Feminizing adrenal tumor in a 6-year-old boy

A 6-year-old boy presented with bilateral gynecomastia and breast tenderness. The condition started since 1 year before medical consultation with gradual onset and progressive course of breast enlargement and accelerated growth with no history of any nipple discharge. There was no history of drug intake or chronic diseases. Investigations showed picture of pseudo precocious puberty with advanced bone age, suppressed LH, FSH and high estradiol (E2). Adrenal precursors (17 OHP, Δ4 A, DHEA, DHEAS) were normal with normal testosterone, cortisol, ACTH. Scrotal U/S was normal while, abdominal U/S revealed right sided hypo echoic supra renal rounded solid mass. Abdominal multi-slice CT with contrast was done and revealed a well-defined hypo dense right adrenal mass with heterogeneous enhancement in the post contrast study showing attenuation of about 25 HU in precontrast and 111 HU in post contrast which makes the mass suspicious of malignancy. Chest X-ray was normal with no lymphadenopathy or pulmonary infiltrates. The diagnosis of feminizing adrenal neoplasm was confirmed and laparoscopic right adrenalectomy was done. Microscopic examination was done after excision and revealed a picture of adrenocortical adenoma with distinct cell borders with no vascular or capsular invasion. The hormonal profile was repeated after 2 weeks of adrenalectomy and revealed normal levels of estradiol (E2), adrenal precursors, FSH and LH. Adrenal tumors can be functional presenting with virilization, Feminization, or Cushing’s syndrome. Feminizing adrenal tumors are rare tumors especially in pediatrics, but should be excluded in cases presented with gynecomastia. The differentiation between benign and malignant tumors may be difficult.