 Hello, and welcome delegates. Me and Dr. Shupaswachi Konar, Jr. to NRS Medical College, Kolkata, is going to present a rare case of adrenocatical carcinoma with pulmonary meds. The case report. A four years, nine month old female child presented to endocrine OPG with chief complaint of endoguas genitalia and hypertrichosis. Patients, parents informed that the child had normal female genitalia at birth. However, slight clitoromegaly was noticed since birth, progressively increasing in size with age. On physical examination, presence of axillary hair, fever, clitoromegaly, Prada 2, and hypertrichosis with two perineal opening noted. There is a large mass in the left side of the abdomen. There are no neurocutaneous markers. There was no family history of malignancy and blood pressure was found to be elevated, which is 130 by 90. On biochemical evaluation, there is high testosterone, high acetic level and high cortisol level. The patient was then sent to the radiology department for further evaluation. This is the USG picture. USG picture showing a large inhomogeneous, mainly hypoechoic, salt looking, salt at the left supranial region with internal vascularity. A few areas of calcification also noted were in it. On CT, a large 15 into 12 into 11 centimeter ill defined heterogeneously enhancing mass seen extending from left lumbar region and superiorly into pigastic and hypochondriac region and posteriorly into retroperitoneal region. The mass is seen displacing the bowel loops left and pushing pancreas anteriorly and the left kidney anteriorly. Pre-contrast constant unit of the mass is 60 and post-contrast HU is 85. Delete HU is 70. Washout is approximately 43%. This is also the CT pictures of the same patient. On HACT thorax, bilateral nodular opposites seen in both lungs suggestive of pulmonary metastasis. On FNAC from the SOL sword, the sheets of dispersed cells with foamy, fragile cytoplasm and uniform enlarged and hyperchromatic nuclei with inclusions and multi-lobed nucleolife diagnosis. From the above findings, it is concluded to be a classical case of adrenocortical carcinoma with pulmonary metastasis and closest differential diagnosis is benile adrenal adrenoma. Now, discussion. Adrenocortical carcinoma is a real endocrine malignancy with aggressive behavior. The estimated annual incidence is 0.5 to 2 cases per million population year. Most of them are sporadic, but two might have a familial association. Familiar SEC can be associated with Lee-Pramonny syndrome, Wildman Beckwith syndrome, multiple endocrine nucleosy type 1 or kidney complex. It displays a bimodal edge distribution with peaks before age 5 and in the fourth to fifth decades of life. These tumors can be functional or non-functional. Non-functional tumors usually present with pressure symptoms or may be diagnosed incidentally. Up to 60% of patients present with symptoms of adrenal steroid excess secondary to increase glucocorticoid, aldosterone or androgyne production. A female predilection has been observed in the pattern of cases. A female to male ratio is approximately 2.5 to 3 is to 1. Male patients tend to be older and unfortunately having a worse prognosis than female patients. It is very tough to differentiate between benign adrenoma and malignant adrenocortical carcinoma. Now with the following features, imaging features favors adrenocortical carcinoma. That is size of tumor more than 4 cm is more likely to herb by SEC and suspicion become even stronger if it is more than 6 cm. Safe is usually well demarcated, but presence of irregular margins are seen in adrenocortical carcinoma texture. Hydrogenous imprints is denoted and calcification can also be seen in the adrenocortical carcinoma and it is an important finding. Atronation in unenhanced image it is more than 10 HU. Bascularity as a SEC is more vascular and contrast was out is less than 50% after 10 minutes of contrast administration. On the right, this is the TNM staging of adrenocortical carcinoma. Despite several developments that have occurred in the diagnosis and management of adrenocortical carcinoma, the estimated survival remains low. SEC tends to grow and metastasize rapidly untreated. In the above described case, adrenocortical carcinoma had grown to a huge size and also metastasized to the lungs. The disease is aggressive and survival is significantly impacted by presence of local invasion and metastasis. Based on the TNM and European Network for Studying Adrenal Tumor and Set Classification of Disease for SEC. Open surgery is the mainstay of treatment in stages 1 to 3. In the cases of severe symptoms, they require some of the medical therapy. Chemotherapy to control tumor growth and adrenalitic drug like mitotin to control symptoms of hormone excess needed. Chemotherapy was advised to the parents of the child, which they did not comply with in this case. Recurrence of the surgery is common in the presence of risk factors including positive margins, ruptured capsule, large size, elevated levels of proliferation marker TI67, hypercorticalism, increased mitotic rate and high grade classification. To conclude, adrenocortical carcinoma is a rare entity associated with poor prognosis. The median survival rates depending on the stage are as follows. With stage 1 to 2, it is 159 months, stage 3, 26 months and stage 4, 5 months. Here we have discussed an extremely rare case of adrenocortical carcinoma. Currently, the only two definitive criteria for diagnosing malignancy are the presence of distant metastases or local inversion on the imaging or surgical specimen. Current treatment algorithm for pediatric adrenocortical carcinoma patients are based on research in adult population. Research for treatment modalities for childhood adrenocortical carcinoma is limited and the need for more investigation into the treatment of this unique population exists. Thank you.