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Histologic Variants of ACC

Pathology, Classification, and Differential Diagnosis

Histologic variants of adrenocortical carcinoma (ACC) are uncommon morphologic patterns that remain within the spectrum of malignant adrenocortical neoplasia but differ from conventional ACC in architecture, cytology, or stromal composition.12 In contemporary adrenal pathology, the best-established variants are oncocytic, myxoid, and sarcomatoid forms, with rarer descriptions of carcinosarcomatous, rhabdoid, and ectopic presentations.3145 These variants are primarily relevant because they complicate classification and differential diagnosis rather than because they define consistently separate treatment pathways.62

Within ACC care, variant histology sits at the intersection of pathology classification, malignancy assessment, and exclusion of non-cortical mimics. Unusual morphology may obscure adrenocortical origin, reduce the interpretability of standard scoring systems, and increase overlap with adenoma, metastatic carcinoma, renal neoplasms, pheochromocytoma, and primary retroperitoneal tumors.317 Current WHO-aligned frameworks therefore treat these patterns as morphologic subtypes of ACC rather than distinct biologic diseases with fully validated variant-specific prognostic models.12

The evidence base is limited and uneven. Most published data derive from retrospective pathology series, institutional reviews, and case reports, with small numbers, referral bias, and inconsistent definitions across older literature.892 As a result, the most reliable conclusions concern diagnostic pitfalls and appropriate use of ancillary pathology methods, whereas claims about variant-specific prognosis remain provisional.102

Diagnostic Context

ACC is morphologically heterogeneous even outside named variants, and variant patterns amplify three recurrent diagnostic tasks: confirming adrenocortical lineage, distinguishing carcinoma from adenoma, and excluding non-adrenocortical malignancies.31 Standard multiparameter systems such as Weiss remain central in routine adrenal pathology, but their individual criteria may be less dependable in some variants, particularly oncocytic and heavily myxoid tumors.1032

No single morphologic feature or immunostain is sufficient across all variant settings. Integrated interpretation of gross findings, histology, invasion, proliferative activity, reticulin pattern, and immunohistochemistry is more reliable, with SF-1 serving as a particularly useful marker for adrenocortical differentiation in difficult cases.112 The practical implication is that variant recognition should refine standard diagnostic workflows rather than replace them, and expert endocrine pathology review may be especially valuable in borderline or unusual tumors.12

This general framework helps explain why the major variants are usually discussed according to the specific interpretive problems they create.

Major Histologic Patterns

Oncocytic ACC

Oncocytic ACC is defined by predominant oncocytic cells with abundant granular eosinophilic cytoplasm related to mitochondrial accumulation.121314 Its main diagnostic significance is that conventional Weiss criteria may overestimate malignancy in pure oncocytic neoplasms because several criteria are influenced by the cytoplasmic phenotype itself.1310 For that reason, pure oncocytic tumors are commonly assessed with variant-specific approaches such as Lin-Weiss-Bisceglia criteria.92

Retrospective comparative data suggest that when a pure oncocytic tumor meets malignant criteria, its clinical behavior may approximate conventional ACC rather than a uniquely indolent entity.69 That conclusion is more reliable than older impressions of uniformly favorable behavior, but it still rests on limited retrospective evidence. Clinically, oncocytic morphology alone does not support de-escalation of management or follow-up.156

Myxoid ACC

Myxoid ACC is characterized by abundant extracellular myxoid stroma, often Alcian blue positive, with cords, trabeculae, microcysts, or pseudoglandular structures.161718 This pattern substantially broadens the differential diagnosis, especially in biopsy or cytology material, where it may simulate metastatic carcinoma, myxoid soft-tissue tumors, or other retroperitoneal neoplasms.1118

Available reports and small series generally associate myxoid ACC with malignant behavior, but the more dependable observation is that extensive myxoid change can make Weiss-based assessment less reliable.16819 In this setting, invasion, mitotic activity, Ki-67, reticulin disruption, and confirmation of adrenocortical lineage may be more informative than architecture alone.82 The practical implication is that myxoid change should trigger a broader differential and more cautious interpretation, not automatic assignment of a distinct prognosis.202

Additional findings such as lipomatous metaplasia appear to widen the morphologic spectrum without establishing a separate subtype.2117 Comparative veterinary reports illustrate similar architectural distortion by myxoid differentiation, but they do not materially strengthen human prognostic inference.222324

Sarcomatoid and Carcinosarcomatous ACC

Sarcomatoid ACC is an exceptionally rare biphasic form in which conventional adrenocortical carcinoma is admixed with spindle-cell or pleomorphic sarcomatoid areas; carcinosarcomatous tumors occupy the same broad spectrum but include heterologous or more overtly divergent mesenchymal elements.252627 The dominant diagnostic problem is distinction from primary adrenal or retroperitoneal sarcoma, sarcomatoid renal cell carcinoma, and other dedifferentiated malignancies.257

The literature repeatedly describes these tumors as highly aggressive, often with necrosis, marked atypia, and rapid progression, but confidence in any precise prognostic estimate is limited by very small numbers and publication bias toward dramatic presentations.262829 What appears more reliable is that preoperative classification is often difficult and that definitive diagnosis usually depends on resection pathology supported by immunohistochemistry for adrenocortical differentiation.303127

Other Rare Patterns

Rhabdoid morphology and ectopic oncocytic ACC have been described only in isolated cases or very small numbers.45 These reports mainly demonstrate the breadth of ACC morphology and the possibility that unusual cytoplasmic features or nonadrenal location may obscure the diagnosis.

Their independent biologic significance is uncertain because the evidence is almost entirely case based. The practical value of recognizing these patterns lies chiefly in avoiding misclassification as malignant rhabdoid tumor, renal neoplasia, pancreatic tumors, or other non-cortical lesions.45

Evidence and Prognostic Interpretation

Across variants, diagnostic conclusions are stronger than outcome conclusions. The most consistent finding is that variant morphology may reduce the reliability of standard malignancy algorithms and increase differential-diagnostic complexity, especially in oncocytic and myxoid tumors.382 This point is sufficiently reproducible to inform routine pathology practice.

By contrast, prognostic trends remain suggestive rather than definitive. Myxoid and sarcomatoid variants are often reported as aggressive, while malignant pure oncocytic ACC may behave similarly to conventional ACC when classified appropriately.26919 In practice, variant histology may justify cautious prognostic framing and close follow-up, but it does not currently provide a robust stand-alone model for risk stratification.62

Common Pitfalls

The principal pitfall is diagnostic error caused by overinterpreting unusual architecture or cytology in isolation. Variant ACC may be confused with adenoma, pheochromocytoma, metastatic carcinoma, renal cell carcinoma, myxoid neoplasms, or primary sarcoma, particularly in limited samples.11718

A second pitfall is overreliance on a single framework. Weiss criteria remain important, but selected variants may require greater emphasis on reticulin alteration, Ki-67, mitotic count, direct evidence of invasion, and immunophenotypic confirmation of cortical origin.1082 The practical implication is that variant recognition should prompt broader clinicopathologic integration, not abandonment of standard ACC criteria.

Role in Management and Research

Recognition of a histologic variant mainly affects diagnosis, pathology reporting, and interpretation of malignant potential rather than establishing a separate therapeutic algorithm. Compared with standard ACC workflows, the additional clinical value lies in prompting broader immunohistochemical workup, subtype-aware scoring, and cautious communication of uncertainty in borderline cases.12 Surgery remains the principal local treatment for resectable disease, and current evidence does not support variant-specific systemic therapy strategies.156

These variants also highlight ongoing research gaps. Larger multi-institutional cohorts using consistent WHO-aligned definitions, standardized ancillary markers, and more complete outcome data are needed to determine whether variant morphologies confer independent biologic significance or mainly represent histologic extremes within ACC.12 Until such data are available, the most reliable role of variant classification remains improvement of diagnostic accuracy rather than confident prognostic separation.

Included Articles

  • PMID 11340712: This case series and literature review describes adrenocortical oncocytic tumors as rare lesions composed almost entirely of mitochondria-rich oncocytic cells, usually nonfunctional and often clinically indolent after resection. It emphasizes distinguishing these tumors from conventional adrenocortical carcinoma and notes that size alone is not a reliable marker of malignancy.12
  • PMID 11490264: This case report highlights oncocytic adrenocortical carcinoma as a rare morphologic variant whose malignant potential may be difficult to establish on initial histopathology. Local recurrence and ovarian metastasis seven years after resection supported malignant classification, with the authors recommending careful follow-up and treating tumors of uncertain malignant potential cautiously.15
  • PMID 12637752: This retrospective ferret series describes a myxoid variant of adrenocortical carcinoma characterized by sheets, cords, and trabeculae of cortical tumor cells forming lumenlike spaces containing alcian blue-positive mucinous material, with greater myxoid extent associated with invasion, metastasis, and death.32
  • PMID 16445821: This case report describes the rare myxoid variant of adrenocortical carcinoma, which may lack conventional non-myxoid ACC areas and show abundant Alcian-blue-positive extracellular myxoid material. It emphasizes the broad retroperitoneal myxoid differential diagnosis and the diagnostic value of histology, immunohistochemistry, and ultrastructural evidence of cortical differentiation.11
  • PMID 18058268: This review describes an exceptionally rare functional oncocytic variant of adrenocortical carcinoma, defined by tumor cells with abundant granular eosinophilic cytoplasm and ultrastructural mitochondrial accumulation. It emphasizes malignant pathologic features, the difficulty distinguishing oncocytic ACC from oncocytoma using standard Weiss criteria, and key differentials supported by immunohistochemistry and electron microscopy.13
  • PMID 20534995: This series describes myxoid adrenocortical tumors as a rare morphologic variant, usually associated with malignant behavior, with two growth patterns and absence of similar patterns in reviewed adenomas. The paper also highlights diagnostic difficulty versus other adrenal and small round cell tumors, including potential confusion from neurofilament positivity and limited applicability of Weiss criteria in pure myxoid lesions.16
  • PMID 23093642: This case report describes primary adrenocortical sarcomatoid carcinoma as an extremely rare ACC variant with mixed epithelial and sarcomatoid morphology, extensive necrosis, invasive growth, adrenal infiltration, and vascular tumor emboli. Diagnosis relied on pathology and immunohistochemistry showing epithelial marker expression in both components with vimentin coexpression.30
  • PMID 23574783: This case report expands the morphologic spectrum of adrenocortical carcinosarcoma, describing a highly aggressive adrenal cortical malignancy with oncocytic areas, sarcomatoid spindle-cell regions, and an undifferentiated primitive neuroectodermal-like component with pseudorosettes. It highlights vascular invasion, necrosis, high mitotic activity, and the need to recognize unusual variant morphology in pathologic differential diagnosis.33
  • PMID 23690121: This case series characterizes myxoid adrenocortical carcinoma as a rare histologic variant showing 10% to 50% alcian blue-positive myxoid stroma, cords or trabeculae and pseudoglandular structures, frequent conventional ACC areas, and occasional lipomatous metaplasia, broadening the retroperitoneal myxoid tumor differential.17
  • PMID 25075137: This review describes adrenocortical sarcomatoid carcinoma as an extremely rare ACC variant characterized by mixed epithelioid and spindle-cell morphology, extensive necrosis, marked atypia, and high mitotic activity. It emphasizes the diagnostic challenge of distinguishing this subtype from mimics such as sarcomatoid renal cell carcinoma and from carcinosarcoma with heterologous elements.25
  • PMID 26038208: This review emphasizes histopathologic diagnosis of ACC, highlighting Weiss criteria as the most reliable system for separating carcinoma from adenoma, with malignancy supported by at least 3 of 9 cytologic, architectural, and invasion features. It also notes important diagnostic difficulties in pediatric and oncocytic adrenal tumors.10
  • PMID 26177320: This review emphasizes that ACC is morphologically heterogeneous, describing oncocytic, myxoid, and sarcomatoid variants as well as intratumoral diversity within conventional tumors. It highlights variant-specific diagnostic pitfalls, including the limited usefulness of Weiss criteria in oncocytic and myxoid tumors and the need to distinguish ACC from adenoma and non-cortical mimics.3
  • PMID 27123074: Primary adrenal sarcomatoid carcinoma is presented as an extremely rare, aggressive ACC variant defined histologically by combined carcinomatous and sarcomatous elements, often with spindle-cell morphology. The report emphasizes that definitive diagnosis relies on histopathology and immunohistochemistry because preoperative diagnosis is difficult.31
  • PMID 27589897: Sarcomatoid ACC is an extremely rare, highly aggressive histologic variant characterized by spindle-cell or heterologous mesenchymal areas and very short postoperative survival in the reported series. The article adds pathologic detail on its morphologic spectrum and emphasizes recognition as a distinct ACC variant.26
  • PMID 28378549: This single-center retrospective series characterizes myxoid and sarcomatoid ACC as rare histologic variants with distinctive gross and microscopic features, including Alcian-Blue-positive myxoid stroma, spindle-cell sarcomatoid areas, and universal reticulin network disruption. The study also notes that Weiss-based assessment may be less reliable in these variants than in conventional ACC.8
  • PMID 31118348: This case report describes myxoid adrenocortical carcinoma as a rare histologic ACC variant marked by abundant Alcian Blue-positive myxoid stroma, corded or pseudoglandular architecture, and aggressive behavior. The tumor showed classic malignant pathologic features including Weiss score 7, vascular and capsular invasion, and high mitotic activity.34
  • PMID 31317933: This review summarizes updated WHO-based diagnostic pathology for adrenocortical carcinoma, emphasizing differential diagnosis from adenoma, medullary and metastatic lesions, marked morphologic heterogeneity, and recognition of classic, oncocytic, myxoid, and sarcomatoid variants with characteristic gross and microscopic features.1
  • PMID 32714505: This case report highlights adrenocortical sarcomatoid carcinoma as an extremely rare ACC variant characterized by mixed carcinomatous and sarcomatous differentiation, high-grade atypia, necrosis, and diagnostic overlap with adrenal or retroperitoneal sarcomas. The diagnosis relied on careful histology plus immunohistochemistry supporting adrenocortical origin.7
  • PMID 34165907: This case report describes the cytologic and histologic features of the myxoid variant of adrenocortical tumor, emphasizing cords, pseudoglandular structures, microcysts, and abundant myxoid stroma. It highlights a key diagnostic pitfall: potential misinterpretation as metastatic carcinoma, especially on fine-needle aspiration.18
  • PMID 35461425: This commentary emphasizes that pure oncocytic adrenocortical carcinoma should not be assumed indolent and argues it should be managed similarly to conventional ACC. It highlights the importance of standardized pathologic classification for oncocytic adrenocortical neoplasms and consistent reporting elements, including Ki-67.6
  • PMID 35499784: This study describes oncocytic adrenocortical neoplasms as a spectrum from benign tumors to carcinomas and applies Lin-Weiss-Bisceglia criteria to classify pure oncocytic lesions. It also reports that pure oncocytic adrenocortical carcinoma shows clinicopathologic behavior broadly similar to conventional ACC after matched comparison.9
  • PMID 35718606: This case report describes adrenocortical sarcomatoid carcinoma as an exceptionally rare, highly aggressive histologic variant of ACC that requires careful histologic and immunohistochemical evaluation for diagnosis. The reported tumor showed necrosis and a very high Ki-67 index, with rapid postoperative recurrence and death within 4 months.28
  • PMID 37530357: This report describes a recently recognized rhabdoid variant of adrenocortical carcinoma characterized by predominant discohesive large cells with abundant eosinophilic cytoplasm and inclusions, eccentric vesicular nuclei, and prominent nucleoli. It emphasizes differential diagnosis from malignant rhabdoid tumor, oncocytic ACC, renal cell carcinoma, and rhabdomyosarcoma using clinicopathologic features and retained INI1 expression.4
  • PMID 38455785: This case report describes adrenocortical sarcomatoid carcinoma as an exceptionally rare, highly aggressive biphasic ACC variant composed of epithelial and sarcomatoid elements, with diagnosis relying on histology and immunohistochemistry. The excerpt highlights malignant spindle-cell morphology and the difficulty of establishing the diagnosis preoperatively.27
  • PMID 39537177: This review summarizes WHO 5th edition pathology updates for ACC, emphasizing use of at least one multiparameter histopathologic scoring system alongside Ki-67, mitotic counts, and confirmation of adrenocortical origin. It highlights diagnostic pitfalls in myxoid, oncocytic, pediatric, and sarcomatoid variants and the role of subtype-specific criteria and SF-1 immunohistochemistry.2
  • PMID 40381941: Sarcomatoid adrenocortical carcinoma is presented as a very rare histologic variant of ACC characterized by a dual tumor pattern, with pleomorphic peripheral areas and a central spindle cell sarcomatoid component. The report also notes its association with poor prognosis.29
  • PMID 40827713: This case report highlights myxoid ACC as a rare histologic subtype defined by extensive Alcian-blue-positive stromal mucin deposition with malignant features including nuclear atypia, diffuse architecture, capsular invasion, and sinusoidal invasion. It also notes that heavy myxoid change can make Weiss-based assessment less reliable, supporting use of the reticulin algorithm in this variant.19
  • PMID 41571237: This case report highlights ectopic oncocytic adrenocortical carcinoma arising adjacent to the pancreas and emphasizes the diagnostic value of correlating nonadrenal location, adjacent adrenal rest tissue, oncocytic morphology, and adrenocortical immunophenotype to distinguish it from pancreatic or other noncortical neoplasms.5
  • PMID 12562242: A 2003 case report described myxoid ACC with extensive lipomatous metaplasia, extending the recognized morphologic range of myxoid tumors and underscoring additional differential diagnostic complexity rather than establishing a distinct subtype.21
  • PMID 15794685: A 2005 quiz case report described a myxoid adrenal cortical neoplasm and underscored the diagnostic difficulty created by abundant myxoid change in an adrenal cortical tumor. It mainly reinforces existing discussion of myxoid ACC as a rare variant with a broad morphologic differential rather than introducing a new management or prognostic framework.20
  • PMID 25911357: A 2015 BMJ Case Reports article described oncocytic adrenocortical carcinoma and documented ultrastructural mitochondrial accumulation underlying the characteristic granular eosinophilic cytoplasm. The report mainly supports existing morphologic definitions of oncocytic ACC rather than adding new outcome data.14
  • PMID 37148257: A veterinary case report in a sheep described adrenocortical carcinoma with myxoid differentiation in the setting of multiple endocrine neoplasia. For this note, its main relevance is comparative: it illustrates striking myxoid morphology, including Alcian blue-positive stromal material and unusual nuclear features, rather than providing direct human outcome data.23
  • PMID 40997878: A 2026 ferret pathology report described adrenocortical carcinoma with myxoid differentiation showing Alcian blue-positive mucinous material, pseudocystic architecture, and pulmonary tumor emboli. While not directly informative for human prognosis, it adds comparative support for the architectural variability and potentially aggressive behavior associated with myxoid differentiation across species.24
  • PMID 30240029: A veterinary case report in a cat described aldosterone-producing ACC with myxoid differentiation, Alcian blue/PAS-positive extracellular matrix, and intranuclear cytoplasmic invaginations. It indirectly extends the note’s comparative pathology section by showing that myxoid change may coexist with hormonal activity and create cytologic diagnostic difficulty across species.22

References

Footnotes

  1. [Current criteria for the diagnosis of adrenocortical carcinoma].. Arkh Patol. 2019. PMID: 31317933. Local full text: 31317933.md ↩ ↩2 ↩3 ↩4 ↩5 ↩6 ↩7 ↩8 ↩9

  2. Updates on WHO 5th edition classification, molecular characteristics and tumor microenvironment of adrenocortical carcinomas.. Endocr J. 2025. PMID: 39537177. Local full text: 39537177.md ↩ ↩2 ↩3 ↩4 ↩5 ↩6 ↩7 ↩8 ↩9 ↩10 ↩11 ↩12 ↩13 ↩14 ↩15 ↩16 ↩17

  3. Dissecting Morphological and Molecular Heterogeneity in Adrenocortical Carcinoma.. Turk Patoloji Derg. 2015. PMID: 26177320. Local full text: 26177320.md ↩ ↩2 ↩3 ↩4 ↩5 ↩6

  4. The rhabdoid variant of adrenocortical carcinoma-Report of three cases and literature review.. Indian J Pathol Microbiol. 2023. PMID: 37530357. Local full text: 37530357.md ↩ ↩2 ↩3 ↩4

  5. Ectopic Adrenocortical Cancer Originating From the Pancreas: A Case Report With Literature Review.. Int J Surg Pathol. 2026. PMID: 41571237. Local full text: 41571237.md ↩ ↩2 ↩3 ↩4

  6. Commentary on “Differences in the Clinicopathologic Behavior of Oncocytic Adrenocortical Neoplasms and Conventional Adrenocortical Carcinomas” by Shirali et al.. Ann Surg Oncol. 2022. PMID: 35461425. Local full text: 35461425.md ↩ ↩2 ↩3 ↩4 ↩5 ↩6

  7. Adrenocortical sarcomatoid carcinoma: a case report and review of the literature.. J Surg Case Rep. 2020. PMID: 32714505. Local full text: 32714505.md ↩ ↩2 ↩3 ↩4

  8. Myxoid and Sarcomatoid Variants of Adrenocortical Carcinoma: Analysis of Rare Variants in Single Tertiary Care Center.. J Korean Med Sci. 2017. PMID: 28378549. Local full text: 28378549.md ↩ ↩2 ↩3 ↩4 ↩5 ↩6

  9. Differences in Clinicopathologic Behavior of Oncocytic Adrenocortical Neoplasms and Conventional Adrenocortical Carcinomas.. Ann Surg Oncol. 2022. PMID: 35499784. Local full text: 35499784.md ↩ ↩2 ↩3 ↩4 ↩5

  10. Adrenocortical carcinoma: review of the pathologic features, production of adrenal steroids, and molecular pathogenesis.. Endocrinol Metab Clin North Am. 2015. PMID: 26038208. Local full text: 26038208.md ↩ ↩2 ↩3 ↩4 ↩5

  11. Myxoid variant of adrenocortical carcinoma: report of a unique case.. Pathol Int. 2006. PMID: 16445821. Local full text: 16445821.md ↩ ↩2 ↩3 ↩4

  12. [Adrenocortical tumors with oncocytic cells: benign or malignant?].. Ann Chir. 2001. PMID: 11340712. Local full text: 11340712.md ↩ ↩2

  13. Functional oncocytic adrenocortical carcinoma.. Endocr Pathol. 2007. PMID: 18058268. Local full text: 18058268.md ↩ ↩2 ↩3

  14. Oncocytic adrenocortical carcinoma—a rare pathological variant.. BMJ Case Rep. 2015. PMID: 25911357. Local full text: 25911357.md ↩ ↩2

  15. Local recurrence of an oncocytic adrenocortical carcinoma with ovary metastasis.. J Urol. 2001. PMID: 11490264. Local full text: 11490264.md ↩ ↩2 ↩3

  16. Adrenocortical tumors with myxoid features: a distinct morphologic and phenotypical variant exhibiting malignant behavior.. Am J Surg Pathol. 2010. PMID: 20534995. Local full text: 20534995.md ↩ ↩2 ↩3

  17. Myxoid adrenocortical carcinoma: a clinicopathologic and immunohistochemical study of 7 cases, including 1 case with lipomatous metaplasia.. Am J Clin Pathol. 2013. PMID: 23690121. Local full text: 23690121.md ↩ ↩2 ↩3

  18. Fine needle aspiration cytology of a myxoid adrenocortical adenoma. A case report.. Diagn Cytopathol. 2021. PMID: 34165907. Local full text: 34165907.md ↩ ↩2 ↩3 ↩4

  19. A Case of Myxoid Adrenocortical Carcinoma With 1p Deletion Identified by Whole Exome Sequencing.. Pathol Int. 2025. PMID: 40827713. Local full text: 40827713.md ↩ ↩2 ↩3

  20. Pathologic quiz case: a 64-year-old man with an adrenal mass. Myxoid adrenal cortical neoplasm.. Arch Pathol Lab Med. 2005. PMID: 15794685. Local full text: 15794685.md ↩ ↩2

  21. A case of myxoid adrenocortical carcinoma with extensive lipomatous metaplasia.. Arch Pathol Lab Med. 2003. PMID: 12562242. Local full text: 12562242.md ↩ ↩2

  22. Aldosterone-producing adrenocortical carcinoma with myxoid differentiation in a cat.. Vet Clin Pathol. 2018. PMID: 30240029. Local full text: 30240029.md ↩ ↩2

  23. Multiple endocrine neoplasia in a sheep: insulinoma, adrenocortical carcinoma with myxoid differentiation, and thyroid C-cell carcinoma.. J Vet Diagn Invest. 2023. PMID: 37148257. Local full text: 37148257.md ↩ ↩2

  24. Abdominal distention and lethargy in a 6-year-old spayed female ferret.. J Am Vet Med Assoc. 2026. PMID: 40997878. Local full text: 40997878.md ↩ ↩2

  25. Adrenal sarcomatoid carcinoma: a case report and review of the literature.. Ulster Med J. 2014. PMID: 25075137. Local full text: 25075137.md ↩ ↩2 ↩3

  26. Sarcomatoid adrenocortical carcinoma: a comprehensive pathological, immunohistochemical, and targeted next-generation sequencing analysis.. Hum Pathol. 2016. PMID: 27589897. Local full text: 27589897.md ↩ ↩2 ↩3 ↩4

  27. Adrenocortical Sarcomatoid Carcinoma Revealed by an Adrenal Incidentaloma: A Case Report.. Cureus. 2024. PMID: 38455785. Local full text: 38455785.md ↩ ↩2 ↩3

  28. Treatment of a case of adrenocortical sarcomatoid carcinoma.. Asian J Surg. 2022. PMID: 35718606. Local full text: 35718606.md ↩ ↩2

  29. Sarcomatoid adrenocortical carcinoma: A rare histological variant.. Cir Esp (Engl Ed). 2025. PMID: 40381941. Local full text: 40381941.md ↩ ↩2

  30. Primary adrenocortical sarcomatoid carcinoma: Report of a case.. Can Urol Assoc J. 2012. PMID: 23093642. Local full text: 23093642.md ↩ ↩2

  31. Primary adrenal sarcomatoid carcinoma metastatic to the lung: Case report and review of the literature.. Oncol Lett. 2016. PMID: 27123074. Local full text: 27123074.md ↩ ↩2

  32. Adrenal cortical carcinomas with myxoid differentiation in the domestic ferret (Mustela putorius furo).. Vet Pathol. 2003. PMID: 12637752. Local full text: 12637752.md ↩

  33. A case report of adrenocortical carcinosarcoma with oncocytic and primitive neuroectodermal-like features.. Hum Pathol. 2013. PMID: 23574783. Local full text: 23574783.md ↩

  34. A novel case of myxoid variant of adrenocortical carcinoma in a patient with multiple endocrine neoplasia type 1.. Endocr J. 2019. PMID: 31118348. Local full text: 31118348.md ↩

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