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Adrenal incidentalomas, defined as masses discovered incidentally during imaging investigation of non-adrenal disorders, have become a rather common finding in clinical practice. The prevalence is not well characterized and varies among studies. The aim of the present study was to perform a prospective evaluation of the prevalence of adrenal incidentalomas among subjects undergoing computerized tomography (CT) scan of the chest in a screening program of lung cancer (Tic TAC study) in Piedmont, a region of Northwestern Italy. This evaluation included 520 subjects (382 males and 138 females, aged between 55-82 yr), referred to our hospital from April to December 2001. Twenty-three patients with adrenal masses were identified: 21 adrenal adenomas, 1 myelolipoma, and 1 metastasis of lung cancer. Therefore, the overall prevalence of adrenal lesions was 4.4%, and that of benign adrenal masses was 4.2%. This prevalence is higher than those found in previous CT scan series reported in the literature, probably because of the use of high-resolution CT scanning technology. Another factor that influenced our results is that subject age is skewed towards the decades characterized by a greater occurrence of adrenal masses. The outcome of this study confirms that we are presently able to identify incidentally discovered adrenal masses more often than in early years and that the prevalence of adrenal incidentalomas on CT images is approaching that of autopsy series. The present study provides a reliable estimate of the prevalence of adrenal incidentaloma with currently used CT scanners. Notwithstanding that our subjects were at increased risk of lung cancer, the rate of adrenal metastases was low. We think that the present results can be generalized even if we may disclose the lack of histological diagnosis.

To investigate the activity of etoposide, doxorubicin, and cisplatin plus mitotane in the management of advanced adrenocortical carcinoma (ACC) patients, 72 patients with measurable disease not amenable to radical surgery were enrolled in a prospective, multicenter phase II trial. EDP schedule (etoposide 100 mg/m 2 on days 5-7, doxorubicin 20 mg/m 2 on days 1 and 8, and cisplatin 40 mg/m 2 on days 1 and 9) was administered intravenously every 4 weeks. Concomitantly, patients were given up to 4 g/day of oral mitotane. Five patients achieved a complete response and 30 a partial response, for an overall response rate of 48.6% (95% CI: 37

IntroductionAdrenocortical carcinoma is a rare tumor of the adrenal cortex which accounts for no more than 0.2% of all malignancies, with two peaks of incidence in early childhood and adults over age 60. It represents an aggressive disease with up to two thirds of cases having distant metastases at the time of diagnosis and a mean survival of less than 30 months, 1-3 although combined treatment modalities, with special reference to mitotane-based therapy, seems to improve its outcome. 4The differential diagnosis of carcinomas from adenomas has been based on several microscopic features, none of them being alone absolutely indicative of malignancy. 5,6 Despite the majority of adrenocortical carcinomas do not represent a diagnostic pitfall in the clinical practice, there are several other cases in which the distinction from their benign counterparts is not straightforward.These cases are a challenge for the pathologist, since the therapeutic strategy in adrenocortical carcinomas is radically different from that of adenomas and an accurate diagnosis is mandatory.This issue is also relevant because adrenal tumors are increasingly recognized in clinical practice:the widespread use of imaging techniques has resulted in the clinical dilemma of the adrenal incidentaloma, 7 and although the vast majority of adrenal incidentalomas are benign lesions, in up to 12% of cases an incidental adrenocortical carcinoma may be discovered. 8Different scoring systems for adrenocortical carcinoma have therefore been developed, using mathematical models or numerical scores based on the association of a given threshold for each considered parameter to malignancy. [9][10][11] The most widely employed scoring system was proposed 11 and revisited in a subsequent report 12 by Weiss, and includes nine parameters related to tumor structure (loss of clear cytoplasm, presence of diffuse architecture and of necrosis), cytological features (atypia, mitotic count, atypical mitotic figures) and invasive properties (sinusoidal, venous and capsular invasion).Unfortunately, Weiss and other scoring systems are sometimes difficult to apply, subjective and/or time consuming, despite several re-visitations and implementations occurred along years to