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Maradana J, Edem D, Menon L, Abraham S, Velamala P, Trivedi N. Mixed Corticomedullary Tumor of the Adrenal Gland: A Case Report and Literature Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1539. [PMID: 37763658 PMCID: PMC10535742 DOI: 10.3390/medicina59091539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/17/2023] [Accepted: 08/18/2023] [Indexed: 09/29/2023]
Abstract
Adrenal mixed corticomedullary tumors (MCMTs) are composed of an admixture of cortical and medullary cells. Owing to the presence of two distinct components of different embryonic lineage, these tumors are extremely rare. Less than 30 tumors of this type have been reported to date. MCMTs have varied presentation including hypertension, Cushing syndrome or even as adrenal incidentalomas. Also noted is a slightly higher female preponderance. We report a case of a 26-year-old female who was evaluated for uncontrolled hypertension. A renal ultrasound followed by MRI abdomen revealed a 9.3 × 8.1 × 7.0 cm partially cystic, partially solid enhancing mass in the region of/replacing the left adrenal gland. Hormonal work-up was significant for elevated catecholamines concerning pheochromocytoma. She underwent laparoscopic left adrenalectomy, with adequate pre-operative adrenergic blockade. Histology and immunochemical testing were consistent with a mixed corticomedullary tumor. She was monitored annually for recurrence of the tumor. We also performed a comprehensive review of literature of the cases published so far to the best of our knowledge.
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Affiliation(s)
- Jhansi Maradana
- Endocrinology and Diabetes Consultants, Wentworth Douglass Hospital, 10 Members Way #400, Dover, NH 03820, USA
| | - Dinesh Edem
- Division of Endocrinology and Diabetes, UAMS, Little Rock, AR 72205, USA; (D.E.); (L.M.)
| | - Lakshmi Menon
- Division of Endocrinology and Diabetes, UAMS, Little Rock, AR 72205, USA; (D.E.); (L.M.)
| | - Sonu Abraham
- Lahey Hospital and Medical Center, 41 Burlington Mall Road, Burlington, MA 01805, USA;
| | - Pruthvi Velamala
- Frisbie Memorial Hospital, 11 White Hall Road, Rochester, NH 03867, USA;
| | - Nitin Trivedi
- Saint Vincent Hospital, 123 Summer Street, Worcester, MA 01608, USA;
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Bertherat J, Bourdeau I, Bouys L, Chasseloup F, Kamenicky P, Lacroix A. Clinical, pathophysiologic, genetic and therapeutic progress in Primary Bilateral Macronodular Adrenal Hyperplasia. Endocr Rev 2022:6957368. [PMID: 36548967 DOI: 10.1210/endrev/bnac034] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 10/07/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022]
Abstract
Patients with primary bilateral macronodular adrenal hyperplasia (PBMAH) usually present bilateral benign adrenocortical macronodules at imaging and variable levels of cortisol excess. PBMAH is a rare cause of primary overt Cushing's syndrome, but may represent up to one third of bilateral adrenal incidentalomas with evidence of cortisol excess. The increased steroidogenesis in PBMAH is often regulated by various G-protein coupled receptors aberrantly expressed in PBMAH tissues; some receptor ligands are ectopically produced in PBMAH tissues creating aberrant autocrine/paracrine regulation of steroidogenesis. The bilateral nature of PBMAH and familial aggregation, led to the identification of germline heterozygous inactivating mutations of the ARMC5 gene, in 20-25% of the apparent sporadic cases and more frequently in familial cases; ARMC5 mutations/pathogenic variants can be associated with meningiomas. More recently, combined germline mutations/pathogenic variants and somatic events inactivating the KDM1A gene were specifically identified in patients affected by GIP-dependent PBMAH. Functional studies demonstrated that inactivation of KDM1A leads to GIP-receptor (GIPR) overexpression and over or down-regulation of other GPCRs. Genetic analysis is now available for early detection of family members of index cases with PBMAH carrying identified germline pathogenic variants. Detailed biochemical, imaging, and co-morbidities assessment of the nature and severity of PBMAH is essential for its management. Treatment is reserved for patients with overt or mild cortisol/aldosterone or other steroid excesses taking in account co-morbidities. It previously relied on bilateral adrenalectomy; however recent studies tend to favor unilateral adrenalectomy, or less frequently, medical treatment with cortisol synthesis inhibitors or specific blockers of aberrant GPCR.
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Affiliation(s)
- Jerôme Bertherat
- Department of Endocrinology and National Reference Center for Rare Adrenal Disorders, Cochin Hospital, Assistance Publique Hôpitaux de Paris, 24 rue du Fg St Jacques, Paris 75014, France
| | - Isabelle Bourdeau
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Lucas Bouys
- Department of Endocrinology and National Reference Center for Rare Adrenal Disorders, Cochin Hospital, Assistance Publique Hôpitaux de Paris, 24 rue du Fg St Jacques, Paris 75014, France
| | - Fanny Chasseloup
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Service d'Endocrinologie et des Maladies de la Reproduction, 94276 Le Kremlin-Bicêtre, France
| | - Peter Kamenicky
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Service d'Endocrinologie et des Maladies de la Reproduction, 94276 Le Kremlin-Bicêtre, France
| | - André Lacroix
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
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Ullah A, Mohamed FAE, Khan J, Tracy K, Khan M, Mohsen S, Yasinzai AQK, Badini K, Sobash PT, Heneidi S, Karim NA. Current Understanding of "Mixed Corticomedullary Adrenal Tumor" and an Insight into Genomic Profiling. Clin Pract 2022; 12:918-925. [PMID: 36412675 PMCID: PMC9680374 DOI: 10.3390/clinpract12060096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 11/05/2022] [Accepted: 11/07/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Malignant mixed corticomedullary adrenal tumors (MCMTs) are extremely rare, with limited cases reported in the literature. The pathophysiology of malignant MCMTs is not well understood; the most prevailing theories are that it is a composite tumor of embryologically derived mesodermal (adrenal cortex) and neural crest (medulla) origin, perpetuating as two distinct cell lines forming a singular mass. Clinical features and laboratory diagnosis are associated with hypersecretions of the adrenal cortex and medulla. Surgical resection is curative in an isolated tumor. We reviewed and compared cases in the literature highlighting the pathogenesis and genetics of benign and malignant MCMT. METHODS Comprehensive literature analysis was conducted on PubMed and all the cases of mixed corticomedullary adrenal tumor published in English were included. RESULTS Most patients were female (73.1%) with a median age of 49 in women and 50 in men. Surgery was performed in all patients, and in four patients with malignant disease, chemotherapy was used as well. Clinically, most patients presented with hypertension (69%) followed by Cushing syndrome (42%) and diabetes (19%). Tumors often produced cortisol (74%), catecholamines (50%), and adrenocorticotrophic hormone (ACTH) (38%), with lower incidence of aldosterone- (7%) or dopamine (4%)-producing tumors. Immunohistochemical staining of 96% of cases showed Chromogranin-A (73%) and Synaptophysin (62%), followed by Inhibin-α (50%), Melan-A (31%), and S-100 (23%). Of the reported four cases with malignant disease, three showed a Ki-67 index of 40-50% with one showing less than 5%. CONCLUSION Mixed corticomedullary adrenal tumors rarely present as a malignant disease requiring chemotherapy. Most MCMTs confer a good prognosis and respond well to surgical resection, though their pathogenesis is largely up to speculation because of limited data. Current theories regarding MCMT pathogenesis should be investigated further with genetic testing. Future research on MCMT may provide ways to guide physician diagnosis and subsequent treatment for refractory cases.
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Affiliation(s)
- Asad Ullah
- Department of Pathology, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | | | - Jaffar Khan
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Katharine Tracy
- Department of Medicine, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
| | - Muhabat Khan
- Department of Medicine, Bolan Medical College, Sandman Provincial Hospital, Quetta 83700, Pakistan
| | - Samiha Mohsen
- Department of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | | | - Kaleemullah Badini
- Department of Medicine, Bolan Medical College, Sandman Provincial Hospital, Quetta 83700, Pakistan
| | - Philip T. Sobash
- Department of Medicine, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
| | - Saleh Heneidi
- Department of Pathology, Cedars Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Nagla Abdel Karim
- Department of Hematology/Oncology, Inova Schar Cancer Institute, University of Virginia, Fairfax, VA 22031, USA
- Correspondence:
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Lopez AG, Duparc C, Renouf S, Machevin E, Le Guillou V, Sabourin JC, Defortescu G, Buffet A, Gimenez-Roqueplo AP, Dubessy C, Louiset E, Lefebvre H. Expression of LHCGR (Luteinizing Hormone/Chorionic Gonadotrophin Receptor) in Pheochromocytomas Unveils an Endocrine Mechanism Connecting Pregnancy and Epinephrine Overproduction. Hypertension 2022; 79:1006-1016. [PMID: 35189708 DOI: 10.1161/hypertensionaha.121.18864] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The mechanisms by which pregnancy may unmask pheochromocytomas and paragangliomas are not totally understood. We hypothesized that gestational hormones may participate in the pathophysiology of catecholamine excess during pregnancy. We report a case of silent pheochromocytoma revealed in a pregnant woman by life-threatening adrenergic myocarditis. METHODS In vitro studies were conducted to investigate the effect of estradiol and the pregnancy hormone hCG (human chorionic gonadotropin) on epinephrine secretion by cultured cells derived from the patient's tumor. Expression of LHCG (luteinizing hormone/chorionic gonadotropin) receptor was searched for in the patient's tumor, and a series of 12 additional pheochromocytoma by RT-Q-PCR and immunohistochemistry. LHCGR expression was also analyzed in silico in the pheochromocytomas and paragangliomas cohorts of the Cortico et Médullosurrénale: les Tumeurs Endocrines and The Cancer Genome Atlas databases. RESULTS hCG stimulated epinephrine secretion by cultured cells derived from the patient's pheochromocytoma. The patient's tumor expressed the LHCG receptor, which was colocalized with catecholamine-producing enzymes. A similar expression pattern of the LHCG receptor was also observed in 5 out of our series of pheochromocytoma. Moreover, in silico studies revealed that pheochromocytomas and paragangliomas display the highest expression levels of LHCG receptor mRNA among the 32 solid tumor types of The Cancer Genome Atlas cohort. CONCLUSIONS Pregnancy may thus favor surges in plasma catecholamine and hypertensive crises through hCG-induced stimulation of epinephrine production by pheochromocytomas.
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Affiliation(s)
- Antoine-Guy Lopez
- Normandie University, UNIROUEN, INSERM U1239, NorDIC, Rouen, France (A.-G.L., C. Duparc, S.R., C. Dubessy, E.L., H.L.).,Department of Endocrinology, Diabetes and Metabolic Diseases, Rouen University Hospital, France. (A.-G.L., H.L.)
| | - Céline Duparc
- Normandie University, UNIROUEN, INSERM U1239, NorDIC, Rouen, France (A.-G.L., C. Duparc, S.R., C. Dubessy, E.L., H.L.)
| | - Sylvie Renouf
- Normandie University, UNIROUEN, INSERM U1239, NorDIC, Rouen, France (A.-G.L., C. Duparc, S.R., C. Dubessy, E.L., H.L.)
| | - Elise Machevin
- Department of Gynaecology-Obstetrics, Evreux Hospital Centre, France (E.M.)
| | - Vincent Le Guillou
- Department of Thoracic and Cardiovascular Surgery, Rouen University Hospital, France. (V.L.G.)
| | - Jean-Christophe Sabourin
- Department of Pathology and INSERM 1245, Rouen University Hospital, France. (J.-C.S,).,Tumor BioBank-Centre for Biological Resources, Rouen University Hospital, France. (J.-C.S., H.L.)
| | - Guillaume Defortescu
- Normandie University, UNIROUEN, INSERM U1239, NorDIC, Rouen, France (A.-G.L., C. Duparc, S.R., C. Dubessy, E.L., H.L.).,Department of Urology, Rouen University Hospital, France. (G.D.)
| | - Alexandre Buffet
- Université de Paris, PARCC, INSERM, Paris, France (A.B., A.-P.G.-R.).,Service de Génétique, Assistance Publique-Hôpitaux de Paris, Hôpital européen Georges Pompidou, Paris, France (A.B., A.-P.G.-R.)
| | - Anne-Paule Gimenez-Roqueplo
- Université de Paris, PARCC, INSERM, Paris, France (A.B., A.-P.G.-R.).,Service de Génétique, Assistance Publique-Hôpitaux de Paris, Hôpital européen Georges Pompidou, Paris, France (A.B., A.-P.G.-R.)
| | - Christophe Dubessy
- Normandie University, UNIROUEN, INSERM, PRIMACEN, Rouen, France (C. Dubessy)
| | - Estelle Louiset
- Normandie University, UNIROUEN, INSERM U1239, NorDIC, Rouen, France (A.-G.L., C. Duparc, S.R., C. Dubessy, E.L., H.L.)
| | - Hervé Lefebvre
- Normandie University, UNIROUEN, INSERM U1239, NorDIC, Rouen, France (A.-G.L., C. Duparc, S.R., C. Dubessy, E.L., H.L.).,Department of Endocrinology, Diabetes and Metabolic Diseases, Rouen University Hospital, France. (A.-G.L., H.L.).,Tumor BioBank-Centre for Biological Resources, Rouen University Hospital, France. (J.-C.S., H.L.)
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Watts D, Jaykar MT, Bechmann N, Wielockx B. Hypoxia signaling pathway: A central mediator in endocrine tumors. Front Endocrinol (Lausanne) 2022; 13:1103075. [PMID: 36699028 PMCID: PMC9868855 DOI: 10.3389/fendo.2022.1103075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 12/21/2022] [Indexed: 01/11/2023] Open
Abstract
Adequate oxygen levels are essential for the functioning and maintenance of biological processes in virtually every cell, albeit based on specific need. Thus, any change in oxygen pressure leads to modulated activation of the hypoxia pathway, which affects numerous physiological and pathological processes, including hematopoiesis, inflammation, and tumor development. The Hypoxia Inducible Factors (HIFs) are essential transcription factors and the driving force of the hypoxia pathway; whereas, their inhibitors, HIF prolyl hydroxylase domain (PHDs) proteins are the true oxygen sensors that critically regulate this response. Recently, we and others have described the central role of the PHD/HIF axis in various compartments of the adrenal gland and its potential influence in associated tumors, including pheochromocytomas and paragangliomas. Here, we provide an overview of the most recent findings on the hypoxia signaling pathway in vivo, including its role in the endocrine system, especially in adrenal tumors.
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6
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Khatri A, Mahajan N, Khan NA, Gupta N. Mixed cortico-medullary adrenal carcinoma in children: looks are deceptive!! ANNALS OF PEDIATRIC SURGERY 2021. [DOI: 10.1186/s43159-021-00134-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Mixed cortico-medullary adrenal carcinoma (MCMAC) is an extremely rare entity with scarce literature on its cytomorphology.
Case presentation
A 2-year-old girl presented with abdominal pain for 3 days and a past history of fever with significant weight loss. On examination, a non-tender left hypochondrial firm mass and an enlarged left supraclavicular node were found. Twenty-four-hour urinary levels of VMA were marginally high. Contrast-enhanced computed tomography of the abdomen showed a suprarenal heterogeneous mass encasing major vessels. Aspiration cytology of both mass and node showed similar features comprising a predominant population of singly scattered large cells with moderate cytoplasm, eccentric nucleus and prominent nucleolus in a necrotic background. Tumour cells expressed Synaptophysin and Melan-A. In view of increasing respiratory distress, debulking surgery was performed, and histopathology of the specimen revealed the presence of both malignant medullary and cortical components supported by immunohistochemistry making a final diagnosis of MCMAC. The patient succumbed to death in the postoperative period. The cytology slides were reviewed and were seen to show a dual cell population.
Conclusion
Coexistent malignant cortical and medullary tumour of the adrenal gland is the first case reported in the paediatric age group in the literature with only three previous case reports in adults.
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7
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Yoshida S, Babaya N, Ito H, Hiromine Y, Taketomo Y, Niwano F, Imamura S, Yamazaki Y, Sasano H, Kawabata Y, Noso S, Ikegami H. Mixed Corticomedullary Tumor Accompanied by Unilateral Aldosterone-Producing Adrenocortical Micronodules: a Case Report. J Endocr Soc 2021; 5:bvab140. [PMID: 34514278 PMCID: PMC8415316 DOI: 10.1210/jendso/bvab140] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Indexed: 12/27/2022] Open
Abstract
Mixed corticomedullary tumors (MCMTs) are rare and comprise medullary and cortical cells in a single adrenal tumor. The mechanisms underlying their development have not been fully elucidated. Here, we report a case of MCMT in a 42-year-old woman. Based on the preoperative clinical findings, the patient was diagnosed as having a pheochromocytoma with subclinical Cushing syndrome. Postoperative pathological diagnosis revealed that the tumor demonstrated morphologically distinct medullary and cortical components, which produced catecholamines and cortisol, respectively. Hybrid tumor cells producing both catecholamines and cortisol were not detected. Adrenocorticotropin (ACTH)-positive tumor cells were identified to be present in the pheochromocytoma. This ectopic production of ACTH can contribute to an autonomous cortisol production in a paracrine manner. In addition, micronodules producing aldosterone were detected in the adrenal tissue adjacent to the tumor. The simultaneous development of these 2 lesions may not be correlated with each other; however, this case confirms the importance of a detailed histopathological examination of the adrenal lesions harboring complicated hormonal abnormalities by providing pivotal and indispensable information on their pathogenesis and the possible interaction of the hormones produced in the adrenal gland.
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Affiliation(s)
- Sawa Yoshida
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka 589-8511, Japan
| | - Naru Babaya
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka 589-8511, Japan
| | - Hiroyuki Ito
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka 589-8511, Japan
| | - Yoshihisa Hiromine
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka 589-8511, Japan
| | - Yasunori Taketomo
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka 589-8511, Japan
| | - Fumimaru Niwano
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka 589-8511, Japan
| | - Shuzo Imamura
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka 589-8511, Japan
| | - Yuto Yamazaki
- Department of Pathology, Tohoku University Graduate School of Medicine, Miyagi 980-8575, Japan
| | - Hironobu Sasano
- Department of Pathology, Tohoku University Graduate School of Medicine, Miyagi 980-8575, Japan
| | - Yumiko Kawabata
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka 589-8511, Japan
| | - Shinsuke Noso
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka 589-8511, Japan
| | - Hiroshi Ikegami
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka 589-8511, Japan
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Uketa S, Shimizu Y, Ogawa K, Utsunomiya N, Asai S, Ishihara M, Kanamaru S. Black adrenal adenoma causing subclinical Cushing's syndrome complicated with pheochromocytoma. IJU Case Rep 2021; 4:56-58. [PMID: 33426500 PMCID: PMC7784729 DOI: 10.1002/iju5.12240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 10/20/2020] [Accepted: 11/08/2020] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION The development of adrenocortical adenoma and pheochromocytoma within the same adrenal gland is very rare. Furthermore, no reports have described coincident black adrenal adenoma and pheochromocytoma. We herein report a rare case of coincident black adrenal adenoma and pheochromocytoma in the same adrenal gland. CASE PRESENTATION A 71-year-old Japanese woman was hospitalized because a right adrenal tumor had been incidentally found by computed tomography. She was diagnosed with subclinical Cushing's syndrome and underwent laparoscopic right adrenalectomy. The tumor contained two adrenal nodules. The cut surface of the larger nodule was brownish-black on macroscopic examination. Pathological studies revealed coincident black adrenal adenoma and pheochromocytoma. CONCLUSION To the best of our knowledge, this is the first report of coincident black adrenal adenoma causing subclinical Cushing's syndrome and pheochromocytoma in the same adrenal gland. The mechanism of this rare scenario is unclear, and further study is necessary.
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Affiliation(s)
- Shoko Uketa
- Department ofUrologyKobe City Nishi‐Kobe Medical CenterKobeJapan
| | - Yousuke Shimizu
- Department ofUrologyKobe City Nishi‐Kobe Medical CenterKobeJapan
| | - Kosuke Ogawa
- Department ofUrologyKobe City Nishi‐Kobe Medical CenterKobeJapan
| | | | - Satsuki Asai
- Department ofPathologyKobe City Nishi‐Kobe Medical CenterKobeJapan
| | - Misa Ishihara
- Department ofPathologyKobe City Nishi‐Kobe Medical CenterKobeJapan
| | - Sojun Kanamaru
- Department ofUrologyKobe City Nishi‐Kobe Medical CenterKobeJapan
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Kanzawa M, Fukuoka H, Yamamoto A, Suda K, Shigemura K, Hara S, Imagawa N, Tsukamoto R, Aoyama Y, Nakamura Y, Fujisawa M, Ogawa W, Takahashi Y, Itoh T. Adrenal Corticomedullary Mixed Tumor Associated With the FGFR4-G388R Variant. J Endocr Soc 2020; 4:bvaa101. [PMID: 32803097 PMCID: PMC7417000 DOI: 10.1210/jendso/bvaa101] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 07/16/2020] [Indexed: 12/26/2022] Open
Abstract
Adrenal corticomedullary mixed tumors (CMMTs) are extremely rare; with only 20 cases being reported to date, the pathogenesis has remained elusive. A 31-year-old woman developed gestational hypertension with psychiatric disturbances persistent to postpartum and was diagnosed with pheochromocytoma, for which adrenalectomy was performed. Histological findings showed mixed adrenocortical adenoma and pheochromocytoma. Double immunostaining of inhibin and INSM1 (insulinoma-associated protein 1) showed that the 2 tumor components had distinct functional properties. Exome analysis of peripheral leukocytes and tumor (singular, as anatomically it is only 1 mass) revealed a homozygous germline FGFR4-G388R variant. As a readout of the variant, serine phosphorylation of signal transducer and activator of transcription 3 (STAT3) was detected only in the nucleus of adrenocortical adenoma component but not in the pheochromocytoma component. No tyrosine phosphorylation of STAT3 was detected. We report a case of CMMT with the germline FGFR4-G388R variant. Although additional studies are required, our immunohistochemical analysis suggests that the variant may play a role in the development of the adrenocortical component within the pheochromocytoma, leading to CMMT.
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Affiliation(s)
- Maki Kanzawa
- Department of Diagnostic Pathology, Kobe University Hospital, Kobe, Japan
| | - Hidenori Fukuoka
- Division of Diabetes and Endocrinology, Kobe University Hospital, Kobe, Japan
| | - Akane Yamamoto
- Division of Diabetes and Endocrinology, Kobe University Hospital, Kobe, Japan
| | - Kentaro Suda
- Division of Diabetes and Endocrinology, Kobe University Hospital, Kobe, Japan
| | - Katsumi Shigemura
- Division of Diabetes and Endocrinology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Shigeo Hara
- Division of Urology, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Naoko Imagawa
- Department of Diagnostic Pathology, Kobe University Hospital, Kobe, Japan
| | - Ryuko Tsukamoto
- Department of Diagnostic Pathology, Kobe University Hospital, Kobe, Japan
| | - Yayoi Aoyama
- Department of Diagnostic Pathology, Kobe City Medical Center General Hospital, Kobe, Japan
| | | | - Masato Fujisawa
- Division of Diabetes and Endocrinology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Wataru Ogawa
- Division of Pathology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Yutaka Takahashi
- Division of Pathology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Tomoo Itoh
- Department of Diagnostic Pathology, Kobe University Hospital, Kobe, Japan
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10
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Stemness regulation of the adrenal mixed corticomedullary tumorigenesis-a case-control study. Neoplasia 2020; 22:263-271. [PMID: 32438306 PMCID: PMC7240194 DOI: 10.1016/j.neo.2020.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 04/12/2020] [Accepted: 04/21/2020] [Indexed: 12/14/2022] Open
Abstract
Mixed corticomedullary tumor is an adrenal tumor intermixed with cortical and medullary cells. It is extremely rare with unclear tumorigenesis. We reported a 32-year-old female, manifested with typical Cushing’s syndrome and hypertension, to be diagnosed with right huge adrenal mixed corticomedullary tumor (8.8 cm). Right adrenalectomy was done to document the tumor intimately admixed with adrenal cortical adenoma and pheochromocytoma by biochemistry and immunohistochemistry. A case-control study was designed to explore the tumorigenesis of mixed corticomedullary tumor by whole exome sequencing. Expression of the stemness markers was controlled by a tissue array of 80 adrenal tumors. Overall, 1559 identical variants coexisted in parts of adrenal cortical adenoma and pheochromocytoma, which mainly (85.8%) originated from germline mutations. These enriched mutations were engaged in stemness control, coherent with substantial expression of the stemness markers (SOX2, CD44 and OCT4) in both parts. The differential stemness expressions were demonstrated in other adrenal tumors as well. The germline mutations were also enriched in signaling involving cancer proliferation, hypoxia inducible factor-1, focal adhesion and extracellular matrix receptor interaction. Somatic mutations affecting mitogen-activated protein kinase signaling, glycolysis and the citrate cycle were found in some tumor elements. This is the first study to verify the rare mixed corticomedullary tumor by molecular and genetic evidence to link with its phenotype. Germline mutations involving the stemness regulation and cancer proliferative signaling may drive intermixed tumor formation. Somatic mutations related to glycolysis and the citrate cycle may contribute to greater tumor outgrowth.
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11
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From ACTH-Dependent to ACTH-Independent Cushing's Syndrome from a Malignant Mixed Corticomedullary Adrenal Tumor: Potential Role of Embryonic Stem Cells. Case Rep Endocrinol 2020; 2020:4768281. [PMID: 32426170 PMCID: PMC7218959 DOI: 10.1155/2020/4768281] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 01/21/2020] [Accepted: 02/22/2020] [Indexed: 12/28/2022] Open
Abstract
Objective To report the immunohistochemical and molecular evaluation of a patient with ectopic ACTH syndrome (EAS) from a MCAT which has single cells with features of both 96 medullary and cortical differentiation. Case Description and Methods. A 16-year-old woman presented with severe EAS and a large right MCAT composed of ACTH-secreting cells resembling pheochromocytoma and another lineage similar to adrenal carcinoma. Immunohistochemistry (IHC) showed positivity for medullary (ACTH, chromogranin A, synaptophysin, and PS-100) and epithelial components (inhibin, melan-A, and calretinin). Embryonic stem cell markers were evaluated using RT/PCR and immunofluorescence. After initial surgery, the tumor recurred shifting to rapidly progressive ACTH-independent liver metastasis. Results Histopathology and IHC revealed two distinct and intermingled cellular patterns, while some cells immunostained for both medullary and cortical markers. Demonstration of all stem cell biomarkers by RT/PCR and immunofluorescence was predominantly localized to the nucleus, whereas SOX2 immunoreactivity was evident in the cytoplasm as well. Conclusion The expression of cancer stem cell biomarkers points towards the involvement of primitive embryonic cells as the origin of this neoplasm and maybe to the clinically aggressive and biochemically changing behavior.
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Xu Y, Wang Z, Bi Y, Duan Z, Yue X. Correlation between CT features of adrenocortical and adrenal medullary tumors and expression of miR-96 in serum. Oncol Lett 2018; 16:2053-2057. [PMID: 30008900 PMCID: PMC6036421 DOI: 10.3892/ol.2018.8863] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 05/25/2018] [Indexed: 12/16/2022] Open
Abstract
Correlation between CT features of adrenocortical and adrenal medullary tumors and the expression of miR-96 in serum were investigated. A total of 230 patients with adrenocortical tumors and 194 patients with adrenal medullary tumors were selected in Dongying People's Hospital from August 2013 to August 2017. The two groups of patients underwent CT examination, and the signs and symptoms were recorded. The expression of miR-96 in the serum of the two groups was detected by RT-PCR, and the correlation between the expression of serum miR-96 and CT features was analyzed. In patients with adrenocortical tumor, serum miR-96 expression levels were significantly higher in patients with tumor diameter ≥5 cm than those with tumor diameter <5 cm (p<0.001). In patients with adrenal medullary tumor, serum miR-96 expression levels were significantly higher in patients with tumor diameter ≥3 cm than those with tumor diameter <3 cm (p<0.001). In patients with adrenocortical or adrenal medullary tumor, serum miR-96 expression levels were significantly higher in patients with peripheral infiltration than those without peripheral infiltration (p<0.001), and serum miR-96 expression levels were also significantly higher in patients with distant metastasis than those without distant metastasis (p<0.001). Serum levels of miR-96 in patients with benign adrenocortical and adrenal medullary tumors were significantly lower than those with malignant tumors in the same group (p<0.001). miR-96 may have oncogenic functions in patients with adrenocortical or adrenal medullary tumors. Increased expression level of miR-96 may promote proliferation, invasion and metastasis of tumors, and serum levels of miR-96 provide references for the diagnosis of adrenocortical and adrenal medullary tumors.
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Affiliation(s)
- Yongyun Xu
- CT Room, Dongying People's Hospital, The Second People's Hospital of Dongying, Dongying, Shandong 257091, P.R. China
| | - Zhenfang Wang
- CT Room, Dongying People's Hospital, The Second People's Hospital of Dongying, Dongying, Shandong 257091, P.R. China
| | - Yangang Bi
- CT Room, Dongying People's Hospital, The Second People's Hospital of Dongying, Dongying, Shandong 257091, P.R. China
| | - Zuyun Duan
- Department of Imaging, The Second People's Hospital of Dongying, Dongying, Shandong 257091, P.R. China
| | - Xuewang Yue
- CT Room, Dongying People's Hospital, The Second People's Hospital of Dongying, Dongying, Shandong 257091, P.R. China
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Duan L, Fang F, Fu W, Fang Z, Wang H, Yu S, Tang Z, Liu Z, Zheng H. Corticomedullary mixed tumour resembling a small adrenal gland-involvement of cancer stem cells: case report. BMC Endocr Disord 2017; 17:9. [PMID: 28193212 PMCID: PMC5307641 DOI: 10.1186/s12902-017-0157-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 02/01/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Adrenal corticomedullary mixed tumours are very rare. Its mechanism is rarely reported. Here we report the first case of a corticomedullary mixed tumour resembling a "small adrenal gland" with distinct arrangement of the cortical and medullary layers. We further hypothesize regarding the tumorigenic mechanism of this tumour. CASE PRESENTATION A 58-year man had been diagnosed with diabetes and hypertension for 3 years. His 24-h urine vanillylmandelic acid (VMA) levels were slightly elevated. An abnormal circadian cortisol rhythm was noted, and his cortisol levels were not suppressed by dexamethasone. Abdominal computed tomography (CT) revealed a right adrenal gland lesion (diameter, 30 × 38 mm), while an enhanced CT showed enhancement and hypervascularization. The tumour was positive for adrenocorticotropic hormone, chromogranin A (CGA), and steroidogenic factor-1 (SF-1) on the tumour surface. Acetaldehyde dehydrogenase 1(ALDH1), CD44, CD133, Nestin, Nerve growth factor receptor (NGFR), and Sex determining region y-box 9(SOX9) staining were positive. Although administration of medications for diabetes and hypertension was stopped until surgery was performed, the blood sugar level and blood pressure were maintained after surgery. CONCLUSIONS This is the first report about a possible mechanism by which cancer stem cells induce adrenal corticomedullary tumours.
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Affiliation(s)
- Lian Duan
- Department of Endocrinology, Xinqiao Hospital, Third Military Medical University, Xinqiao Street No.183, Shapingba District, Chongqing 400037 China
| | - Fang Fang
- Department of Endocrinology, Chongqing Hospital of Traditional Chinese Medicine, Chongqing, China
| | - Wanlei Fu
- Department of Pathology, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Zhenqiang Fang
- Department of Urology, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Hui Wang
- Department of Endocrinology, Xinqiao Hospital, Third Military Medical University, Xinqiao Street No.183, Shapingba District, Chongqing 400037 China
| | - Shicang Yu
- Institute of Pathology and Southwest Cancer Center, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Zili Tang
- Molecular & Translational Radiation Oncology, Heidelberg Ion Therapy Center, Heidelberg Institute of Radiation Oncology, University of Heidelberg Medical School and National Center for Cancer Diseases, German Cancer Research Center, Heidelberg, Germany
| | - Zhenqi Liu
- Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia Health System, Charlottesville, VA USA
| | - Hongting Zheng
- Department of Endocrinology, Xinqiao Hospital, Third Military Medical University, Xinqiao Street No.183, Shapingba District, Chongqing 400037 China
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Mixed corticomedullary adrenal carcinoma - case report: Comparison in features, treatment and prognosis with the other two reported cases. Int J Surg Case Rep 2017; 31:254-261. [PMID: 28199934 PMCID: PMC5310178 DOI: 10.1016/j.ijscr.2017.01.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 01/05/2017] [Accepted: 01/05/2017] [Indexed: 11/21/2022] Open
Abstract
Adrenal incidetaloma could be mixed tumor, and should be considered in every case. Radiological signs play an important rules in differentiate malignant from benign adrenal tumor. Complete immunohistochemical study is necessary to confirm pheochromocytoma that presents normally in the clinic. Additional reported cases and clinical trials are needed to put more effective treatment plans for Mixed corticomedullary adrenal carcinoma.
Introduction Adrenal corticomedullary adenoma was reviewed in many cases in PubMed Library, While the coincidence corticomedullary adrenal carcinoma in the same gland was just described in two cases in the medical literature. Our case is the third to be reported and was treated with surgery and adjuvant chemotherapy and followed for two years. Presentation of case A 50-year-old man suffered from a mass effect in the left abdominal side. While the laboratory showed a mild elevation in the levels of both serum cortisol and 24 h urine cortisol, radiological images were highly suggested an adrenal malignant tumor without metastasis. At surgery a 22 cm sized mass was completely resected. Immunohistochemical study identified expression of both adrenocortical carcinoma and pheochromocytoma markers. Discussion Cases of coincidence corticomedullary tumor have been published in many reviews, cortical and/or medulllary hypersecretion were not always detected preoperatively by biochemical tests. Mixed corticomedullary carcinoma are exceedingly rare, we came across three reported cases in medical literature, in one case laboratory tests confirmed both cortical and medulla hypersecretion, while the two others detected only cortical hypersecretion. The final diagnosis was always confirmed by immunohistochemical staining. Conclusion It could be noted that this is the first comparison of presentation, diagnosis, treatments and follow-up of the three cases of Mixed corticomedullary carcinoma. This could contribute to understanding the behavior and management of this rare malignancy and make it more familiar in clinical practice.
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Pant L, Kalita D, Chopra R, Das A, Jain G. Malignant Perivascular Epithelioid Cell Tumor (PEComa) of the Adrenal Gland: Report of a Rare Case Posing Diagnostic Challenge with the Role of Immunohistochemistry in the Diagnosis. Endocr Pathol 2015; 26:129-34. [PMID: 25724713 DOI: 10.1007/s12022-015-9360-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Histological diagnosis of adrenal tumors is often challenging as diverse groups of tumors, both primaries and metastatic, may be seen in the adrenal gland with overlapping morphological features. Immunohistochemistry (IHC) plays the most important role in their diagnosis. Perivascular epithelioid cell tumor (PEComa), a rarely reported tumor in the adrenal gland, shares many features with another rare tumor sarcomatoid adrenocortical carcinoma (ACC). Extensive immunohistochemical study is required to distinguish this tumor from adrenocortical carcinoma and from other morphologically similar tumors. The unique combination of immunoreactivity for melanocytic markers, such as HMB-45 and Melan A, and myogenic markers, such as smooth muscle actin, is the hallmark of PEComas biological behavior, and prognosis of malignant PEComas is yet to be fully understood. Few cases of malignant PEComa have been reported in the adrenal gland. We report a case of malignant PEComa of the adrenal gland posing diagnostic challenge and compare its morphological and immunohistochemical features with those of sarcomatoid ACC.
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Affiliation(s)
- Leela Pant
- Department of Pathology, North DMC Medical College and Hindu Rao Hospital, Delhi, 110007, India
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Park GE, Cho YY, Hong YS, Kang SH, Lee KH, Lee HW, Kim JH. A functioning adrenal adenoma and pheochromocytoma in the same adrenal gland: two discrete adrenal incidentalomas. Korean J Intern Med 2015; 30:114-7. [PMID: 25589844 PMCID: PMC4293550 DOI: 10.3904/kjim.2015.30.1.114] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Revised: 03/31/2014] [Accepted: 07/10/2014] [Indexed: 11/27/2022] Open
Affiliation(s)
- Ga Eun Park
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yoon Young Cho
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yun Soo Hong
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Su Hoon Kang
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyung Ho Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyun Woo Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Hyeon Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Lefebvre H, Prévost G, Louiset E. Autocrine/paracrine regulatory mechanisms in adrenocortical neoplasms responsible for primary adrenal hypercorticism. Eur J Endocrinol 2013; 169:R115-38. [PMID: 23956298 DOI: 10.1530/eje-13-0308] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
A wide variety of autocrine/paracrine bioactive signals are able to modulate corticosteroid secretion in the human adrenal gland. These regulatory factors, released in the vicinity of adrenocortical cells by diverse cell types comprising chromaffin cells, nerve terminals, cells of the immune system, endothelial cells, and adipocytes, include neuropeptides, biogenic amines, and cytokines. A growing body of evidence now suggests that paracrine mechanisms may also play an important role in the physiopathology of adrenocortical hyperplasias and tumors responsible for primary adrenal steroid excess. These intra-adrenal regulatory systems, although globally involving the same actors as those observed in the normal gland, display alterations at different levels, which reinforce the capacity of paracrine factors to stimulate the activity of adrenocortical cells. The main modifications in the adrenal local control systems reported by now include hyperplasia of cells producing the paracrine factors and abnormal expression of the latter and their receptors. Because steroid-secreting adrenal neoplasms are independent of the classical endocrine regulatory factors angiotensin II and ACTH, which are respectively suppressed by hyperaldosteronism and hypercortisolism, these lesions have long been considered as autonomous tissues. However, the presence of stimulatory substances within the neoplastic tissues suggests that steroid hypersecretion is driven by autocrine/paracrine loops that should be regarded as promising targets for pharmacological treatments of primary adrenal disorders. This new potential therapeutic approach may constitute an alternative to surgical removal of the lesions that is classically recommended in order to cure steroid excess.
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Affiliation(s)
- H Lefebvre
- Laboratory of Neuronal and Neuroendocrine Differentiation and Communication, Institut National de la Santé et de la Recherche Médicale Unité 982, 76821 Mont-Saint-Aignan, France
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Donatini G. Editorial comment to dopamine-secreting corticomedullary mixed tumor of the adrenal gland. Int J Urol 2012; 19:1124-5. [PMID: 22897694 DOI: 10.1111/j.1442-2042.2012.03124.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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