Adrenal myelolipoma within myxoid cortical adenoma associated with Conn's syndrome

Functional Adrenal Collision Tumor in a Patient with Cushing's Syndrome

Adrenal collision tumors are rare and produce unique diagnostic challenges for clinicians. We report the case of a 45-year-old woman with obesity and diabetes mellitus and an incidentally-discovered adrenal mass containing macroscopic fat, thought to be a myelolipoma. A functional workup confirmed adrenocorticotropic hormone- (ACTH-) independent Cushing's syndrome. The patient underwent a successful laparoscopic adrenalectomy with pathology showing an adrenal collision tumor consisting of an adrenocortical adenoma and a myelolipoma. Postoperatively, the clinical symptoms, body mass index, and hemoglobin A1C all improved. Clinicians should consider a functional workup in patients with radiographically diagnosed myelolipomas as some may prove to be hormonally active collision tumors.

Pseudoglandular myxoid adrenocortical adenoma with positive epithelial markers: a case report and review of the literature

Myxoid adrenal cortical adenoma with a pseudoglandular structure is a special histological variant and is extremely rare. We report about a 32-year-old Chinese woman with a right adrenal mass during a routine physical examination. The cut surface of the mass had a vague nodular, which gross appearance was pale, yellowish, and semitransparent. Histologically, the region is mostly characterised by pseudoglandular pattern with myxoid stroma. They are filled with clear cells or eosinophilic cells, as well as semitransparent regions, in which anastomosing small eosinophilic cells arranged in pseudoglandular, cord-like, or wreath-shaped structure float in the mucous pool. Immunohistochemical staining shows Melan-A, vimentin, and CD56 were positive and CK (AE1/AE3) were nucleus-side staining. A small number of tumor cells were positive for alpha-inhibin and synaptophysin, ki-67 labeling index was 3%. EMA, chromogranin A, WT-1, and P63 were negative. This report aimed to emphasize pseudoglandular patterns with mucus secretion which could occur in adenomas of the adrenal cortex, nucleus-side positive for CK is remarkable. However, this type may have malignant potential, so regular follow-up is needed.

Adrenal myelolipoma: a comprehensive review

INTRODUCTION

Adrenal myelolipoma is an invariably benign neoplasm of the adrenal gland that is the second most common primary adrenal incidentaloma following adrenocortical adenomas. It is composed of elements of adipose tissue and extramedullary hematopoiesis. Hypotheses on stem cells and hormonal factors have been formulated regarding its pathogenesis that is still obscure. Despite its benign behavior, adrenal myelolipoma is clinically relevant as it might cause significant difficulties in the differential diagnosis of adrenal tumors.

METHODS

We have reviewed 420 cases reported between 1957 and 2017 on adrenal myelolipoma retrieved from PubMed and Scopus databases and also 20 of our case series to provide a comprehensive analysis of their pathology, epidemiological and clinical features.

RESULTS AND CONCLUSIONS

The average age for its diagnosis was 51 years, and no gender difference was observed. The average size of tumors was 10.2 cm. Congenital adrenal hyperplasia was associated to 10% of all cases analyzed, while other adrenal hypersecretory disorders (cortisol, aldosterone) were found in 7.5% of cases. Computed tomography and magnetic resonance imaging can be reliably used for its differential diagnosis. If the diagnosis of an adrenal myelolipoma is unambiguous, and no associated symptoms or hormonal activity are established, surgical intervention is usually not necessary.

Myxoid adrenocortical adenoma with a pseudoglandular pattern: a case report and literature review

Adrenocortical adenoma is a benign neoplasm derived from cells of the adrenal cortex. The myxoid variant of this tumor is extremely rare. To our knowledge, only 23 cases of myxoid adrenocortical adenoma have been reported so far and 19 of them mentioned the pseudoglandular pattern. We reported a new case of 56-year-old Chinese female patient whose left adrenal gland was shown a neoplastic lesion by computed tomography (CT) and magnetic resonance (MR) imaging. Histopathological study showed that the mass was a myxoid adrenocortical adenoma with a pseudoglandular pattern. Then, we performed immunohistochemistry with 28 biomarkers to make differential diagnosis and found that tumor cells were diffusely positive for vimentin, melan-A, CD56, NSE and USP10, and focally positive for cytokeratin pan, cytokeratin 8/18 and VEGF. The labeling index of Ki-67 and Cyclin D1 were about 1% and 50%, respectively. No immunoreactivity was found for EMA, cytokeratin 7, HMB45, S-100, alpha-inhibin, calretinin, synaptophysin, chromogranin A, P53, EGFR, MMP2, DNA topo II alpha, CA125, E-cadherin, P63, P16 and Her-2. The patient has been followed up for 37 months after tumor resection and no evidence was found to suggest any local recurrence or any metastatic disease. Myxoid adrenocortical adenoma with a pseudoglandular pattern is extremely rare. The accurate diagnosis should be based on combined consideration of clinical characteristics, CT, MR imaging and pathological features, and should be distinguished from other retroperitoneal myxoid tumors.

Lipomatous tumours in adrenal gland: WHO updates and clinical implications

Adrenal lipomatous tumour is a group of adrenal tumours with a significant component of adipose tissue. According to the current World Health Organization (WHO) classification of tumours of endocrine organs, adrenal myelolipoma is the only entity amongst the group of tumours being described. In the literature, other more recently documented adrenal lipomatous tumours included 24 lipomas, 32 teratomas and 16 angiomyolipomas. Rare fatty tumours of the adrenal gland comprised liposarcoma, hibernoma, adrenocortical tumours with fat component and rare adrenal tumours with fat component. Myelolipoma comprises approximately 3% of primary adrenal tumour. It is noted more commonly in females and in the right adrenal gland. Approximately 40 bilateral myelolipomas were reported. The tumour is most frequently recorded in patients between fifth and seventh decades of life. Adrenal lipomas are often seen in males and in the right adrenal gland. They were commonly noted in patients in the sixth decade of life. The diagnosis could only be possible on examination of the surgically removed specimen. Adrenal teratomas were more common in females and with a bimodal age distribution. Slightly over 60% of the patients with adrenal teratoma are symptomatic. Adrenal angiomyolipomas were often symptomatic, more common in females and in the fifth decades of life. To conclude, adrenal lipomatous tumour is uncommon. They are often benign and non-functional. It is important to recognize the features of this group of lipomatous tumours in the adrenal gland as they are being detected on increasing incidence as a result of the wide-spread use of modern imaging modalities.

Adrenal myelolipoma: a mingle of progenitor cells?

Adrenal myelolipoma (AML) is a rare benign tumour composed or mature haematopoietic tissue and fat. The tumour is functionally inert and is usually detected incidentally. Mainly introduced in case reports, the tumourigenesis of AML is poorly understood with 3 historical hypotheses seemingly unrelated to each other. Here we propose the tumourigenic pathway based on the novel findings on stem/progenitor cell and our preliminary data. We hypothesize the tumourigenesis as follows: the fat components are derived by the mesenchymal stem cells of stromal fat of adrenal cortex under certain stimuli. Mature adipocytes begin to accumulate and become inflammatory stimulating neighbouring adrenal cortex tissue to release possibly G-CSF to recruit circulating haematopoietic progenitors. During the tumour growth, haematopoietic cell in the central part acquire energy from burning the surrounding fat until they are fully differentiated and division stops. Lacking the ability to further grow, the central part undergoes necrosis and calcification whilst the peripheral part continues to slowly pile up newly derived adipocytes and haematopoietic progenitor cells. The necrosis or calcification of the tumour the inflammation persists and the tumour generates a self-growing signalling loop, entailing a continuous growth even without further stimuli. Our theory offers a logical explanation to the diverse phenomena identified on AML and unifies the historical theories. Future studies may focus on the stem/progenitor cell profiles of AML to confirm and supplement our hypothesis.

Novel report of an adrenal adenoma in a newborn

An adrenal mass in a newborn usually suggests a diagnosis of neuroblastoma or hemorrhage. A 6-week-old girl was referred for evaluation of a left adrenal mass. The initial findings were most consistent with an adrenal hemorrhage. On surveillance imaging, the lesion was characterized as a complex cystic mass. The patient subsequently developed lesions in the right adrenal gland and liver as well as multiple cutaneous lesions. Although the contralateral adrenal and hepatic lesions resolved spontaneously, the left adrenal and cutaneous lesions persisted. Subsequent imaging revealed that the mural components of the left adrenal mass had increased in size, and at age 13 months, a laparoscopic left adrenalectomy was performed. A benign adrenal adenoma with myxoid changes was reported on surgical pathology. This is the first reported case in a newborn.

Adrenocortical neoplasia: evolving concepts in tumorigenesis with an emphasis on adrenal cortical carcinoma variants

Adrenocortical carcinoma (ACC) is a rare, heterogeneous malignancy with a poor prognosis. According to WHO classification 2004, ACC variants include oncocytic ACCs, myxoid ACCs and ACCs with sarcomatous areas. Herein, we provide a comprehensive review of these rare subtypes of adrenocortical malignancy and emphasize their clinicopathological features with the aim of elucidating aspects of diagnostic categorization, differential diagnostics and biological behavior. The issue of current terminology, applied to biphasic tumors with pleomorphic, sarcomatous or sarcomatoid elements arising in adrenal cortex, is also discussed. We additionally present emerging evidence concerning the adrenal cortical tumorigenesis and the putative adenoma-carcinoma sequence as well.

Primary adrenal angiosarcoma and functioning adrenocortical adenoma: an exceptional combined tumor

CONTEXT

Primary adrenal angiosarcoma is an extremely rare neoplasm, as are combined tumors within a given adrenal lesion.

CLINICAL PRESENTATION AND INTERVENTION

A 35-year-old man presented with hypokalemic hypertension leading to the discovery of a 6 cm diameter malignant-appearing right adrenal tumor. The lesion displayed marked (18)F-fluorodeoxyglucose uptake on positron emission tomography scanning. Endocrine investigations revealed secretion of both cortisol and aldosterone by the neoplasm. The entire right adrenal gland along with the periadrenal fat tissue was removed during laparoscopic surgery.

RESULTS

Histological examination revealed two intermingled tumor cell proliferations, namely an angiosarcoma and an adrenocortical adenoma. An extensive post-operative search revealed no other primary tumor site, nor metastases. The lesion was then considered to be a primary adrenal angiosarcoma combined with a secreting adrenocortical adenoma. The patient received four cycles of chemotherapy (adriamycin/ifosfamide). At 2-year follow-up, he is alive and well, with no sign of relapse.

CONCLUSION

To the best of our knowledge, this is the first case of an adrenal neoplasm combining a primary angiosarcoma and a functioning adrenocortical adenoma.

Adrenocortical tumors with myxoid features: a distinct morphologic and phenotypical variant exhibiting malignant behavior

Myxoid changes have been rarely reported both in adrenocortical adenomas and carcinomas. The recent observation by our group of an adrenal myxoid tumor with morphologically borderline features, but aggressive clinical behavior prompted us to review a series of 196 adrenocortical lesions, comprising 122 carcinomas and 74 adenomas, to define the morphologic, phenotypical and clinical characteristics of adrenocortical tumors with myxoid features. Fourteen cases, including 12 carcinomas and 2 borderline tumors, formed the basis of this report, and were characterized by a variably abundant myxoid component (from 5% to 90% of tumor) and 2 distinct cellular growth patterns: the first (10 cases), mostly associated with a predominant myxoid stromal component, was made of small cells with mild atypia arranged in cords and microcysts; the second (4 cases) was characterized by focal myxoid changes in tumors otherwise similar to conventional adrenocortical carcinoma, with large atypical cells having an eosinophilic cytoplasm and a diffuse or nodular architecture. The above mentioned patterns were absent in all adenomas reviewed. A peculiar reactivity to neurofilaments was seen, mostly associated to the presence of predominant rather that focal myxoid stromal changes, and in 40% of conventional adrenocortical carcinomas, thus representing an undescribed potential pitfall in the differential diagnosis of adrenal lesions. Myxoid adrenocortical tumors probably represent a rare but histologically and phenotipically distinct entity and, although rare cases of benign lesions are on record, they seem to be generally associated to morphologic and clinical features of malignancy.

Adrenal mass imaging with multidetector CT: pathologic conditions, pearls, and pitfalls

The adrenal gland is involved by a range of neoplasms, including primary and metastatic malignant tumors; however, the most common tumor detected is the incidental benign adenoma. Although computed tomographic (CT) findings will not always yield a definitive diagnosis, attention to these findings provides a road map to guide image interpretation. Adenomas typically demonstrate rapid washout, which is defined as an absolute percentage washout (APW) of more than 60% and a relative percentage washout (RPW) of more than 40% on delayed images. Adrenocortical carcinoma typically has an RPW of less than 40%; however, large size and heterogeneity are more reliable indicators of the diagnosis than are washout values. Washout characteristics of pheochromocytoma are variable; in conjunction with high levels of dynamic enhancement, pheochromocytomas may mimic adenoma (ie, APW > 60%, RPW > 40%). Myelolipomas appear as well-defined masses with variable quantities of fat and soft tissue. After contrast material administration, metastases usually demonstrate slower washout on delayed images (APW < 60%, RPW < 40%) than do adenomas, although hypervascular metastases may enhance similarly to pheochromocytoma. Finally, a number of nonadrenal pathologic conditions have been reported to mimic adrenal masses at CT.