Oncocytic adrenocortical neoplasm arising from adrenal rest in the broad ligament of the uterus

Serous Cystadenoma with Ectopic Adrenal Cell Rest of Ovary: A Rare Case Report

Ectopic adrenal tissue is an uncommon entity in females. It is usually seen in male children, and the commonly involved sites are the kidney, retroperitoneum, spermatic cord, and paratesticular region. The ectopic adrenal gland in adults has been described in few studies only. Ectopic adrenal tissue was diagnosed as an incidental finding in histopathological examination of serous cystadenoma of the ovary. A 44-year-old female presented with a complaint of vague abdominal discomfort for the past few months. Ultrasound was suggestive of a left ovarian complex cystic lesion. The histopathological examination revealed serous cystadenoma with ectopic adrenal cell rest. Here, we present this case as it is a rare finding incidentally detected in a patient being operated on for a different pathology.

Case report: An ectopic adrenocortical adenoma in the renal sinus

Background

Ectopic adrenal tissue is rare in adults, with an incidence of only about 1%. We report a rare case of ectopic adrenocortical adenoma in the left renal sinus.

Case Preentation

A 57-year-old woman was admitted to the Department of Urology due to “a left kidney tumor” on physical examination. Multislice helical computed tomography (CT) showed the left kidney with an anterior lip mass near the hilum, approximately 2.3 cm × 2.2 cm in size. Preoperative renal artery CT angiography (CTA) showed no obvious abnormality. Laparoscopic resection of the left renal sinus mass was performed, and postoperative pathological findings showed ectopic adrenocortical adenoma. The tumor was a nonfunctional adenoma.

Conclusion

Renal ectopic adrenal cortical adenoma is rare. Most of them are nonfunctional adenomas, which cannot be clearly diagnosed by preoperative imaging examination and can often be diagnosed by postoperative pathology.

Overview of the 2022 WHO Classification of Adrenal Cortical Tumors

The new WHO classification of adrenal cortical proliferations reflects translational advances in the fields of endocrine pathology, oncology and molecular biology. By adopting a question-answer framework, this review highlights advances in knowledge of histological features, ancillary studies, and associated genetic findings that increase the understanding of the adrenal cortex pathologies that are now reflected in the 2022 WHO classification. The pathological correlates of adrenal cortical proliferations include diffuse adrenal cortical hyperplasia, adrenal cortical nodular disease, adrenal cortical adenomas and adrenal cortical carcinomas. Understanding germline susceptibility and the clonal-neoplastic nature of individual adrenal cortical nodules in primary bilateral macronodular adrenal cortical disease, and recognition of the clonal-neoplastic nature of incidentally discovered non-functional subcentimeter benign adrenal cortical nodules has led to redefining the spectrum of adrenal cortical nodular disease. As a consequence, the most significant nomenclature change in the field of adrenal cortical pathology involves the refined classification of adrenal cortical nodular disease which now includes (a) sporadic nodular adrenocortical disease, (b) bilateral micronodular adrenal cortical disease, and (c) bilateral macronodular adrenal cortical disease (formerly known primary bilateral macronodular adrenal cortical hyperplasia). This group of clinicopathological entities are reflected in functional adrenal cortical pathologies. Aldosterone producing cortical lesions can be unifocal or multifocal, and may be bilateral with no imaging-detected nodule(s). Furthermore, not all grossly or radiologically identified adrenal cortical lesions may be the source of aldosterone excess. For this reason, the new WHO classification endorses the nomenclature of the HISTALDO classification which uses CYP11B2 immunohistochemistry to identify functional sites of aldosterone production to help predict the risk of bilateral disease in primary aldosteronism. Adrenal cortical carcinomas are subtyped based on their morphological features to include conventional, oncocytic, myxoid, and sarcomatoid subtypes. Although the classic histopathologic criteria for diagnosing adrenal cortical carcinomas have not changed, the 2022 WHO classification underscores the diagnostic and prognostic impact of angioinvasion (vascular invasion) in these tumors. Microscopic angioinvasion is defined as tumor cells invading through a vessel wall and forming a thrombus/fibrin-tumor complex or intravascular tumor cells admixed with platelet thrombus/fibrin. In addition to well-established Weiss and modified Weiss scoring systems, the new WHO classification also expands on the use of other multiparameter diagnostic algorithms (reticulin algorithm, Lin-Weiss-Bisceglia system, and Helsinki scoring system) to assist the workup of adrenal cortical neoplasms in adults. Accordingly, conventional carcinomas can be assessed using all multiparameter diagnostic schemes, whereas oncocytic neoplasms can be assessed using the Lin-Weiss-Bisceglia system, reticulin algorithm and Helsinki scoring system. Pediatric adrenal cortical neoplasms are assessed using the Wieneke system. Most adult adrenal cortical carcinomas show > 5 mitoses per 10 mm² and > 5% Ki67. The 2022 WHO classification places an emphasis on an accurate assessment of tumor proliferation rate using both the mitotic count (mitoses per 10 mm²) and Ki67 labeling index which play an essential role in the dynamic risk stratification of affected patients. Low grade carcinomas have mitotic rate of ≤ 20 mitoses per 10 mm², whereas high-grade carcinomas show > 20 mitoses per 10 mm². Ki67-based tumor grading has not been endorsed in the new WHO classification, since the proliferation indices are continuous variables rather than being static thresholds in tumor biology. This new WHO classification emphasizes the role of diagnostic and predictive biomarkers in the workup of adrenal cortical neoplasms. Confirmation of the adrenal cortical origin of a tumor remains a critical requirement when dealing with non-functional lesions in the adrenal gland which may be mistaken for a primary adrenal cortical neoplasm. While SF1 is the most reliable biomarker in the confirmation of adrenal cortical origin, paranuclear IGF2 expression is a useful biomarker in the distinction of malignancy in adrenal cortical neoplasms. In addition to adrenal myelolipoma, the new classification of adrenal cortical tumors has introduced new sections including adrenal ectopia, based on the potential role of such ectopic tissue as a possible source of neoplastic proliferations as well as a potential mimicker of metastatic disease. Adrenal cysts are also discussed in the new classification as they may simulate primary cystic adrenal neoplasms or even adrenal cortical carcinomas in the setting of an adrenal pseudocyst.

A novel 8.57-kb deletion of the upstream region of PRKAR1A in a family with Carney complex

Carney complex (CNC) is a rare hereditary syndrome that involves endocrine dysfunction and the development of various types of tumors. Chromosome 2p16 and PRKAR1A on chromosome 17 are known susceptibility loci for CNC. Here we report a mother and son with CNC caused by an 8.57‐kb deletion involving the transcription start site and non‐coding exon 1 of PRKAR1A. The proband is a 28‐year‐old male with bilateral large‐cell calcified Sertoli cell testicular tumors and pituitary adenoma. Comprehensive genomic profiling for cancer mutations using Foundation One CDx failed to detect any mutations in PRKAR1A in DNA from the testicular tumor. Single‐nucleotide polymorphism array analysis of the proband’s genomic DNA revealed a large deletion in the 5′ region of PRKAR1A. Genomic walking further delineated the region an 8.57‐kb deletion. A 1.68‐kb DNA fragment encompassed by the deleted region showed strong promoter activity in a NanoLuc luciferase reporter assay. The patient’s mother, who is suffering from recurrent cardiac myxoma, a critical sign for CNC, carried an identical deletion. The 8.57‐kb deleted region is a novel lesion for CNC and will facilitate molecular diagnosis of the disease.

Adrenal Rests in the Uro-genital Tract of an Adult Population

Ectopic adrenal rests are a rare condition which can be found in various sites, generally in the retroperitoneum or pelvis along the path of gonadal descent. Their real prevalence is unknown. Males are more commonly affected, at least in the pediatric age. Adrenal rests are usually clinically silent and incidentally found in surgical samples, mostly in the pediatric population, and rarely in adults. With the aim of increasing knowledge and estimating the prevalence of ectopic adrenocortical tissue in the adult population, 44 adrenal rests in the urogenital tract of 40 adults are described. These represent approximately 0.07% of the total number of urogenital and gynecological surgeries performed in the 22 considered years. Adrenal rests were identified in the spermatic cord (10 males) and in paraovarian, parasalpingeal, or infundibulopelvic ligament locations (30 females). All but one was incidental findings. One case regarded an adrenocortical carcinoma arisen in adrenal rests. A literature review of adrenal ectopia in the urogenital tract of adults identified 57 reported cases from 53 patients, with similar clinicopathological features as those of our series, with the exception of a lower incidence of parasalpingeal locations. Despite their limited clinical implications, awareness of ectopic adrenal rests is essential also in adults for at least two reasons: (a) to correctly identify sources of adrenocortical hormone production in case of adrenal insufficiency or hormonal imbalance and (b) to avoid misinterpretations in the diagnostic workup of renal cell carcinoma, adrenocortical tumors, and rare gonadal neoplasms, including Sertoli/Leydig cell tumors.

Oncocytic adrenocortical tumor with uncertain malignant potential in pediatric population: A case report and review of literature

BACKGROUND

Oncocytic adrenocortical tumor (OACT) is rare, with few cases reported in the literature. No more than 20 cases in children have been reported. The clinical characteristics, diagnosis, treatment and prognosis of children with OACT are summarized based on a literature review, in order to improve the understanding of OACT in children.

CASE SUMMARY

We report a case of a 17-mo-old patient who was admitted to our hospital due to symptoms of odynuria and fever, which are clinical features consistent with a functional adrenocortical tumor. The patient was diagnosed with OACT of uncertain malignant potential. Computed tomography indicated a soft tissue giant tumor in the right adrenal region, approximately 4.3 cm × 5.5 cm in size. Multiple nodular and speckled calcifications were observed in the lesion. The patient received robot-assisted laparoscopic right adrenal tumor resection. Postoperative pathological results were consistent with OACT, and immunohistochemical results showed cytokeratin^+/-, chromogranin A⁺, synaptophysin^-, neuron-specific enolase^-, S100^-, Ki67 about 10%, CD34^- and D2-40^-. After surgery, urinary tract ultrasonography was reviewed monthly, catecholamine hormone and sex hormone levels were examined every 2 mo and computed tomography was performed every 6 mo. To date, no tumor metastasis or recurrence has been identified in this patient. The levels of sex hormones and catecholamine hormones decreased to normal 1 mo after surgery.

CONCLUSION

OACT is rare in the pediatric population, with few cases reported in the literature. Although most pediatric OACTs are benign, malignant cases have been reported. Surgical resection is the preferred option in most patients.

Adrenal Cortical Rests in the Fallopian Tube: Report of a Case and Review of the Literature

We report an extremely unusual finding discovered incidentally during a routine pathologic evaluation of a fallopian tube, surgically removed on the grounds of ectopic pregnancy. We came across a minute yellowish nodule situated within the wall of the salpinx, which corresponded to ectopic adrenal cortex, as verified by microscopical examination, and coexisted with salpingitis isthmica nodosa. A research of the available English literature on this subject confirmed the rareness of the entity we encountered. This case is presented because of its uniqueness, aiming to raise awareness of a rare condition which is discussed along with potential diagnostic dilemmas, its prognostic significance, and possible complications.

Adrenocortical oncocytic neoplasm: A systematic review

BACKGROUND

Adrenocortical oncocytic neoplasms are rare tumors, generally regarded as benign and hormonally nonfunctional. We performed a systematic review to update the literature on adrenocortical oncocytic neoplasms by reviewing patient and tumor characteristics, as well as management trends, because the literature is composed of predominately single-case reports.

METHODS

A systematic search was performed in PubMed, Embase, and Cochrane Library through June 2017. Malignant potential was determined by applying the Lin-Weiss-Bisceglia criteria to cases.

RESULTS

Included for analysis were 84 citations describing 140 adrenocortical oncocytic neoplasms, including our own case. These were diagnosed predominantly in females (66%), on the left side (64%), and were nonfunctional (66%). Average age at diagnosis was 44 years (2.5-77), and median tumor size was 80 mm (16-285). A total of 35% of adrenocortical oncocytic neoplasms were benign, 41% borderline, and 24% malignant. Male patients were more likely to have a malignant tumor compared with females (36% versus 18%, P = .035). The 5-year overall survival for benign adrenocortical oncocytic neoplasms was 100%, borderline 88%, and malignant 47%. Hormonal function did not discriminate malignant from benign lesions. Adrenocortical oncocytic neoplasms that stained positive for synaptophysin (50%, P < .001) and negative for vimentin (62%, P = .009) are more often benign.

CONCLUSION

We found that the majority of adrenocortical oncocytic neoplasms (65%) were either malignant or had malignant potential, contrary to the previous literature. The Lin-Weiss-Bisceglia criteria are useful in identifying those patients for whom closer surveillance is warranted, because their prognosis is dependent on the Lin-Weiss-Bisceglia diagnosis.

Functional plurihormonal adrenal oncocytoma: case report and literature review

We present a 27-year-old woman with an adrenal oncocytoma. This is a very rare entity. We provide a review of the clinical, biochemical and pathological features of cases reported in the literature.

Ectopic adrenal tissue associated with borderline mucinous cystadenoma of ovary: a case report with review of the literature

Ectopic adrenal tissue in the ovary is a rare entity. We reported a case of ectopic adrenal tissue in borderline mucinous cystadenoma of the left ovary. A 22 year-old student presented with progressive abdomen distension associated with discomfort for 3 months. Imaging investigation was suggestive of mucinous left ovarian cyst. Left salpingo-oophorectomy was performed and the histopathology revealed borderline mucinous cystadenoma with an incidental finding of ectopic adrenal tissue. This is an interesting case because of its rarity and potential risk of neoplasm changes.

Adrenal ectopy of adult groin region: a systematic review of an unexpected anatomopathologic diagnosis

PURPOSE

Adrenal ectopy is a rare condition, caused by abnormal embryological development of the adrenal glands and testis. This anomaly is asymptomatic and is generally diagnosed in childhood. Most cases of adrenal ectopy of the groin region have been found incidentally during surgery. This review aims to evaluate the incidence of adrenal ectopy of the adult groin region, as well as its short- and long-term significance.

METHODS

A systematic literature search was performed using the EMBASE, MEDLINE, PubMed and Cochrane Central databases to identify all studies published until December 2015. Articles written in English containing the keywords: ''ectopic adrenal tissue'' or ''aberrant adrenal tissue'' or ''adrenal heterotopy'' combined with ''groin region'' or ''inguinal'' or ''testicular" or "scrotum" and "adult" were selected.

RESULTS

Fifteen articles matched the review criteria. A total of 21 cases (100 % male) were included. No cases of bilateral nodules have been reported. The mean age at diagnosis was 43.5 years old (range 19-78 years). A predominance of right-sided lesions was observed (71.4 %). The mean size reached 7.6 mm (range 2-40 mm) and hernia sacs were the most common location (47.6 %). All histological analyses of harvested tissues consisted of adrenal cortex without medulla.

CONCLUSIONS

Our results suggest that routine pathological examination of any groin tissue excised during inguinal hernia repairs is required for the diagnosis of adrenal ectopy in the groin. Although there is no current evidence that endocrine or oncologic complications can occur from excision of ectopic adrenal tissue, further confirmatory studies may be required.

Ectopic adrenocortical adenoma in the renal hilum: a case report and literature review

Background

Ectopic (accessory) adrenocortical tissue, also known as adrenal rests, is a developmental abnormality of the adrenal gland. The most common ectopic site is in close proximity to the adrenal glands and along the path of descent or migration of the gonads because of the close spatial relationship between the adrenocortical primordium and gonadal blastema during embryogenesis. Ectopic rests may undergo marked hyperplasia, and occasionally induce ectopic adrenocortical adenomas or carcinomas.

Case presentation

A 27-year-old Chinese female patient who presented with amenorrhea of 3 months duration underwent computed tomography urography after ultrasound revealed a solitary mass in the left renal hilum. Histologically, the prominent eosinophilic tumor cells formed an alveolar- or acinar-like configuration. The immunohistochemical profile (alpha-inhibin+, Melan-A+, synaptophysin+) indicated the adrenocortical origin of the tumor, diagnosed as ectopic adrenocortical adenoma. The patient was alive with no tumor recurrence or metastasis at the 3-month follow-up examination.

Conclusions

The unusual histological appearance of ectopic adrenocortical adenoma may result in its misdiagnosis as oncocytoma or clear cell renal cell carcinoma, especially if the specimen is limited. This case provides a reminder to pathologists to be aware of atypical cases of this benign tumor. Although uncommon, an ectopic adrenal lesion should be included in the differential diagnosis of tumors involving the renal hilum. A misdiagnosis of this benign condition as a malignant renal tumor may have severe consequences for the patient, including unnecessary radical nephrectomy. Preoperative biopsy and appropriate immunohistochemical staining will assist in determining the origin and nature of the tumor and in avoiding intraoperative uncertainty.

Ectopic Paratubal Adrenal Cell Rest Associated with Mucinous Cystadenoma of Ovary

Ectopic adrenal cortex is a rare entity. Usually found in male children; commonly located around kidney, retroperitoneum, spermatic cord and para-testicular region. Rarely, adults with heterotopic adrenal glands are described. Incidence in females is very less; though sometimes detected accidentally in hysterectomy specimens. We describe a case of ectopic adrenal cortical cell in paratubal region in a patient with mucinous cyst adenoma of ovary. A 26-year-old female presented with complains of menstrual irregularities and abdominal discomfort for 6 months. Investigations suggested a right ovarian cyst. Right ovarian cystectomy with partial salpingectomy was performed; histopathology revealed mucinous cyst adenoma. Sections from tube showed presence of ectopic adrenal cortical rest in the paratubal region, incidentally discovered on microscopy. We present this case because of its rarity in females, interesting presentation with another unrelated gynaecological pathology, its potentiality for malignant transformation and possible complications.

Lesions of the Broad Ligament: A Review

The differential diagnosis of lesions arising in the broad ligament is quite large. Many of these lesions can be clinically interpreted before surgery as adnexal or uterine neoplasms. Although some lesions are similar to those arising in other müllerian sites, there are unique lesions as well. The lesions are uncommon and may prove challenging to clinicians. The purpose was to review the scope of lesions affecting the broad ligament. A literature review was conducted. A Medline search was performed using the terms broad ligament, mesosalpinx, and mesovarium. A review of the scope of broad ligament lesions is presented to assist in developing a differential diagnosis if a patient with such a lesion is encountered.