagnosis may be established earlier in order to improve the outcome. One third of the patients are negative for a clear hormonal expression or they have an atypical presentation. We introduce an adult patient diagnosed with adrenal carcinoma and a rapid lethal outcome who initially presented with pale skin and non-specific abdominal pain. A multidisciplinary team is essential for adequate diagnosis and prompt intervention. Severe bleeding at the level of the adrenal carcinoma causing symptomatic anaemia is a rare event. The prognosis in adrenocortical carcinoma is severe and the presence of humoral hypercalcemia represents a sign of short survival time. [ABSTRACT FROM AUTHOR]