A case with metastatic ACC. Abdominal (A) and whole-body computed tomography (CT) (C) and positron emission tomography (PET) (B) scanning in March 2014, of a large, right-sided adrenal mass (red arrow and red asterisks), which underwent immediate adrenalectomy with nephrectomy (D, white asterisk). Grading of the tumor was assessed by Ki67 (E) and Weiss scoring. The Ki67 image is presented alongside H&E (F) and programmed cell death ligand-1 (PD-L1) (G) staining. An enlarged inset image is provided for PD-L1, with the dashed line separating positively staining cells from negative cells. Follow-up (May 2015) PET (H) and CT (I) scan imaging demonstrating bilateral lung nodules (red circles).