“The most common clinical presentation for functioning ACC is Cushing’s syndrome, characterized by symptoms related to excess corticosteroid synthesis including truncal obesity, diabetes, hypertension, easy bruising, and menstrual cycle irregularities. In females, virilization resulting from excess androgens may accompany signs of excess cortisol. A small percentage of male patients, present with signs of estrogen excess, such as gynecomastia, breast tenderness, decreased libido, and testicular atrophy.”
Adrenal cortical carcinoma: pathology, genomics, prognosis, imaging features, and mimics with impact on management 
Ayahallah A. Ahmed et al.
Abdom Radiol 2020 Apr;45(4):945-963

“Although the majority of ACCs develop sporadically, many cases arise in association with various familial cancer syndromes including Li–Fraumeni, Beckwith–Wiedemann, and Lynch syndromes. Several genetic alterations have been noted to play an important role in the pathogenesis of ACC. Most of the drivers for the pathogenesis of ACC are related to mutations or downregulation of tumor suppressor genes, overexpression of certain growth factors, chromosomal aberrations, and dysregulation of certain important signaling pathways.” 
Adrenal cortical carcinoma: pathology, genomics, prognosis, imaging features, and mimics with impact on management 
Ayahallah A. Ahmed et al.
Abdom Radiol 2020 Apr;45(4):945-963

“ACCs are typically large, with roughly 70% of tumors larger than 6 cm at the time of diagnosis. Size of the adrenal tumor, pattern of contrast enhancement, and degree of heterogeneity by CT are all important predictors of the malignant potential of the adrenal lesion. ACC is typically heterogeneous by CT and displays mixed intratumoral attenuation. An attenuation value of more than 10 HU on non-contrast CT has high sensitivity for detecting malignancy (93%), but a specificity of only 71–73%. Contrast enhancement is heterogeneous and may be increased peripherally due to central necrosis.”
Adrenal cortical carcinoma: pathology, genomics, prognosis, imaging features, and mimics with impact on management 
Ayahallah A. Ahmed et al.
Abdom Radiol 2020 Apr;45(4):945-963

“Although the presence of macroscopic fat is most commonly seen in benign myelolipoma, ACC may show areas of macroscopic fat as well. Other imaging and biochemical features should be kept in consideration to differentiate this rare manifestation of ACC from myelolipoma, as previously discussed. With any adrenal lesion, the appropriate workup depends on a variety of factors. Incorporating clinical, imaging, and biochemical data allow the formulation of a proposed systematic approach.”
Adrenal cortical carcinoma: pathology, genomics, prognosis, imaging features, and mimics with impact on management 
Ayahallah A. Ahmed et al.
Abdom Radiol 2020 Apr;45(4):945-963