Adrenal oncocytic neoplasm: a systematic review

Oncocytic adrenal cortical adenoma: a benign lesion mimicking malignancy

Adrenocortical tumours are rare in children and account for only 0.3%-0.4% of all neoplasms in childhood. They present with variable signs and symptoms, depending on the type of hormonal hypersecretion. The majority of the adrenocortical tumours in children are functional (90%) and malignant (88%). Here, we describe a functional plurihormonal oncocytic adrenal cortical adenoma in a young girl, that mimicked a malignant adrenal lesion, clinically as well as on imaging and biochemical features. This report bears the objective of being aware of the atypical biochemical as well as imaging characteristics of oncocytic adrenal tumours.

N-Nitrosomorpholine-induced oncocytic transformation in rat endocrine organs

BACKGROUND

N-Nitrosomorpholine (NMO) is one of the most common N-nitroso compounds. An oncocytic transformation has been demonstrated in renal tubules of NMO-treated rats. In our study, we aimed to investigate the potential transformation of oncocytic cells in 6 endocrine organs, i.e., thyroid, adrenal and pituitary glands, pancreas, testis, and bone, of NMO-exposed rats.

METHODS

Thirty male rats were born and raised. Fifteen of them were given a single dose of 320 mg NMO per kg body weight, dissolved in drinking water, by a gavage tube. At the end of 52 weeks, the animals in both series were killed. Right after the killing, 6 different endocrine organs (hypophysis, thyroid, pancreas, adrenal gland, bone [femur], and testicles) of each animal were excised.

RESULTS

There was no evidence of oncocytic cell development in the control group. In contrast, oncocytes were observed in 8 out of 13 NMO-treated rats: 2 in the adrenal sections, 1 in the thyroid sections, 3 in the pituitary sections, and 2 in the pancreas sections. Thesticle and bone sections were completely normal.

CONCLUSIONS

We showed that NMO induced an oncocytic change in pancreas, thyroid, pituitary, and adrenal glands. To date, no identified specific environmental risk factors that lead to an oncocytic transformation in endocrine glands have been reported previously. Given the increasing prevalence of endocrine-disrupting chemicals in the environment, personal care products, manufactured goods, and food sources, there is a need to advance our understanding of the pathological mechanisms underlying oncocytosis in endocrine organs.

Prognosis of Adrenal Oncocytic Neoplasms (AONs): Literature Review of 287 Cases and Presentation of the Oldest Patient

INTRODUCTION

The adrenocortical oncocytic neoplasms (AONs) are rare tumors of the adrenal gland, classified as oncocytoma (AO), oncocytic neoplasm of uncertain malignant potential (AONUMP) and oncocytic carcinoma (AOC). The aim of this study was to perform a review of the literature, in order to evaluate the prognosis of these rare cancers. We also reported the oldest patient with AON.

METHODS

A comprehensive literature review using as key words "adrenal oncocytoma", "adrenal oncocytic neoplasm", and "adrenal oncocytic carcinoma" was performed.

REPORT OF THE CASE

We report the case of an 88-year-old woman receiving a left open adrenalectomy for an AON (15 × 10 × 8 cm). The considerable size and weight together with the presence of necrosis were indicative for a lesion with an uncertain potential for malignancy, according to Weiss modified criteria. After two years, the patient was free from any sign of recurrence.

RESULTS

Only 287 AONs were detected in the scientific literature, exploring OVID, MEDLINE, PubMed and SCOPUS as dataset. These tumors are usually incidentalomas with an unpredictable malignant potential. Surgical resection remains the mainstay of treatment for AON.

CONCLUSION

AO and AONUMP have an excellent prognosis and a low mortality rate, with only three cases of recurrence reported in the literature and one metastatic case four years after first adrenal surgery. In contrast, AOC carries a high risk of local relapses, distant metastasis, and a significantly higher mortality rate (30%). Surgical resection remains the primary treatment for adrenal oncocytic neoplasms.

Incidental Adrenal Masses: A Case Report of an Adrenal Oncocytoma

A 59-year-old woman underwent an abdominal and pelvic computed tomography (CT) scan to rule out non-obstructive urolithiasis. The patient was asymptomatic, with the exception of occasional bilateral low back pain. A physical examination did not reveal any notable findings. The CT scan revealed the presence of an incidental solid left adrenal lesion, which displaced the body of the pancreas and the left kidney. The lesion measured 7 cm × 6.5 cm and exhibited a rounded morphology with well-defined margins. It showed progressive and heterogeneous contrast uptake. Additionally, magnetic resonance imaging (MRI) was performed, confirming the presence of an adrenal lesion with intense and heterogeneous hypersignal on T2. The lesion also demonstrated heterogeneous and persistent enhancement in a dynamic study. Furthermore, there were some indistinct and non-specific hypointense areas identified on both T1 and T2 sequences. The lesion exhibited moderately restricted diffusion. Although the imaging features were non-specific, there were no indications of invasion or distant metastasis, which made a benign large adrenal mass the most likely diagnosis. Non-functioning pheochromocytoma, lipid-poor adrenal adenoma, as well as metastasis or primary adrenal carcinoma, were considered differential diagnoses. The patient underwent an elective adrenalectomy, during which the identified lesion was completely resected. The patient's postoperative recovery was uneventful, and she was discharged three days after the procedure. Subsequent histopathological evaluation revealed an oncocytic neoplasm of the adrenal cortex - specifically, an oncocytoma.

Oncocytic adrenocortical neoplasm of borderline uncertain malignant potential diagnosed after robot-assisted adrenalectomy case report

BACKGROUND

Adrenal incidentalomas are radiologically discovered tumors that represent a variety of pathologies, with the diagnosis clinched only on surgical pathology. These tumors may be clinically monitored, but triggers for surgery include size > 4 cm, concerning features on radiology, or hormonally functioning. Adrenal oncocytic neoplasms (AONs) are notably rare and typically nonfunctional tumors that are discovered as incidentalomas and exist on a spectrum of malignant potential.

CASE PRESENTATION

We discovered an exceptionally large (15 cm in the greatest dimension) incidentaloma in a 73-year-old man with left back pain and he was treated with robotic-assisted adrenalectomy. Surgical pathology was consistent with AON of borderline uncertain malignant potential; adjuvant mitotane and radiation were omitted based on shared decision-making.

CONCLUSION

Large AONs are rare, usually benign tumors that can be safely treated with robotic-assisted adrenalectomy. Surgical pathology is the crux of diagnosis and post-operative management, as it informs both the initiation of adjuvant therapy and the stringency of post-operative surveillance.

Oncocytic Tumors: An Uncommon Benign Adrenal Gland Lesions With Features of Malignancy

Oncocytic cell neoplasms are usually found in the thyroid or salivary glands and the kidneys. Adrenal oncocytoma (AO) is an extremely rare localization. It is often non-functional and the suspicion of malignancy is considered when the size of an adrenal incidentaloma is greater than 4 cm. These adrenal oncocytomas, however, are large, round, and encapsulated with a benign presentation and evolution. We report on a 40-year-old male patient. Upon suspicion of a SARS-CoV-2 infection, the general physician instructed a chest CT scan, which, fortuitously, revealed a suspicious left adrenal lesion measuring 62x45mm. A biochemical investigation was negative for either pheochromocytoma or Cushing's syndrome, allowing the recommended surgery to be performed. The anatomopathological analysis showed an uncommon benign adrenal lesion, an adrenal oncocytoma.

A rare case of co-secreting adrenocortical oncocytoma

Here we present a rare case of a large co-secreting adrenocortical oncocytoma undergoing laparoscopic retroperitoneal-to-open removal. Our case was referred for surgical opinion as a result of a left suprarenal mass being identified as part of a work-up for new onset hirsutism and post-menopausal bleeding. We provide example of our surgical approach as well as discussion on this unique adrenal tumour variant.

Oncocytic adrenocortical tumour presenting as an incidentaloma: a diagnostic challenge

Oncocytic adrenocortical neoplasms are a rare histopathological subtype of adrenal tumours which are usually benign and, if malignant, are less likely to metastasise. We report a case of a non-functioning oncocytic adrenocortical tumour, identified incidentally in a middle-aged woman. It was initially reported as a left-sided 3.5×3.4×5.6 cm adrenal adenoma. It however increased in size to 5.4×4.0×4.3 cm on follow-up scans. Subsequent review of the scans revealed an indeterminate lesion with a precontrast density of 30 Hounsfield units, an absolute washout of 42.6% and a relative washout of 28.6%. As a result, laparoscopic left adrenalectomy was performed. Histology confirmed oncocytic adrenocortical carcinoma when using the Lin-Weiss-Bisceglia system, though it was deemed benign when using the Helsinki scoring system. There has been no evidence of recurrence to date. This case highlights the potential pitfalls in the diagnosis of oncocytic neoplasms and the increased specificity of the Helsinki score in assessing metastatic potential.

Differences in Clinicopathologic Behavior of Oncocytic Adrenocortical Neoplasms and Conventional Adrenocortical Carcinomas

BACKGROUND

Oncocytic adrenocortical neoplasms (OANs) are rare endocrine tumors that present as a spectrum from benign to malignant. The outcomes after surgical resection of the oncocytic variant of adrenocortical carcinoma remain poorly understood. We sought to characterize the clinicopathologic features of OAN and compare oncocytic adrenocortical carcinoma (OAC) with conventional adrenocortical carcinoma (ACC).

PATIENTS AND METHODS

Adult patients who underwent adrenalectomy for OAN or ACC between January 1990 and September 2020 were identified. Demographics, clinicopathologic factors, American Joint Committee on Cancer stage, and cancer-related outcomes were reviewed. A matched cohort analysis of disease-free survival (DFS) and overall survival (OS) was performed between patients with OACs and those with ACCs.

RESULTS

Forty-one patients with OAN and 214 patients with ACC were included. The OAN cohort median age was 45.2 years [interquartile ratio (IQR) 38.5-54.0 years], and 61.0% were female. OANs were benign (n = 11), of uncertain malignant potential (UMP, n = 9), or OAC (n = 21). Disease recurrence occurred in 12 (57.1%) patients with OAC compared with 1 (11.1%) and 0 patients with UMP or benign OAN, respectively (p < 0.001). Seven (33.3%) patients with OAC died during follow-up compared with 0 patients with UMP or benign OAN (p = 0.020). Kaplan-Meier survival analysis found no difference in DFS between ACC and OAC groups before (p = 0.218) and after 2:1 matching (p = 0.417). Overall survival was shorter for patients who had ACC compared with those who had OAC (p = 0.031), but the difference was not evident with matched analysis (p = 0.200).

CONCLUSIONS

OAN presents as a spectrum from benign indolent tumors to aggressive carcinomas. OACs demonstrate similar clinicopathologic behavior and recurrence-free and overall survival when matched to conventional ACCs.

Oncocytic adrenocortical neoplasm with undetermined malignant potential and autonomous cortisol secretion

Increasing incidence of adrenal incidentalomas with hypercortisolemia not associated with overt features of Cushing's syndrome has led to the evolution of the term autonomous cortisol secretion. Oncocytic adrenocortical neoplasms (OANs) are rare adrenal cortex neoplasms with only 250 reported cases worldwide. We present a woman in her 30s with menometrorrhagia, weight gain and increasing abdominal girth who was found to have a large right adrenal mass on abdominal CT scan. Serum cortisol was not suppressed after 1 mg dexamethasone (31.5 µg/dL) and adrenocorticotrophic hormone was not detectable (<1.0 pg/mL). She underwent right adrenalectomy under glucocorticoid coverage. Hypertension, weight, visceral adiposity and menometrorrhagia improved postoperatively. Histopathology with immunohistochemistry showed OAN with undetermined malignant potential. These kinds of tumours can only be definitively diagnosed postsurgically using the Lin-Weiss-Bisceglia system. Although they have better prognosis compared with adrenocortical carcinomas and do not require chemotherapy, patients should be closely monitored to identify recurrence promptly.

Two Subsequent Metachroneus Solid Tumors: Oncocytic Variant Adrenocortical Carcinoma and Rhabdomyosarcoma of Childhood: Case Report and Literature Review

Most cases of malignancies appear to be sporadic, but some syndromes are associated with malignancies with germline variants. Herein, a child with an unusual association of oncocytic variant adrenocortical carcinoma (ACC) and rhabdomyosarcoma (RMS) was presented. An 18-month-old-boy was admitted with virilization of the genital area, penis enlargement and erection, which had begun six months earlier. Serum total testosterone (457 ng/dL; NR <10), androstenedione (3.35 ng/mL; NR <0.5) and dehydroepiandrosterone-SO₄ (206 mcg/dL; NR<35) were above the normal ranges. Right adrenal mass was detected. After adrenalectomy, histopathological examination revealed an oncocytic variant ACC. Three-month after surgery, he then presented with 6x8 cm sized swelling of the left leg. Histopathological examination revealed embryonal RMS. Testing for tumor protein (TP53) variant by DNA sequence analysis was positive; however; fluorescence in situ hybridization analysis was negative. After chemotherapy and local radiotherapy, the patient is in good condition without tumor recurrence. Only about one-third of these tumors have a variant of TP53. This status also applies to other genetic variants related to cancer. However, a significant association of malignancies strongly suggests a problem in tumor suppressor genes or new variants. Another as yet unidentified suppressor gene may also be present and effective in this locus. The occurrence of ACC as a part of a syndrome and positive family history of malignancies in patients are clinically important. These patients and their families should be scanned for genetic abnormalities. The patient with ACC should be followed-up carefully for other tumors to detect malignancy early.

Central precocious puberty after resection of a virilising adrenocortical oncocytic tumour

Adrenocortical oncocytic tumours are a histological subtype of adrenal neoplasms with a distinctive morphological appearance. Since these tumours are composed of cells of the adrenal cortex, they may act as functional tumours with excess hormone production. They may cause Cushing's syndrome, inappropriate virilisation or precocious puberty. Though rare during childhood, adrenocortical oncocytic tumours should be suspected in a child with peripheral precocious puberty and marked elevation of dehydroepiandrosterone sulfate levels. We describe a 6-year girl who presented with peripheral precocious puberty due to a functional adrenocortical oncocytic tumour. Three months after tumour removal, she developed true central precocious puberty. This report highlights that peripheral precocious puberty may trigger central precocious puberty, particularly after resolution of the underlying cause of the peripheral precocious puberty.

A case of a borderline adrenal oncocytoma in a 62-year old female

INTRODUCTION

Adrenal oncocytomas are a rare pathology and only about 160 cases have been reported in the literature.

CASE DESCRIPTION

We describe the case of a 62-year old female with an incidentaloma found in the right adrenal gland on a CT scan. Endocrine testing showed a non-secreting lesion. An MRI was performed to get a more precise diagnosis. It excluded a simple adenoma and a malignant tumor had to be suspected. Open adrenalectomy was performed, and pathology results confirmed a borderline adrenal oncocytoma.

DISCUSSION

Oncocytomas are usually found in the kidneys, salivary glands, parathyroid, lung, pituitary gland, and ovaries. It is important to differentiate them from, for example, pheochromocytomas, adrenal cortical carcinoma, and metastasis. Most oncocytomas are non-functioning (17% are functional). Usually, they are found as incidentalomas on a CT or MRI scan. The only way to confirm the diagnosis at present is pathological examination. Bisceglia and his colleagues have proposed a new system to classify adrenal oncocytomas. The presence of one major criterion indicates malignancy, the presence of one to four minor criteria is indicative of uncertain potential. The absence of all major and minor criteria indicates benign behavior. Treatment options are open surgery, laparoscopic surgery and rarely robotic surgery.

CONCLUSION

An adrenal oncocytoma remains a rare diagnosis and has a wide array of differential diagnosis. It should be treated by surgical removal and a close follow up is suggested. More research should be done regarding diagnosis, treatment and follow-up.

Adrenal cancer: relevance of different grading systems and subtypes

PURPOSE

The subclassification of adrenal cancers according to the WHO classification in ordinary, myxoid, oncocytic, and sarcomatoid as well as pediatric types is well established, but the criteria for each subtype are not sufficiently determined and the relative frequency of the different types of adrenal cancers has not been studied in large cohorts. Therefore, our large collection of surgically removed adrenal cancers should be reviewed o establish the criteria for the subtypes and to find out the frequency of the various types.

METHODS

In our series of 521 adrenal cancers the scoring systems of Weiss et al., Hough et al., van Slooten et al. and the new Helsinki score system were used for the ordinary type of cancer (97% of our series) and the myxoid type (0.8%). For oncocytic carcinomas (2%), the scoring system of Bisceglia et al. was applied.

RESULTS

Discrepancies between benign and malignant diagnoses from the first thee classical scoring systems are not rare (22% in our series) and could be resolved by the Helsinki score especially by Ki-67 index (more than 8% unequivocally malignant). Since all our cancer cases are positive in the Helsinki score, this system can replace the three elder systems. For identification of sarcomatoid cancer as rarest type in our series (0.2%), the scoring systems are not practical but additional immunostainings used for soft tissue tumors and in special cases molecular pathology are necessary to differentiate these cancers from adrenal sarcomas. According to the relative frequencies of the different subtypes of adrenal cancers the main type is the far most frequent (97%) followed by the oncocytic type (2%), the myxoid type (0.8%) and the very rare sarcomatoid type (0.2%).

CONCLUSIONS

The Helsinki score is the best for differentiating adrenal carcinomas of the main, the oncocytic, and the myxoid type in routine work. Additional scoring systems for these carcinomas are generally not any longer necessary. Signs of proliferation (mitoses and Ki-67 index) and necroses are the most important criteria for diagnosis of malignancy.

Case Report of a Rare Adrenocortical Oncocytoma Suspected to be an Adrenal Carcinoma

An adrenal oncocytic neoplasm is an extremely rare tumour arising from the adrenal gland and it should be considered in the differential diagnosis of an adrenal incidentaloma, since it is frequently non-functioning. The suspicion for malignancy is high when an adrenal incidentaloma is >4 cm in size; however, adrenal oncocytomas are large, measuring an average of 8 cm, are round and encapsulated, and normally have a benign behaviour. We present a case of a 55-year-old male patient with dyslipidaemia, medicated with simvastatin. Upon complaints of abdominal pain, the general physician asked for an abdominal ultrasound that revealed an adrenal lesion, further characterized with a computed tomography scan, which showed an adrenal lesion measuring 49 × 64 × 56 mm and a calcification focus. The patient was referred to the general surgery and endocrinology department. The analytical study was negative for pheochromocytoma or Cushing's syndrome, which allowed surgery to be conducted, as is recommended. The aim of this case report is to contribute to the knowledge on adrenal oncocytomas, since there is scarce information based on singular experiences.

Case Report: A Virilizing Adrenal Oncocytoma

A 64-year-old female was admitted to our clinic with a 9-cm-sized adrenal mass. The patient's main symptom was hirsutism, which included thinning scalp hair and excessive hair growth over her torso and arms. Upon investigation, elevated values of testosterone, androsterone D4, and DHEA-S were found. Contrast-enhanced abdominal CT and MRI scans revealed a heterogenous large mass (diameter 9 × 8.5 cm) with focal calcifications, necrotic areas, and a clear distinction from the adjacent structures. The patient underwent a right adrenalectomy. The histological examination of the tumor revealed a borderline adrenocortical oncocytoma. The patient had an uncomplicated postoperative course and was discharged on postoperative day 8. Similar cases reported in the literature are also being reviewed in this case report.

Case Report of a Rare Adrenocortical Oncocytoma Suspected to be an Adrenal Carcinoma

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A case of adrenocortical oncocytic carcinoma arising in ectopic adrenal tissue: a multidisciplinary diagnostic challenge

Adrenocortical oncocytic neoplasm arising in ectopic adrenal tissue is a rare finding and presents as a unique diagnostic challenge. We report a case of a 26-year-old female who presented with vague left-sided abdominal pain and a large left retroperitoneal mass. She underwent exploratory laparotomy and resection of the mass and was diagnosed with extra-adrenal adrenocortical oncocytic carcinoma.

Multidisciplinary collaborative approach for management of adrenal tumors: Outcomes of minimally invasive adrenalectomy at a single center

INTRODUCTION

Laparoscopy is currently the gold standard for the management of adrenal tumors as it is associated with less morbidity. Owing to technological advances, even large adrenal tumors are currently amenable to laparoscopic removal. In this work, we describe our multidisciplinary collaborative approach for management of adrenal tumors at a single center.

MATERIAL AND METHODS

Between January 2017 and January 2020, 18 patients with adrenal lesions were operated at our center. Five of these patients had incidentalomas. All patients were evaluated in coordination with endocrinologists and anesthetists. All patients underwent transperitoneal laparoscopic adrenalectomy. The surgical complications were classified as per Clavein-Dindo system. All patients with pheochromocytoma and Cushing syndrome were followed up by the endocrinologist for further evaluation and titration of glucocorticoids and antihypertensive medication.

RESULTS

Two out of the 18 patients had American Society of Anesthesiologists (ASA) physical status III. Out of the 18 patients, only one required conversion to open surgery. Five patients developed intraoperative hypertensive crisis while three patients developed hypotensive crisis. All patients were ambulated on the first postoperative day and were discharged on the third post operative day. None of the patients developed any major (Clavein-Dindo III-V) intra operative or post operative complications.

CONCLUSION

Laparoscopic adrenalectomy is the procedure of choice for adrenal tumors. A multi-disciplinary approach involving the endocrinologist, anesthesiologist, and laparoscopic surgeon can help achieve favorable outcomes.

Laparoscopic resection of an adrenal oncocytic neoplasm: Report of a case and review of the literature

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Oncocytic adrenal neoplasms are rare and mostly benign lesions.

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Preoperative determination of malignancy remains difficult.

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Surgical excision planification is based on preoperative investigations.

Introduction

Oncocytic adrenal neoplasms are rare and mostly benign lesions. Available literature supports indication for a surgical resection, but criteria to predict aggressive behavior are unreliable, thus making decision of surgical approach (laparotomy versus laparoscopy), and extent of resection, difficult to define.

Presentation of case

This is the case of a 46-year-old male, with an incidental finding of a 10 cm asymptomatic tumor in the left adrenal gland identified by MRI, performed in the setting of the initial assessment of liver steatosis. Adrenal hormone levels were in the normal range, thus, a CT-guided needle biopsy was performed and showed an adrenocortical oncocytic neoplasm. A laparoscopic left adrenalectomy was performed sparing the adjacent left kidney. Histological examination of the resected tumor showed a 10 cm oncocytic adrenocortical neoplasm of uncertain malignant potential with negative resection margins. A follow-up MRI was scheduled at six months after surgery, and no recurrence was found.

Conclusions

Although rare, oncocytic neoplasms should be included in the differential diagnosis of adrenal “incidentalomas”. Determination of their malignant potential is difficult in the preoperatory setting. Final diagnosis is based on histological analysis of the whole surgical specimen. Laparoscopic complete excision with negative resection margins is feasible and safe.

A rare case of oncocytic adrenocortical carcinoma clinically presented as an incidentaloma

Adrenocortical carcinoma (ACC) is a rare aggressive tumor originating from adrenocortical parenchymal cells and its incidence is approximately 1 per million population per year. An oncocytic ACC is a recently identified entity among the several known histopathological variants of ACC, which is characterized by oncocytic cells, and only a few cases in the available literature have reported this tumor. In contrast to conventional ACCs, oncocytic ACCs usually manifest as solitary lesions presenting in adults without any sex predilection. We report a case of a 70-year-old Japanese man who presented with an incidentally discovered retroperitoneal mass without any evidence of excessive corticosteroid secretion. Laboratory and imaging studies, as well as transgastric endoscopic ultrasound-guided fine needle aspiration failed to establish a definitive diagnosis. Thus, the patient underwent surgical resection of the left-sided peritoneal tumor. Weiss score was positive in 6/9 points and the tumor met two major criteria of the Lin-Weiss-Bisceglia (LWB) system leading to a diagnosis of an oncocytic variant of ACC. Based on our findings in this patient, we conclude that a combination of the Weiss and LWB criteria is required to determine the malignant potential of oncocytic adrenal tumors because ACCs and oncocytomas could be frequently indistinguishable. Careful histopathological examination is pivotal in confirming the oncocytic component in the lesion and hence definitive diagnosis of ACCs.

Adrenocortical neoplasm of uncertain malignant potential with a myelolipomatous component

Macroscopic fat inside an adrenal lesion on CT is pathognomonic for myelolipoma, a benign neoplasm. Without macroscopic fat, it can be difficult to discern the nature of an indeterminate adrenal mass on imaging. One possible diagnosis for an indeterminate lesion without macroscopic fat is an adrenal oncocytic neoplasm (AON). Despite its typical benign presentation cases of malignant AON have been reported. Patients with malignant AON are often not surgical candidates and survival for unresected disease is 20%-35%. We present the third report of an AON of uncertain malignant potential (AONUMP) associated with a macroscopic fatty component with the largest reported size and longest duration of follow-up in the literature. This report details diagnostic and therapeutic challenges posed by AONUMP. This case highlights how pathognomonic radiographical findings associated with benign myelolipoma might mask rare, potentially malignant, lipomatous tumours.

Urinary steroid profiling in diagnostic evaluation of an unusual adrenal mass

SUMMARY

Adrenal oncocytomas are rare tumours, with only approximately 160 cases reported in the literature. We report the use of urinary steroid profiling as part of their diagnostic evaluation and prognostication. A 45-year-old woman presented with clinical features of hyperandrogenism. Serum biochemistry confirmed androgen excess and computed tomography (CT) demonstrated a 3.2 cm adrenal tumour with density 39 HU pre-contrast. Urine steroid profiling showed elevated tetrahydro-11 deoxycortisol (THS), which is associated with adrenal malignancy. Laparoscopic adrenalectomy was performed, and histopathology diagnosed adrenal oncocytoma. Serum and urinary biochemistry resolved post-operatively and remained normal at 1-year follow-up.

LEARNING POINTS

Differential diagnosis of adrenal masses is challenging. Current techniques for differentiating between tumour types lack sensitivity and specificity. 24-h urinary steroid profiling is a useful tool for reflecting steroid output from adrenal glands. Gas chromatography-mass spectrometry (GC-MS) of urinary steroid metabolites has sensitivity and specificity of 90% for diagnosing adrenocortical carcinoma. Adrenal oncocytoma are rare tumours. Differentiating between benign and malignant types is difficult. Data guiding prognostication and management are sparse.

Oncocytic subtypes of adrenal cortical carcinoma: Aggressive in appearance yet more indolent in behavior?

BACKGROUND

Adrenal cortical carcinoma is an aggressive malignancy and typically heralds a poor prognosis. The oncocytic subtype of this neoplasm is rare but may be associated with more favorable outcomes.

METHODS

The Provincial Cancer Registry was searched for cases of adrenal cortical carcinoma between 1992 and 2017. Comprehensive chart reviews were performed and data gathered related to presentation, treatment, and outcomes.

RESULTS

In the study, 82 patients with adrenal cortical carcinoma were identified. Complete data were available for 67 patients (82%). In the 41 patients who underwent resection, 9 (22%) had oncocytic subtypes. When compared with the total group of adrenal cortical carcinomas, the oncocytic subtypes were larger at presentation (19.8 cm vs 11.0 cm), more commonly symptomatic and hormonally active, and despite larger tumor size, were often early stage I and II. Recurrent disease was observed in 3 out of 9 oncocytic subtype (vs 23 out of 32 adrenal cortical carcinoma), with greater median time to recurrence (17.5 vs 8 months). Univariate analysis suggested that age, T-stage, M-stage, and overall stage were associated with survival. There was a trend toward improved overall survival for patients with oncocytic subtype on Kaplan-Meier and multivariate analysis.

CONCLUSION

Despite our small numbers of patients with oncocytic subtype, our data suggest that oncocytic subtype are typically larger at presentation but more often early stage and recur less frequently than adrenocortical carcinomas. Modifications to treatment and surveillance strategies may be appropriate in this subtype.

Diagnosis and Treatment of Adrenocortical Oncocytoma: Case Report of Five Cases and Review of the Literature

Objective: To investigate the diagnosis and treatment of adrenocortical oncocytoma, and have a literature of review.

Materials and Methods: The clinical data of 5 cases of adrenocortical oncocytoma treated in our hospital was retrospectively analyzed. The clinical manifestations, imaging examination, endocrine examination, and pathological results were analyzed respectively.

Results: Oncocytic adrenocortical neoplasms are extremely rare. Oncocytic adrenocortical neoplasms are usually discovered incidentally, only the tumors with endocrine function could exhibit specific manifestations. No specific imageological features of oncocytic adrenocortical neoplasms have been found.

Conclusions: The diagnosis of adrenocortical oncocytoma mainly depends on the pathological examination. Surgical resection is the main treatment method.

Laparoscopic Trans-Abdominal Right Adrenalectomy for a Large Primitive Adrenal Oncocytic Carcinoma: A Case Report and Review of Literature

Patient: Male, 48

Final Diagnosis: Adrenal oncocytic carcinoma

Symptoms: Asymptomatic

Medication: —

Clinical Procedure: Transabdominal laparoscopic right adrenalectomy

Specialty: Surgery

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.

Adrenocortical oncocytoma: 11 Case reports and review of the literature

RATIONALE

Adrenocortical oncocytoma is an extremely rare tumor of the adrenal gland. Its diagnostic criteria and biological behavior has not yet reached a consensus. The purpose of this study is to investigate the clinical characteristics of adrenocortical oncocytoma.

PATIENT CONCERNS

The clinical data from 11 cases of adrenocortical oncocytoma were retrospectively analyzed. Five patients found the tumor incidentally during the healthy examination, and 3 cases found the tumor during the diagnostic work-up for the evaluation of flank pain or hypertension. A female patient manifested virilization, and Cushing's syndrome showed in two patients. The tumor diameter was ranging from 2.0-13.0 cm.

DIAGNOSES

The serum cortisol, plasma aldosterone and catecholamine metabolites were used to evaluate the function of the tumors, and enhanced CT scan was used to confirm the tumor boundary, enhancement, and lymph nodes condition.

INTERVENTIONS

Seven cases underwent laparoscopic adrenal tumor resection, 4 patients underwent open surgery. Pathological report indicated adrenocortical oncocytoma in all cases, three of which were potentially malignant.

OUTCOMES

The patients were followed up for 19-72 months, no local recurrence and distant metastases were detected in 3 cases of malignant potential cases.

LESSONS

The majority of adrenocortical oncocytoma with or without function are benign, and close follow-up observation is essential.

Adrenal Oncocytic Neoplasm with Paradoxical Loss of Important Mitochondrial Steroidogenic Protein: The 18 kDA Translocator Protein

The adrenal glands produce a variety of hormones that play a key role in the regulation of blood pressure, electrolyte homeostasis, metabolism, immune system suppression, and the body's physiologic response to stress. Adrenal neoplasms can be asymptomatic or can overproduce certain hormones that lead to different clinical manifestations. Oncocytic adrenal neoplasms are infrequent tumors that arise from cells in the adrenal cortex and display a characteristic increase in the number of cytoplasmic mitochondria. Since the rate-limiting step in steroidogenesis includes the transport of cholesterol across the mitochondrial membranes, in part carried out by the 18-kDa translocator protein (TSPO), we assessed the expression of TSPO in a case of adrenal oncocytic neoplasm using residual adrenal gland of the patient as internal control. We observed a significant loss of TSPO immunofluorescence expression in the adrenal oncocytic tumor cells when compared to adjacent normal adrenal tissue. We further confirmed this finding by employing Western blot analysis to semiquantify TSPO expression in tumor and normal adrenal cells. Our findings could suggest a potential role of TSPO in the tumorigenesis of this case of adrenocortical oncocytic neoplasm.

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.

Update on Adrenal Tumours in 2017 World Health Organization (WHO) of Endocrine Tumours

The fourth edition of the World Health Organization (WHO) classification of endocrine tumours contains substantial new findings for the adrenal tumours. The tumours are presented in two chapters labelled as "Tumours of the adrenal cortex" and "Tumours of the adrenal medulla and extra-adrenal paraganglia." Tumours of the adrenal cortex are classified as cortical carcinoma, cortical adenoma, sex cord stromal tumours, adenomatoid tumour, mesenchymal and stromal tumours (myelolipoma and schwannoma), haematological tumours, and secondary tumours. Amongst them, schwannoma and haematological tumours are newly documented. The major updates in adrenal cortical lesions are noted in the genetics of the cortical carcinoma and cortical adenoma based on the data from The Cancer Genome Atlas (TCGA). Also, a system for differentiation of oncocytoma from oncocytic cortical carcinoma is adopted. Tumours of the adrenal medulla and extra-adrenal paraganglia comprise pheochromocytoma, paraganglioma (head and neck paraganglioma and sympathetic paraganglioma), neuroblastic tumours (neuroblastoma, nodular ganglioneuroblastoma, intermixed ganglioneuroblastoma, and ganglioneuroma), composite pheochromocytoma, and composite paraganglioma. In this group, neuroblastic tumours are newly included in the classification. The clinical features, histology, associated pathologies, genetics, and predictive factors of pheochromocytoma and paraganglioma are the main changes introduced in this chapter of WHO classification of endocrine tumours. The term "metastatic pheochromocytoma/paraganglioma" is used to replace "malignant pheochromocytoma/paraganglioma." Also, composite pheochromocytoma and composite paraganglioma are now documented in separate sections instead of one. Overall, the new classification incorporated new data on pathology, clinical behaviour, and genetics of the adrenal tumours that are important for current management of patients with these tumours.

Malignant renal schwannoma in a cat

A nine-year-old male European shorthair cat with rapidly enlarging mass at the left kidney doubted to be malignant was presented. The purpose of this study is to present the clinical, radiological and pathological findings of a primary renal tumor in the cat. Grossly, the mass mostly encapsulated the kidney. Histologically, excisional biopsy showed worrying histological features. A sarcoma-like tumor composed mainly of neoplastic spindle-shaped cells. Neoplastic nodules of aggregations of fusiform cells arranged in multidirectional bundles. Immunohistochemically, several immunohistochemical satins (melan-A, S-100, vimentin, actin, desmin, cytokeratin, neurofilament, melan-A, NSE, synaptophysin, chromogranin, Glial Fibrillary Acidic Protein GFAP, Collagen IV and CD99) were used to differentially diagnose the mass. The stained neoplastic sections positively tested to S-100, but negative to the other aforementioned immunohistochemical stains. Immunohistochemistry with S-100 antibody staining showed an unusually strong positive reaction throughout the tumor cells. Based on our comparative diagnosis relative to other tumors, in addition to the progressive clinical signs, histopathological and immunohistochemical results, this case was presumptively diagnosis as a malignant schwannoma. According to our investigation of the relevant literature, this study of malignant renal Schwannoma (malignant peripheral nerve sheath tumor) is a highly rare case not previously characterized in a cat.

Adrenal Mass: Unusual Presentation and Outcome

Aim:

Adrenal mass may be functioning or nonfunctioning with varied clinical presentations. This study aimed to report the nature and management of uncommon adrenal mass and to review literature.

Materials and Methods:

This was an retrospective observational analysis of children with uncommon adrenal mass admitted during 2009–2015. Clinical features, investigations, and management of patients were analyzed.

Results:

Among six, two each were adolescent and neonate, and one each was young infant and prenatal. Clinical presentation was variable; hypertensive retinopathy,[1] virilization[1] and bleeding diathesis,[1] antenatal suprarenal mass,[1] prenatal adrenal angiolipoma,[1] and spontaneous resolution of Stage III suprarenal mass.[1] Ultrasound and contrast-enhanced computed tomography revealed well-defined, heterogeneous adrenal mass. Size varied from 2 to 15 cm. Urinary metanephrine and serum testosterone were raised in adolescent hypertensive boys and virilized girls, respectively. Laparoscopy-assisted adrenalectomy was done in two and other four were managed conservatively. Histopathology of tumor revealed pheochromocytoma and borderline oncocytoma. Spontaneous resolution of adrenal mass had varied etiology; adrenal hemorrhagic lesion,[1] simple cyst,[1] neuroblastoma.[1] Follow-up varied from 3 months to 2 years. All patients were asymptomatic on last follow-up.

Conclusion:

Close clinical follow-up, contrast-enhanced tomography, and limited/specific endocrine work-up have definite role in the management of uncommon adrenal mass.

Adrenal Tumors in Adults

Although most adrenal tumors are not diagnostic dilemmas, there are cases that are challenging. This may be due to the tissue provided, for example fragmented tissue received in the setting of morcellation, or it may be due to inherently challenging histology, such as in cases with equivocal features of malignancy. Additionally, much has been learned about the molecular alterations of adrenal tumors, especially pheochromocytomas. Many of these alterations represent germline mutations with significant clinical implications for patients and their families. The aim of this review is to provide an overview of the most common adrenal tumors in adults so that pathologists can tackle these interesting tumors.

Plurihormonal Cosecretion by a Case of Adrenocortical Oncocytic Neoplasm

Adrenocortical oncocytic neoplasms (oncocytomas) are extremely rare; only approximately 159 cases have been described so far. The majority are nonfunctional and benign. We describe an unusual case of a functional oncocytoma secreting an excess of glucocorticoids (cortisol) and androgens (androstenedione and DHEAS), a pattern of plurihormonal cosecretion previously not reported in men, presenting with endocrine manifestations of Cushing's syndrome. The neoplasm was considered to be of uncertain malignant potential (borderline) according to the Lin-Weiss-Bisceglia criteria.

Voluminous Incidental Oncocytic Neoplasm of the Adrenal Gland With Uncertain Malignant Potential

A 74-year-old man presented with right flank pain and a palpable mass in the left flank. Blood pressure was normal. Contrastenhanced computed tomography (CT) showed a 17 × 16 × 12 cm retroperitoneal mass over the left kidney, solid and heterogeneous. There were also 3 retro aortic lymph nodes and bilateral renal lithiasis. Twenty four-hour urinary metanephrines and normetanephrines were normal. The patient underwent a resection of the mass with left adrenalectomy by a lumbar incision. Histological findings revealed an adrenal oncocytic neoplasm (AON) with uncertain malignant potential. Six months after surgery, CT control showed neither local nor distant recurrence.

A Case of Oncocytic Adrenocortical Neoplasm of Borderline (Uncertain) Malignant Potential

Oncocytic neoplasms are tumors composed predominantly or exclusively of oncocytes (large polygonal cells with granular eosinophilic cytoplasm due to abnormal mitochondrial accumulation). These tumors are frequently reported in the thyroid, kidneys, and salivary glands. However, they are distinctly rare in the adrenal cortex. Oncocytic adrenocortical neoplasms (OAN) are classified regarding their biological behavior by their histological features according to the Lin-Weiss-Bisceglia system (LWB). Here, we report a case of OAN of borderline or uncertain malignant potential (BMP) with subsequently identified papillary thyroid carcinoma (PTC). A 34-year-old female with a nine-month history of fatigue presented with chest pain. A right adrenal mass was incidentally found while ruling out pulmonary embolism. A CT-guided adrenal biopsy, although not routinely indicated, was performed and interpreted as malignant with no definitive origin. Hormonal workup was unremarkable. PET-scan showed hypermetabolic adrenal mass with peak standardized uptake value of 15, suspicious of malignancy. A hypermetabolic thyroid nodule was also identified, but there was no evidence of metastatic disease. The patient underwent adrenalectomy, and the initial pathology report was interpreted as atypical pink cell tumor. A second pathology report from another laboratory favored OAN based on the morphology and immunohistochemical staining. While the histologic criteria of malignancy were not met, the large tumor size makes it compatible with BMP according to LWB criteria. A follow-up thyroid ultrasound revealed a complex thyroid nodule. A total thyroidectomy was performed, and pathology was consistent with PTC. Of interest, PTC frequently shows an increase in mitochondrial content, which is characteristic of oncocytic tumors. This case illustrates that OAN, although rare, should be considered in the differential diagnosis of adrenal masses. When OAN is identified, it should be classified regarding its biological behavior as benign or malignant using the LWB system and, eventually, the reticulin algorithm of Duregon, et al. Oncocytoma can be confirmed ultrastructurally or by immunohistochemistry. Studying the gene mutations in patients presenting with oncocytic malignancies and other tumors that demonstrate mitochondrial proliferation as PTC might help to understand the role of mitochondrial proliferation in cancer development.

A Rare Case of Functioning Adrenocortical Oncocytoma Presenting as Cushing Syndrome

Functioning adrenocortical oncocytoma is very rare neoplasm. It is usually nonfunctional and benign and incidentally detected. Generally, these tumors originate in the kidneys, thyroid, parathyroid, and salivary or pituitary glands; they have also been reported in other sites including choroid plexus, respiratory tract, and larynx. Histologically, they are characterized by cells with eosinophilic granular cytoplasm and numerous packed mitochondria. We reported a case of a 44-year-old female who presented with Cushing syndrome for hypersecretion of cortisol due to adrenocortical oncocytoma. Magnetic resonance of abdomen revealed a right adrenal mass. Laparoscopic adrenalectomy was performed and the tumor was pathologically confirmed as benign adrenocortical oncocytoma. After surgical treatment, Cushing's syndrome resolved.

Adrenal oncoctyoma of uncertain malignant potential: a rare etiology of adrenal incidentaloma

A rare cause for rapid adrenal enlargement is adrenal oncocytoma of uncertain malignant potential. A full biochemical evaluation is warranted to screen secreting adrenal adenomas as well as to evaluate adrenal cortical carcinoma. Careful pathologic evaluation is required as the diagnosis of AOC cannot be made by imaging.

Oncocytic Adrenocortical Neoplasm Diagnosed after Robot-Assisted Adrenalectomy

Oncocytic tumors, composed of eosinophilic, mitochondria-rich cells, can occur in several locations throughout the body. These tumors can occur in the adrenal cortex and are rarely malignant. We report a case of a patient presenting with an incidental adrenal mass which was later diagnosed as a oncocytic adrenocortical neoplasm (OAN). The patient is a 53-year-old man found to have a 7.2 cm right adrenal mass, incidentally found by computed tomography (CT). After metabolic workup was negative, a right robotic adrenalectomy (RA) was performed. Pathologic analysis revealed clusters of large cells with abundant eosinophilic and granular cytoplasm, consistent with OAN. This pathology is rare, with only about 150 cases described in the literature. It occurs in females 2.5 times more frequently and more commonly on the left side. Diagnosis is usually made by imaging criteria, typically with CT or magnetic resonance imaging (MRI). Treatment is generally surgical, since OAN can be malignant in some cases. Differentiation between benign and malignant OAN is done based on the Lin-Weiss-Bisceglia criteria and can be difficult. If malignancy is diagnosed, recurrence is common and close surveillance should be performed.

Imaging Features of Various Adrenal Neoplastic Lesions on Radiologic and Nuclear Medicine Imaging

OBJECTIVE

The purpose of this review is to describe the features of diverse adrenal neoplastic lesions on radiologic and nuclear medicine imaging.

CONCLUSION

Various neoplastic lesions with or without malignant potential can occur in the adrenal gland. Knowledge of imaging features of adrenal lesions on radiologic and nuclear medicine imaging will facilitate differential diagnosis and assessment of malignant potential.