Phaeochromocytoma and mixed corticomedullary tumour - a rare cause of Cushing's syndrome and labile hypertension in a primigravid woman postpartum

Mixed Corticomedullary Tumor of the Adrenal Gland: A Case Report and Literature Review

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.

Mixed ganglioneuroma and cortical adenoma in adrenal gland: A case report

RATIONALE

Adrenal mixed corticomedullary tumors (MCMTs) are single tumor masses composed of an intimately admixed population of both adrenal cortical cells and medullary components. Most medullary tumor components are pheochromocytomas; however, MCMTs composed of ganglioneuroma and adrenal cortical adenoma are extremely rare. The current case is a rare case of adrenal MCMT composed of ganglioneuroma and adrenal cortical adenoma with primary aldosteronism.

PATIENT CONCERNS

A 49-year-old male was admitted because of hypokalemia and an adrenal mass. He was diagnosed with hypertension in his 20s and was taking blood pressure medications.

DIAGNOSIS

Plasma aldosterone concentration 376.5 pg/dL (normal 37.8~233.0 pg/mL) and potassium 2.8 mmol/L (normal 3.4~4.9 mmol/L) were detected. The aldosterone-to-renin ratio [the ratio of plasma aldosterone concentration (ng/dL) to PRA (ng/mL/hour)] was 38. The saline loading test showed that serum aldosterone (49.4 ng/dL) was not suppressed, compared with the basal level (28.4 ng/dL). The adrenal venous sampling test showed that the aldosterone level markedly increased to 1521.2 pg/mL. Abdominal computed tomography revealed an enlarged relatively well-circumscribed multinodular mass (35 × 13 × 30 mm) in the right adrenal gland.

INTERVENTIONS

Laparoscopic right adrenalectomy was performed under the clinical diagnosis of a functioning adrenal cortical adenoma.

OUTCOMES

After laparoscopic right adrenalectomy, the serum aldosterone and renin levels returned to normal. The patient maintained a normal aldosterone level without recurrence for 16 months.

LESSONS

Adrenal MCMTs of the ganglioneuroma and cortical adenomas in the ipsilateral adrenal gland are extremely rare. Adrenal MCMTs exhibit benign clinical behavior, with no metastasis or death due to the tumor. With the development of diagnostic imaging technology, it is possible to identify mixed tumors. However, surgical resection of adrenal gland is a common treatment and a final diagnosis should be made based on the pathological results after surgery. Because this is to rule out the occurrence of rare malignant tumors and confirm the pattern of mixed tumors.

Current Understanding of "Mixed Corticomedullary Adrenal Tumor" and an Insight into Genomic Profiling

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.

Mixed corticomedullary tumor of the adrenal gland

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.

Adrenal medulla development and medullary-cortical interactions

The mammalian adrenal gland is composed of two distinct tissue types in a bidirectional connection, the catecholamine-producing medulla derived from the neural crest and the mesoderm-derived cortex producing steroids. The medulla mainly consists of chromaffin cells derived from multipotent nerve-associated descendants of Schwann cell precursors. Already during adrenal organogenesis, close interactions between cortex and medulla are necessary for proper differentiation and morphogenesis of the gland. Moreover, communication between the cortex and the medulla ensures a regular function of the adult adrenal. In tumor development, interfaces between the two parts are also common. Here, we summarize the development of the mammalian adrenal medulla and the current understanding of the cortical-medullary interactions under development and in health and disease.

Black adrenal adenoma causing subclinical Cushing's syndrome complicated with pheochromocytoma

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.

Corticomedullary mixed tumour resembling a small adrenal gland-involvement of cancer stem cells: case report

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.

Adrenal cortical and chromaffin stem cells: Is there a common progeny related to stress adaptation?

The adrenal gland is a highly plastic organ with the capacity to adapt the body homeostasis to different physiological needs. The existence of stem-like cells in the adrenal cortex has been revealed in many studies. Recently, we identified and characterized in mice a pool of glia-like multipotent Nestin-expressing progenitor cells, which contributes to the plasticity of the adrenal medulla. In addition, we found that these Nestin progenitors are actively involved in the stress response by giving rise to chromaffin cells. Interestingly, we also observed a Nestin-GFP-positive cell population located under the adrenal capsule and scattered through the cortex. In this article, we discuss the possibility of a common progenitor giving rise to subpopulations of cells both in the adrenal cortex and medulla, the isolation and characterization of this progenitor as well as its clinical potential in transplantation therapies and in pathophysiology.

Mixed corticomedullary adrenal carcinoma - case report: Comparison in features, treatment and prognosis with the other two reported cases

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Adrenal incidetaloma could be mixed tumor, and should be considered in every case.

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Radiological signs play an important rules in differentiate malignant from benign adrenal tumor.

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Complete immunohistochemical study is necessary to confirm pheochromocytoma that presents normally in the clinic.

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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.

Mixed corticomedullary adrenal carcinoma

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.

Mixed corticomedullary carcinoma of the adrenal gland: a case report

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.

Corticomedullary mixed tumor of the adrenal gland-a clinical and pathological chameleon: case report and review of literature

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.

Corticomedullary mixed adrenal tumor: case report and literature review

We report a 66-year-old woman with a mixed corticomedullary tumor of the left adrenal gland. The patient was found to harbor an adrenal incidentaloma while investigated for a spigelian hernia. Due to the atypical radiological features and the relatively large size of the adrenal lesion she underwent a left adrenalectomy following endocrine testing to exclude a functional lesion. Subclinical Cushing's syndrome was suggested by the failure to obtain adequate cortisol suppression (less than 1.8 microg/dL) following dexamethasone administration pre-operatively; cortisol suppression was restored postoperatively following the excision of the tumor. Histology was consistent with a corticomedullary mixed adenoma, a lesion for which, there is paucity of published data regarding its natural history and long term outcome. The finding of this case highlights the importance of this extremely rare entity which should be included in the long list of causes of adrenal incidentaloma since cases with intra-operative complications have been described. The previously reported reappearance of this tumor in the contralateral adrenal gland emphasizes the need for prolonged follow-up.