INTRODUCTION: To assess the impact of size at presentation in patients with adrenocortical carcinoma (ACC) on rates of synchronous metastatic disease and survival following resection using a large administrative dataset. MATERIALS AND METHODS: We queried the National Cancer Database (NCDB) dataset to assemble a cohort of patients with ACC based on SEER staging (1985-2000). Patients were stratified into three groups based on surgical tumor size cutoffs: < 4 cm, 4 cm-6 cm, and > 6 cm. Rates of metastatic disease at presentation in all ACC patients as well as relative survival for patients after resection of localized lesions were calculated and compared among groups. RESULTS: A total of 2248 patients had available staging information for analysis. Tumor size at presentation did not relate to likelihood of non-localized disease at presentation (p = 0.09). A restricted cubic splines analysis revealed a clinically insignificant relationship between tumor size and advanced disease at presentation (OR = 1.02 for each centimeter change in tumor size, p = 0.004, 95% CI 1.01-1.03). On multivariate analysis, only patient age (p < 0.01), and not tumor size, was a significant predictor of overall survival among patients undergoing resection of localized ACCs. CONCLUSIONS: Our data suggest that tumor size is imperfect in predicting presence of distant disease at presentation, nor does it consistently correlate with patient survival after resection of localized ACC.