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Molecular characterization of adrenocortical carcinomas (ACC) by The Cancer Genome Atlas (TCGA) has highlighted a high prevalence of
TERT
alterations, which are associated with disease progression. Herein, 78 ACC were profiled using a combination of next generation sequencing (
n
= 76) and FISH (
n
= 9) to assess for
TERT
alterations. This data was combined with TCGA dataset (
n
= 91). A subset of borderline adrenocortical tumors (
n
= 5) and adrenocortical adenomas (
n
= 7) were also evaluated. The most common alteration involving the
TERT
gene involved gains/amplifications, seen in 22.2% (37/167) of cases. In contrast, “hotspot” promoter mutations (C > T promoter mutation at position -124, 7/167 cases, 4.2%) and promoter rearrangements (2/165, 1.2%) were rare. Recurrent co-alterations included 22q copy number losses seen in 24% (9/38) of cases. Although no significant differences were identified in cases with and without
TERT
alterations pertaining to age at presentation, tumor size, weight, laterality, mitotic index and Ki67 labeling, cases with
TERT
alterations showed worse outcomes. Metastatic behavior was seen in 70% (28/40) of cases with
TERT
alterations compared to 51.2% (65/127,
p
= 0.04) of cases that lacked these alterations. Two (of 5) borderline tumors showed amplifications and no
TERT
alterations were identified in 7 adenomas. In the borderline group, 0 (of 4) patients with available follow up had adverse outcomes. We found that
TERT
alterations in ACC predominantly involve gene amplifications, with a smaller subset harboring “hotspot” promoter mutations and rearrangements, and 70% of
TERT
-altered tumors are associated with metastases. Prospective studies are needed to validate the prognostic impact of these findings.