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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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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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Engur CO, Apaydın T, Ones T, Gozu HI, Ozguven S. Corticomedullary Mixed Tumor of the Adrenal Gland with Apparent 18F-Fluorodeoxyglucose Activity But No 68GA-DOTATATE Uptake on Positron Emission Tomography/Computed Tomography. Indian J Nucl Med 2022; 37:297-298. [PMID: 36686306 PMCID: PMC9855236 DOI: 10.4103/ijnm.ijnm_194_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 02/27/2022] [Accepted: 03/16/2022] [Indexed: 01/24/2023] Open
Abstract
Corticomedullary mixed tumor (CMT) is a single adrenal tumor mass composed histologically by an admixture of adrenal cortical and medullary cells. It is a rare condition, with approximately 20 cases reported to date. To our knowledge, the positron emission tomography (PET) imaging findings of this mostly benign tumor have not been reported in the literature. We present a case of CMT who was evaluated with both 18F-fluorodeoxyglucose (18F-FDG) and 68Ga-DOTATATE. The hypermetabolic tumor seen on 18F-FDG PET/computed tomography scan showed no abnormal uptake by 68Ga-DOTATATE.
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Affiliation(s)
- Ceren Ozge Engur
- Department of Nuclear Medicine, Marmara University, Pendik Training and Research Hospital, Istanbul, Turkey
| | - Tugce Apaydın
- Department of Endocrinology and Metabolism, Marmara University, Pendik Training and Research Hospital, Istanbul, Turkey
| | - Tunc Ones
- Department of Nuclear Medicine, Marmara University, Pendik Training and Research Hospital, Istanbul, Turkey
| | - Hulya Iliksu Gozu
- Department of Endocrinology and Metabolism, Marmara University, Pendik Training and Research Hospital, Istanbul, Turkey
| | - Salih Ozguven
- Department of Nuclear Medicine, Marmara University, Pendik Training and Research Hospital, Istanbul, Turkey
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Kimura N, Motoyama T, Saito J, Nishikawa T. Mixed corticomedullary tumor of the adrenal gland. Front Endocrinol (Lausanne) 2022; 13:1026918. [PMID: 36187098 PMCID: PMC9524188 DOI: 10.3389/fendo.2022.1026918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 08/30/2022] [Indexed: 11/21/2022] Open
Abstract
Mixed corticomedullary tumor (MCMT) of the adrenal gland is an extremely rare tumor characterized by an admixture of steroidogenic cells and chromaffin cells in a single tumor mass simultaneously producing adrenocortical hormones and catecholamines; it is associated with ectopic adrenocorticotropic hormone (ACTH) in some cases. We reviewed and summarized clinicopathological data of 28 MCMTs, including four metastatic tumors in 26 previous reports. These reports included 21 females and 7 males, and the average tumor sizes were 4.8 ± 2.5 cm and 12.6 ± 6.4 cm in the non-metastatic and metastatic groups, respectively (P<0.001). The clinical manifestations and laboratory data were as follows: Cushing or subclinical Cushing syndrome, 58% (14/24); hypertension, 71% (17/24); elevated adrenocortical hormones, 75% (18/24); elevated catecholamines, 75% (18/24); and ectopic ACTH, 71% (10/14). All four patients with metastatic MCMTs had poor prognoses and elevated adrenocortical hormone levels; however, only two patients had elevated catecholamine levels. Immunohistochemistry was essential for the pathologic diagnosis of MCMTs. In this study, using an improved technique, we detected ectopic ACTH-producing cells in the same paraffin-embedded sections reported to be negative in our previous reports. As MCMT is composed of cells with embryologically different origins, its pathogenesis has been explained by various hypotheses. We compared MCMT to the adrenal gland of birds and the early stage of human fetuses, in which nests of chromaffin cells and steroidogenic cells admix without the formation of cortex and medulla. MCMT is characterized by the immaturity of organogenesis and might be classified as an adrenal embryonal tumor.
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Affiliation(s)
- Noriko Kimura
- Department of Clinical Research, National Hospital Organization Hakodate Hospital, Hakodate, Japan
- Department of Diagnostic Pathology, National Hospital Organization Hakodate Hospital, Hakodate, Japan
- *Correspondence: Noriko Kimura,
| | - Teiich Motoyama
- Department of Pathology, Yamagata University School of Medicine, Yamagata, Japan
| | - Jun Saito
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama, Japan
| | - Tetsuo Nishikawa
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama, Japan
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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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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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Papathomas TG, de Krijger RR, Tischler AS. Paragangliomas: update on differential diagnostic considerations, composite tumors, and recent genetic developments. Semin Diagn Pathol 2013; 30:207-23. [PMID: 24144290 DOI: 10.1053/j.semdp.2013.06.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Recent developments in molecular genetics have expanded the spectrum of disorders associated with pheochromocytomas (PCCs) and extra-adrenal paragangliomas (PGLs) and have increased the roles of pathologists in helping to guide patient care. At least 30% of these tumors are now known to be hereditary, and germline mutations of at least 10 genes are known to cause the tumors to develop. Genotype-phenotype correlations have been identified, including differences in tumor distribution, catecholamine production, and risk of metastasis, and types of tumors not previously associated with PCC/PGL are now considered in the spectrum of hereditary disease. Important new findings are that mutations of succinate dehydrogenase genes SDHA, SDHB, SDHC, SDHD, and SDHAF2 (collectively "SDHx") are responsible for a large percentage of hereditary PCC/PGL and that SDHB mutations are strongly correlated with extra-adrenal tumor location, metastasis, and poor prognosis. Further, gastrointestinal stromal tumors and renal tumors are now associated with SDHx mutations. A PCC or PGL caused by any of the hereditary susceptibility genes can present as a solitary, apparently sporadic, tumor, and substantial numbers of patients presenting with apparently sporadic tumors harbor occult germline mutations of susceptibility genes. Current roles of pathologists are differential diagnosis of primary tumors and metastases, identification of clues to occult hereditary disease, and triaging of patients for optimal genetic testing by immunohistochemical staining of tumor tissue for the loss of SDHB and SDHA protein. Diagnostic pitfalls are posed by morphological variants of PCC/PGL, unusual anatomic sites of occurrence, and coexisting neuroendocrine tumors of other types in some hereditary syndromes. These pitfalls can be avoided by judicious use of appropriate immunohistochemical stains. Aside from loss of staining for SDHB, criteria for predicting risk of metastasis are still controversial, and "malignancy" is diagnosed only after metastases have occurred. All PCCs/PGLs are considered to pose some risk of metastasis, and long-term follow-up is advised.
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Affiliation(s)
- Thomas G Papathomas
- Department of Pathology, Josephine Nefkens Institute, Erasmus MC-University Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
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Abstract
Truly mixed corticomedullary tumors (MCMTs) are extremely rare and present as a single tumor mass composed of an intimately admixed population of both adrenal cortical cells and pheochromocytes. The current study describes the first case of a mixed corticomedullary adrenal carcinoma. In addition, we also review the published data on MCMTs to determine their clinical features, biochemical characteristics, pathological findings, and management. In order to compose this review, a search of the international literature for MCMTs was conducted. Fifteen related articles were found. The clinical and pathological information was obtained for all reported cases. MCMTs were found almost exclusively in females. In the vast majority of patients, the symptoms were related to the tumor's hormone hypersecretion. Hypertension and diabetes were present in 80 and 40 % of cases, respectively. Cushing's syndrome was reported in eight cases (53.33 %). A final diagnosis was made in all cases after surgery based on the pathological results. As of the writing of this article, all published cases of MCMTs had benign clinical behavior, with no instances of metastasis or death due to the tumor. MCMTs are currently considered to be benign tumors. Ours is the first case of malignant MCMT reported in the literature. The potential for malignancy should therefore be considered for these tumors.
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Turk AT, Asad H, Trapasso J, Perilli G, LiVolsi VA. Mixed corticomedullary carcinoma of the adrenal gland: a case report. Endocr Pract 2012; 18:e37-42. [PMID: 22548942 DOI: 10.4158/ep11222.cr] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To report the case of a 78-year-old woman with mixed corticomedullary carcinoma of the adrenal gland, and to review other reported lesions that exhibit clinical and/or histopathologic features of both adrenal cortical and medullary differentiation. METHODS We describe the patient's clinical findings and laboratory test results, as well as the gross and histopathologic features of her tumor. We also review the literature pertaining to mixed corticomedullary adenomas and cortical tumors with clinical features of pheochromocytoma, and vice versa. RESULTS A 78-year-old woman with a 10-cm left adrenal mass was hospitalized for management of hypertensive urgency. Laboratory workup revealed elevated urinary metanephrine excretion and elevated serum dehydroepiandrosterone sulfate levels. She underwent left adrenalectomy. Pathologic examination of the lesion showed mixed cortical and medullary histologic characteristics, as well as gross and microscopic evidence of malignancy. Including the present case, we identified 17 cases of neoplasms that exhibit features of mixed corticomedullary differentiation. CONCLUSIONS This report represents the first documented case of mixed corticomedullary carcinoma. Several benign lesions combine clinical, biochemical, and/or histopathologic evidence of both adrenal cortical and medullary differentiation, including mixed corticomedullary adenomas and corticotropin-secreting pheochromocytomas. The differential diagnosis of a lesion with mixed cortical and medullary features should also include a malignant neoplasm.
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Affiliation(s)
- Andrew T Turk
- Department of Pathology and Cell Biology, Columbia University, New York, New York 11032, USA.
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Corticomedullary mixed tumor of the adrenal gland-a clinical and pathological chameleon: case report and review of literature. Updates Surg 2012; 65:161-4. [PMID: 22228558 DOI: 10.1007/s13304-011-0132-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2011] [Accepted: 12/30/2011] [Indexed: 10/14/2022]
Abstract
Adrenal tumors mostly present with specific and unique clinical features, regarding their endocrine metabolism. A 53-year-old man came to our Department for a left adrenal mass discovered incidentally. Biochemical and imaging findings were suspicious for a pheochromocytoma. The patient underwent a laparoscopic left adrenalectomy. A well-circumscribed 5.5-cm mass was removed. It was composed of adrenal cells intimately admixed with pheochromocytes. Immunohistochemical studies were positive both for cortical cells (inibin-α, synaptophysine and melan-A) and medullary cells (S-100 and chromogranine A). Final pathology was of corticomedullary mixed tumor (CMT). CMT is a rare tumor with 14 cases previously reported in literature, with wide variable biochemical behavior, such as his radiological and pathological features. Prevalence and actual malignant potential are yet unknown to our knowledge.
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Mixed cortical adenoma and composite pheochromocytoma-ganglioneuroma: an unusual corticomedullary tumor of the adrenal gland. Ann Diagn Pathol 2011; 15:185-9. [DOI: 10.1016/j.anndiagpath.2010.02.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2010] [Accepted: 02/16/2010] [Indexed: 11/23/2022]
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