Spontaneous rupture of a benign giant adrenal adenoma

Can we differentiate neoplastic and non-neoplastic spontaneous adrenal bleeding? Imaging findings with radiopathologic correlation

Spontaneous adrenal bleeding is a rare clinical event with non-specific clinical features. Life-threatening bleeding in the adrenal glands may be promptly diagnosed with imaging. Computed tomography (CT) is generally the first imaging modality to be used in these patients. However, in the acute phase of bleeding, it may be difficult to detect the underlying mass from the large hematoma. In these patients, additional imaging studies such as magnetic resonance imaging or positron emission tomography/CT may be utilized to rule out a neoplastic mass as the source of bleeding. In patients where an underlying neoplastic mass could not be identified at the time of initial diagnosis, follow-up imaging may be helpful after the acute phase subsides.

Diagnostic dilemmas in enlarged and diffusely hemorrhagic adrenal glands

We have noted an increasing number of cases of enlarged adrenal glands where the underlying diagnosis was masked by a diffusely hemorrhagic process. We identified from our database 59 cases (32 consults, 27 routine) of adrenal glands with diffuse (>25%) hemorrhage received between 2000 and 2014. Fifty-three adrenalectomies and 6 biopsies were identified. The diagnoses after central review were 41 adrenocortical adenomas, 1 nodular adrenocortical hyperplasia with associated myelolipoma, 1 benign adrenocortical cyst, and 10 nonneoplastic adrenal glands with hemorrhage. A definitive diagnosis for the 6 biopsies was precluded by the sample size. The adrenocortical adenomas (size, 1-13 cm; 25%-95% hemorrhage) showed clear cell change in the neoplastic area (10%-80% of the tumor), 19 showed focal calcification (1 with ossification), 11 showed areas of papillary endothelial hyperplasia, 10 showed scattered lymphoplasmacytic inflammation, 6 showed benign cortical tissue extending beyond the adrenal capsule into soft tissue, 1 showed necrosis in the form of ghost cells, 2 showed lipomatous change, and 6 were associated with incidental benign lesions (1 cortical cyst, 1 schwannoma, and 4 myelolipomas). Twenty-four of the adrenocortical adenomas were consults where the referring pathologist had trouble classifying the lesion. Of the 10 nonneoplastic adrenals (4.5-22 cm; 40%-80% hemorrhage), 2 were consults. In summary, pathologists have difficulties recognizing adrenocortical adenomas in the setting of a massively enlarged and hemorrhagic adrenal gland. Although there is a correlation between adrenocortical malignancy and size, hemorrhage into nonmalignant adrenal glands can result in markedly enlarged adrenals.

Giant non-functional adrenal adenoma: A case report

Adenomas of the adrenal cortex are common and asymptomatic when the diameter is 3-3.5 cm. However, adrenal tumors over 4 cm in diameter are diagnosed as malignant. Adrenal adenomas with a diameter over 20 cm are rare. In the present study, we present a case of non-functional giant benign adrenal adenoma. Following surgery, an adenoma of the adrenal cortex with a diameter of 32 cm and a weight of 7,500 g was found. A detailed search of the literature revealed this to be the largest benign tumor of the adrenal cortex described to date.

Spontaneous adrenal hemorrhage with associated masses: etiology and management in 6 cases and a review of 133 reported cases

BACKGROUND

Spontaneous adrenal hemorrhage associated with a mass is uncommon and treatment strategies are not standardized. Current treatment modalities range from supportive management and blood transfusion to embolization or immediate operative extirpation. Our objectives were to describe six cases from a single institution and to perform a literature review of the etiology of the condition and recommended management of patients with hemorrhagic adrenal masses.

METHODS

Records from six patients diagnosed with adrenal hemorrhage and an associated mass at a single institution were reviewed. Clinical records and outcomes were analyzed. A comprehensive review of 133 reported cases in the literature was performed.

RESULTS

Six patients presented with spontaneous adrenal hemorrhage that appeared to be associated with a mass, with tumor sizes ranging from 3.7 to 15 cm. Three patients underwent adrenalectomy for pheochromocytoma or adrenocortical cancer. Three patients did not undergo adrenalectomy: one had a metastasis from lung cancer, one underwent embolization, and one had resolution of the mass on interval imaging. A comprehensive review of the literature identified 133 cases, with pheochromocytoma the most commonly reported lesion (48%).

CONCLUSIONS

Spontaneous adrenal hemorrhage is rare. When it does occur, a high level of suspicion for malignant disease or pheochromocytoma should be maintained. The possibility of a hematoma masquerading as a neoplasm should also be considered. In cases of ongoing hemorrhage, embolization may be a lifesaving temporizing measure. Acute surgical intervention should be considered in selected patients, and surgery may not be required in all patients. A cautious approach with a comprehensive biochemical and imaging work-up is advised prior to operation.

Spontaneous rupture of a functioning adrenocortical carcinoma

Adrenocortical carcinoma (ACC) is a rare malignancy with poor prognosis, and it can be classified as either a functional or nonfunctional tumor. Affected patients usually present with abdominal pain or with symptoms related to the mass effect or hormonal activity of the tumor. Several cases of spontaneously ruptured nonfunctional adrenocortical carcinoma have been reported, but no case of a spontaneous rupture of functioning adrenocortical carcinoma has been described. We report a functioning adrenocortical carcinoma that spontaneously ruptured during a work-up.

Molecular classification and prognostication of adrenocortical tumors by transcriptome profiling

PURPOSE

Our understanding of adrenocortical carcinoma (ACC) has improved considerably, yet many unanswered questions remain. For instance, can molecular subtypes of ACC be identified? If so, what is their underlying pathogenetic basis and do they possess clinical significance?

EXPERIMENTAL DESIGN

We did a whole genome gene expression study of a large cohort of adrenocortical tissues annotated with clinicopathologic data. Using Affymetrix Human Genome U133 Plus 2.0 oligonucleotide arrays, transcriptional profiles were generated for 10 normal adrenal cortices (NC), 22 adrenocortical adenomas (ACA), and 33 ACCs.

RESULTS

The overall classification of adrenocortical tumors was recapitulated using principal component analysis of the entire data set. The NC and ACA cohorts showed little intragroup variation, whereas the ACC cohort revealed much greater variation in gene expression. A robust list of 2,875 differentially expressed genes in ACC compared with both NC and ACA was generated and used in functional enrichment analysis to find pathways and attributes of biological significance. Cluster analysis of the ACCs revealed two subtypes that reflected tumor proliferation, as measured by mitotic counts and cell cycle genes. Kaplan-Meier analysis of these ACC clusters showed a significant difference in survival (P < 0.020). Multivariate Cox modeling using stage, mitotic rate, and gene expression data as measured by the first principal component for ACC samples showed that gene expression data contains significant independent prognostic information (P < 0.017).

CONCLUSIONS

This study lays the foundation for the molecular classification and prognostication of adrenocortical tumors and also provides a rich source of potential diagnostic and prognostic markers.