The pathology of the adrenal gland in Cushing's syndrome

The Adrenal Gland in Dogs with Hyperadrenocorticalism; A Pathologic Study

Bilateral adrenocortical hyperplasia was present in 24 of 27 dogs with hyperadrenocorticalism. Two dogs had a unilateral adenoma, and one had a carcinoma of the adrenal cortex.

Bilateral cortical hyperplasia was diffuse or nodular. The difference between the two patterns of hyperplasia was not associated with any consistent varation in the clinical or endocrinologic features. In the three dogs with adrenal cortical neoplasia there was marked cortical atrophy of the contralateral adrenal gland. Extracapsular nodular hyperplasia was common in the adrenals of dogs with hyperadrenocorticalism and also in older control dogs without endocrine disease. Ten of the dogs with bilateral adrenocortical hyperplasia were examined postmortem; two had a chromophobe adenoma of the pituitary, but no pituitary lesion was found in the others.

Primary bimorphic adrenocortical disease: cause of hypercortisolism in McCune-Albright syndrome

McCune-Albright syndrome (polyostotic fibrous dysplasia, café-au-lait skin spots, and precocious puberty) is a genetically mosaic disorder with populations of mutant and normal cells in affected organs. Cushing syndrome, a rare feature of the condition, usually affects infants and is the result of corticotropin-independent primary bilateral adrenal disease, usually interpreted as nodular adrenocortical hyperplasia. In this study of 9 patients with Cushing syndrome and McCune-Albright syndrome, light microscopy revealed a characteristic bimorphic pattern of diffuse and nodular hyperplasia and a distinctive form of cortical atrophy with apparent zona glomerulosa hyperplasia in 8 patients, all very young. The pattern could be explained by the presence of a mosaic distribution of mutant and normal cells in the adrenal glands. The findings are different from those in inherited or other forms of genetically caused Cushing syndrome. The ninth patient, aged 17 years, had an adrenal adenoma and diffuse cortical hyperplasia in each adrenal gland.

Lipomatous adrenal metaplasia: computed tomography findings in 2 presumed cases

We present 2 computed tomography cases of adult asymptomatic patients whose adrenal glands contained nonfocal collections of fat diffusely distributed throughout the limbs. Although no pathological proof is available, this pattern of fat distribution corresponds to a well-described pathological entity, lipomatous adrenal metaplasia.

Le système de weiss : un outil toujours d’actualité pour le diagnostic de malignité des tumeurs de la corticosurrenale

Adrenocortical carcinomas are rare tumors. In the absence of the gold standard that constitutes metastases, local invasion or recurrence, the diagnosis of malignancy may represent a great challenge for both clinicians and pathologists. Several multiparametric systems have been developed to assess this malignancy. Among them, the Weiss system, established in 1984 and based on nine microscopic criteria, appears to be the most employed because of its simplicity and reliability. The presence of three and more criteria is in favor of malignancy. However, the application of such system is not devoid of difficulties and subjectivity. A more precise definition of the different microscopic criteria and the proposition of a modified Weiss system based on the most reliable criteria could help. Besides, the Weiss system is of limited value for the diagnosis of malignancy in oxyphil tumors and children tumors of the adrenal cortex.

Extensive lipomatous metaplasia in bilateral macronodular adrenocortical hyperplasia

OBJECTIVE

We describe a case of macronodular hyperplasia with marked adrenal enlargement in which mature adipose tissue was a significant component. To our knowledge, this condition has not been reported previously.

METHODS

A 42-year-old woman with newly diagnosed Cushing's syndrome underwent endoscopic bilateral adrenalectomy to remove bilateral adrenal masses.

RESULTS

Both adrenal glands displayed features of macronodular hyperplasia with marked adrenal enlargement, and abundant mature adipose tissue was identified in some nodules of both glands.

CONCLUSIONS

Lipomatous metaplasia is histologically demonstrated in a case of macronodular hyperplasia with marked adrenal enlargement. This distinctive change may be secondary to metaplastic transformation of either stromal cells or adrenocortical cells. The presence of lipomatous metaplasia would appear to indicate adrenocortical process, since, to our knowledge, it has never before been described in the adrenal nodule.

Macronodular adrenal hyperplasia causing Cushing's syndrome: report of two cases and an overview

Of the various entities producing adrenal hyperfunction, nodular adrenal hyperplasia is rarely described, however, recent reports have established it as a distinct cause of Cushing's syndrome. Although the etiology of this disease remains uncertain, two distinct forms are recognised, namely: macronodular hyperplasia and micronodular dysplasia. Establishing the diagnosis preoperatively is difficult but essential to ensure the correct treatment is performed. Two cases of macronodular hyperplasia are reported herein followed by a review of the available literature on this subject.

Marked elevation of serum dehydroepiandrosterone sulphate in Cushing's disease with macronodular adrenocortical hyperplasia

A 30-year-old man presented with longstanding hypercortisolism and biochemical studies typical of pituitary-dependent Cushing's disease. After unsuccessful transsphenoidal surgery, plasma ACTH transiently became undetectable and adrenal computed tomography (CT) was consistent with macronodular hyperplasia. Serum dehydroepiandrosterone sulphate (DHEA-S) exceeded 10,000 ng/ml (normal 2,000-3,350 ng/ml). Despite either transient adrenal autonomy or variable adrenocortical ACTH hyperresponsiveness, urinary cortisol normalized within eight months following pituitary irradiation alone. Serum DHEA-S fell progressively but remained mildly elevated (4,000 ng/ml). Follow-up CT showed minimal residual adrenal nodularity. Given these findings and a review of the literature, we propose that chronic cosecretion of non-ACTH proopiomelanocortinderived peptides may have stimulated both hypersecretion of DHEA-S and adrenocortical macronodularity in this patient.

[Cushing syndrome--a leading symptom in bronchial carcinoid]

Bilateral adrenalectomy was performed in a 27-year-old male because of Cushing's syndrome. After 7 years a peripheral bronchial carcinoid was diagnosed; ACTH values went back to normal only after removal of the carcinoid. In the literature, there are 31 case reports on bronchial carcinoids associated with Cushing's syndrome. The Cushing's syndrome precedes the diagnosis of a tumor for months to years in at least half of the cases. Most of these patients first underwent adrenalectomy and/or hypophysectomy for their primarily endocrine symptoms and signs.

Structural change of adrenocortical adenoma in Cushing's syndrome

Eight adrenocortical adenomata from patients with Cushing's syndrome were examined by light and electron microscopy. Light microscopically, the reticulin fibers were markedly prominent in areas of the compact-type cells and ran tangentially to the adenoma cells or parenchymal cells. Electron microscopically, adrenocortical adenoma was composed of parenchymal cells, interstitial cells, and endothelial cells. In areas of the clear-type cells, the parenchymal cells were arranged in long columns and covered by the sinusoidal wall. In areas of the compact-type cells, the sinusoid was well-developed and meandering. The dilated intercellular space was conspicuous and filled with filamentous substance and collagen fibrils. The parenchymal cells appeared to produce the filamentous substance and collagen fibrils, and underwent fragmentation. Interstitial cells and fragmented cytoplasm of the parenchymal cells were found in the intercellular and perisinusoidal space. It was likely that the fragmented cytoplasm flowed into the sinusoid. Experimental study using cell culture methods revealed these phenomena, especially a production of collagen fibrils.

Adrenocortical adenoma with Cushing's syndrome in culture

Two adrenocortical adenomata with Cushing's syndrome were examined employing cell culture methods. The results revealed that the clear-type cells changed into compact-type cells, and that the compact cells played a role in the production and secretion of steroid hormones. Furthermore, it is likely that they underwent fragmentation and produced collagen fibrils.

Histopathology of the human adrenal cortex

The morphological features of the adult human adrenal cortex are described with particular respect to changes induced by alterations in function of the hypothalamo-pituitary axis. The occurrence of nodules in the normal and hyperplastic cortex (Cushing's and Conn's syndromes) is discussed in relation to the diagnostic problems that they still pose. Explanations based on the normal mechanisms of functional zonation in the cortex are provided for the different cell types which comprise cortical neoplasms associated with various syndromes of hypercorticalism (Cushing's, adrenogenital and Conn's syndromes), together with morphological and functional criteria to distinguish adenomas from carcinomas.

Cushing's syndrome. Analysis of 18 cases

Eighteen patients with Cushing's syndrome were analyzed retrospectively. Eleven patients had diffuse or adenomatous hyperplasia, 5 an adenoma and 3 a carcinoma. Iodocholesterol scanning provides considerable help in localization of the disease. Surgical treatment, while curative for benign cases, affects only slightly the course of malignant disease.

Pituitary ACTH dependency of nodular adrenal hyperplasia in Cushing's syndrome. Report of two cases and review of the literature

Cushing's syndrome due to nodular adrenal hyperplasia comprises a clinically and biochemically heterogeneous group of disorders whose pathogenesis is unclear. We describe two patients with atypical steroid dynamics and large unilateral adrenal nodules who had pituitary ACTH-dependent disease. In the differential diagnosis of Cushing's syndrome, we recommend repeated ACTH measurement and selective venous sampling-particularly in those patients with impaired dexamethasone suppressibility and abnormal findings on computerized tomography.

Familial congenital Cushing's syndrome due to bilateral nodular adrenal hyperplasia

Two siblings with congenital Cushing's syndrome due to bilateral nodular adrenal hyperplasia are described. The older, a boy, presented with severe hypertension and died soon after subtotal adrenalectomy. His sister, who had clitoral enlargement and showed persistent hyponatraemia, had a two-stage total adrenalectomy and is still alive. Investigations in the second case showed grossly elevated urinary cortisol metabolites, 17-oxosteroids and 3 beta-hydroxy-5-ene-steroids. These were not suppressed by dexamethasone, and plasma ACTH was undetectable, indicating that the disorder was not due to excessive ACTH secretion. Cell culture studies on the resected adrenals failed to demonstrate an abnormal pattern of steroid synthesis in vitro, and normal trophic responses were obtained with 1-24 ACTH and monobutyryl cyclic AMP. No stimulation of steroid synthesis was obtained with a range of polypeptide hormones, and the cause of the adrenal hyperplasia remains unknown.

The pathology of adrenocortical neoplasia: a correlated structural and functional approach to the diagnosis of malignant disease

The structural and functional characteristics of nine functioning adrenocortical tumors (four adenomas and five carcinomas) causing Cushing's syndrome or virilization were studied. All tumors that we considered to show histologic evidence of malignant disease and that subsequently metastasized or recurred also showed in cell culture at least one significant functional or behavioral difference from benign tumors. No single defect was common to all carcinomas, but predominant changes included secretion of precursor steroids, such as 11-deoxycortisol (S) and a blunted or absent response to ACTH. All adenomase examined were normal in these respects in comparison with nondiseased cortical cells in culture. In carcinomas whose functions deviated only minimally from normal the presence of highly differentiated ultrastructural characteristics did not, however, confer a better prognosis.

Cushing's syndrome, nodular adrenal hyperplasia and virilizing carcinoma

A 48-year-old hypertensive diabetic woman rapidly became virilized. Urine 17-oxo-and oxogenic steroids and plasma testosterone, androstenedione, DHEA, DHEA-sulphate and androstenediol were greatly elevated. Plasma cortisol was constantly high and was not suppressed by dexamethasone. Circulating immunoreactive ACTH was consistently detectable at 18-24 ng/l. A 450 g carcinoma arising from a nodular hyperplastic right adrenal gland was resected. Production by the tumour of 17a-hydroxypregnenolone, 17a-hydroxyprogesterone and five C-19 steroids, but very little prenenolone, progesterone or cortisol, was shown by blood sampling, tumour culture and dramatic falls after operation. The plasma cortisol fell to half, with no diurnal variation, consistent with persistent Cushing's syndrome, and the plasma ACTH rose to 55 ng/l. She died 3 months later from a myocardial infarction. Autopsy revealed a pituitary basophil adenoma at a site where radiologically there had been an indentation in the fossa floor for at least 7 years. The left adrenal gland showed nodular hyperplasia. Therefore we conclude that mild pituitary-dependent Cushing's syndrome may have been present for many years before development of a virilizing carcinoma. This case demonstrates that adrenal carcinoma in man can sometimes develop as a consequence of nodular adrenal hyperplasia which may in turn be due to long-standing trophic hyper-stimulation.

Parathyroid adenomas associated with the malabsorption syndrome and chronic renal disease

The pathology of the parathyroid glands in two cases in which hyperparathyroidism was associated with chronic renal disease and 10 in which the association was with the malabsorption syndrome is described. It is concluded that whereas in chronic renal disease the development of an autonomous adenoma may be preceded by anatomical secondary diffuse hyperplasia such a stage is not proven when the adenomas develop against a background of the malabsorption syndrome. The importance of this latter association is stressed.