Adrenocortical carcinomas: an ultrastructural study of 22 cases

Melan A (A103) is expressed in adrenocortical neoplasms but not in renal cell and hepatocellular carcinomas

Most adrenocortical neoplasms, renal cell carcinomas, and hepatocellular carcinomas are diagnosed by a combination of clinical and morphologic features. However, occasionally this histologic differential diagnosis requires additional ancillary tests, such as immunohistochemistry. The authors investigated the potential value of A103 in the differential diagnosis of these tumors. Thirty-two adrenocortical neoplasms, 86 renal cell carcinomas, and 57 hepatocellular carcinomas were evaluated by immunohistochemistry using a monoclonal antibody A103 and a standard ABC method. The adrenocortical neoplasms were 21 adenomas and 11 carcinomas. Thirty-one of the 32 adrenocortical neoplasms showed strong and diffuse granular cytoplasmic staining for Melan A. No nuclear reaction was observed. There were no differences in staining patterns between adrenocortical adenomas and carcinomas. With the exception of one clear cell renal cell carcinoma, all non-adrenocortical neoplasms were negative. The authors conclude that A103 is a useful addition to the immunohistochemical panel in the differential diagnosis of adrenocortical neoplasms from both renal cell and hepatocellular carcinomas. This marker, however, does not separate benign from malignant adrenocortical neoplasms.

Glycogen-rich mesothelioma

A glycogen-rich epithelial mesothelioma is described. This variant is uncommon, but important to recognize since it is readily confused on routine light microscopy with other clear cell tumors involving the pleura. Ultrastructural and immunohistochemical studies can be helpful in establishing the correct diagnosis. Significant recent advances in the immunohistochemistry of epithelial mesothelioma are briefly reviewed.

Pulmonary clear cell carcinoid tumor: another entity in the differential diagnosis of pulmonary clear cell neoplasia

A clear cell variant of primary pulmonary carcinoid tumor is described. The tumor arose in a 53-year-old woman who was incidentally found to have a solitary pulmonary nodule in the left upper lobe during routine chest roentgenography. Histologically, the tumor was composed of predominantly clear to lightly eosinophilic, polygonal cells with bland nuclei arranged in sheets and nests. Nuclear pleomorphism, necrosis, vascular invasion, and mitotic figures were not seen. The tumor cells were negative for oil-red-O and periodic acid-Schiff stains with and without diastase pretreatment on frozen and formalin-fixed sections, respectively. During immunohistochemical evaluation, the tumor cells were focally positive for cytokeratin and diffusely positive for neuron-specific enolase and chromogranin. Electron microscopy performed on paraffin block-retrieved tissue showed the presence of electron-dense, neurosecretory-type granules and variably sized vacuolated areas within the cytoplasm. the nature of which remained unclear. Intracytoplasmic glycogen or lipid were not identified. To our knowledge, this is the first report of pulmonary clear cell carcinoid tumor.

Immunoreactivity for A103, an antibody to melan-A (Mart-1), in adrenocortical and other steroid tumors

The Melan-A (MART-1) gene encodes an antigen recognized by cytotoxic T cells. It has been said to be restricted in its expression to melanocytes. However, here we report the presence of immunoreactivity for A103, an antibody to Melan-A, in five adrenocortical adenomas, 16 primary and 13 metastatic adrenocortical carcinomas, four Leydig cell tumors of the testis, and three Sertoli-Leydig cell tumors of the ovary. To evaluate the potential diagnostic role of this antibody, we studied immunoreactivity for A103 in 111 carcinomas, 40 germ cell tumors, and 33 miscellaneous nonmelanocytic epithelioid tumors. All of them were negative for A103. Our findings suggest that once melanoma is excluded, A103 can aid in the recognition of steroid hormone-producing tumors and may be particularly useful in the diagnosis of adrenocortical carcinoma. The presence of immunoreactivity for A103 practically excludes any other carcinoma that may enter into the differential diagnosis of adrenocortical tumors.

Clear cell mesothelioma

A clear cell form of epithelial mesothelioma is described. This variant does not appear to have been previously described, and it merits recognition since it is readily confused by routine light microscopy with other tumors that involve the pleura, including metastatic carcinomas composed predominantly of cells with optically clear cytoplasm. Ultrastructural and immunohistochemical studies were helpful in reaching the diagnosis in this case, and electron microscopy is particularly recommended to investigate the differential diagnosis of unusual pleural tumors.

The Italian Registry for Adrenal Cortical Carcinoma: analysis of a multiinstitutional series of 129 patients. The ACC Italian Registry Study Group

BACKGROUND

Adrenal cortical carcinoma is an uncommon tumor with a poor prognosis. The low incidence of this tumor makes it difficult to achieve reliable data on clinical manifestations, natural history, and the impact of therapies. The purpose of this study was to evaluate such aspects in a large series.

METHODS

A retrospective series of 129 cases (55 men and 74 women, mean age of 49 years) was collected from 18 surgical institutions. At the time of diagnosis 45.7% of patients had endocrine symptoms. One hundred twenty-four patients underwent surgery, which was considered curative in 91 cases and palliative in 33. Sixty-three patients had local disease, 48 had regional disease, and 43 had distant metastases.

RESULTS

This study confirmed a higher incidence in the 40- to 50-year-old population with a female prevalence; hormonal hyperincretion was more common in women, but it was not caused by advanced disease. The overall 5-year survival rate was 35%. Tumor stage and curative resection affected prognosis significantly. The influence of gender, side, age, and hormonal function has not been confirmed. Adjuvant therapies were ineffective in prolonging survival. Reoperated patients experienced better survival (mean, 41.5 months) than nonreoperated cases (mean, 15.6 months).

CONCLUSIONS

The poor prognosis of adrenal cortical carcinoma may be improved by early diagnosis and complete resection. Radical surgery is the sole effective therapy, particularly in early stages. Surgical treatment of recurrence seems to improve survival and should be attempted systematically. Adjuvant therapies obtained contrasting results, and their role should be evaluated in prospective multicentric trials.

Transcription factor adrenal 4 binding protein as a marker of adrenocortical malignancy

Adrenal 4 binding protein (Ad4BP) is a transcription factor that regulates the expression of the steroidogenic enzymes and is expressed primarily in steroidogenic cells. We immunolocalized Ad4BP in adrenocortical carcinoma (eight cases) and various malignancies that histologically simulate an adrenocortical carcinoma to evaluate the value of Ad4BP as an immunohistochemical marker of adrenocortical carcinoma. These malignancies examined were renal cell carcinoma (20 cases), hepatocellular carcinoma (10 cases), malignant melanoma (eight cases), ovarian (six cases) and uterine (three cases) clear cell carcinoma, large cell carcinoma of the lung (five cases), and pheochromocytoma (three cases). Nuclear Ad4BP immunoreactivity was observed only in adrenocortical carcinoma cases but not in other tumors examined. Almost all of the adrenocortical carcinoma cells were immunohistochemically positive for Ad4BP including cells associated with bizarre nuclei. These results show that application of Ad4BP immunostain can contribute greatly to the differential diagnosis of adrenocortical carcinoma.

Ultrastructure of adrenal cortical carcinoma

The ultrastructural features of 30 adrenal cortical carcinomas have been reviewed and compared with those seen in adrenal cortical adenomas, adrenal cortical hyperplasia, and the normal cortex. A broad range of ultrastructural appearances was found among the carcinomas, but the differences were mainly in the amount of cytoplasmic lipid, number of lysosomes, and quantity and architecture of the mitochondria and endoplasmic reticulum. Structural variants among the carcinomas included lipid-rich, oncocytic, and glycogen-rich cells. Electron microscopy can be extremely useful in differential diagnoses that include adrenal cortical carcinoma.

Adrenocortical oncocytoma: case report with immunocytochemical and ultrastructural study

An adrenocortical oncocytic neoplasm was detected incidentally in a 58-year-old man. The tumour weighted 315 g, showing haemorrhagic areas and broad fibrous bands. It was composed exclusively of large eosinophilic cells packed with mitochondria showing flat and infrequent tubulovesicular cristae and regression of steroid-related organelles. Occasional annulate lamellae and mitochondrial osmiophilic inclusions were present. Vimentin was diffusely expressed, whereas AE1/AE3 cytokeratin was detected in half of the cells; a focal punctate pattern of staining was exclusively observed for cytokeratin peptides 8 and 18. The patient had no evidence of disease 21 months after surgery.

Oncocytic adrenal cortical carcinoma

A case of adrenal cortical carcinoma composed of mitochondria-rich cells is reported. The cells contained condensed zones and loose whorls of smooth endoplasmic reticulum. Crystalline matrical inclusions were present in some of the mitochondria, whereas others contained round, homogeneous, dense matrical inclusions. Flow cytometry revealed a hyperdiploid stem line with a DNA index of 1.3.

Adrenal cortical carcinoma

The records of 110 patients (58 females and 52 males) with histologically proven adrenal cortical carcinoma were studied. Fifty-six of 110 (50.9%) patients had abdominal symptoms and 33 (30.0%) had a palpable abdominal mass. Surgery for localized and regional disease was associated with a disease-free survival time of at least 2 years in 28 of the 50 (56%) patients. Abdominal radiotherapy, systemic chemotherapy, and 1,1 dichloro-2 (O-chlorophenyl)-2 (P-chlorophenyl) ethane (OPDDD) were effective in three of 19 (15.8%) patients, three of 31 (9.7%) patients, and 21 of 72 (29.2%) patients, respectively. Combined radiotherapy and OPDDD did not confer any additional benefit over OPDDD alone. Six of seven patients who received OPDDD as adjuvant treatment are still alive at 1 to 4 years. Distant metastases occurred most commonly in the lungs, liver, peritoneum, lymph nodes, and bones. Only 23% of the patients survived 5 years or more. We conclude that early diagnosis and complete surgical excision offer the best prospects for long-term survival and that the efficacy of adjuvant OPDDD needs to be evaluated further.

Inappropriate ACTH concentrations in two patients with functioning adrenocortical carcinoma

Two female patients with functioning adrenocortical carcinomas had plasma ACTH detectable by RIA at presentation. In both patients there was evidence for biological activity of ACTH. There was no evidence for an ectopic source of ACTH, nor for a pituitary tumour. Urinary steroid analysis showed patterns of multiple hormone secretion characteristic of adrenocortical carcinomas. The finding of detectable ACTH concentrations in a patient with Cushing's syndrome does not exclude the presence of an adrenocortical tumour.

Ectopic anterior pituitary corticotropic tumour in a six-year-old boy. Histological, ultrastructural and immunocytochemical study

The report documents a silent, oncocytic, ACTH-producing ectopic anterior pituitary tumour in a 6-year-old boy. The invasive intrahemispheric neoplasm had no connection with the pituitary gland, the sella turcica or the sphenoid sinuses. The apparent similarities existing between this tumour, some choroid plexus carcinomas and steroid-producing neoplasms are discussed.

The ultrastructure and immunocytochemistry of renal cell carcinoma

The spectrum of ultrastructural features of a series of primary renal cell adenocarcinomas, including clear cell, granular, oncocytic, and sarcomatoid types, and a group of metastatic renal cell adeno-carcinomas has been studied. The contributions of electron microscopy and immunocytochemistry as adjuncts to light microscopy and histochemistry in the differential diagnosis of metastatic renal cell adenocarcinoma in various anatomic locations are reviewed.

Juxtadrenal schwannoma: verification of the diagnosis by immunohistochemical and ultrastructural studies

Solitary schwannomas arising in the juxtadrenal region are exceedingly rare. A middle-aged woman with a confusing clinical course was found to have a solid periadrenal mass, which was surgically excised. The gross and light microscopic appearance of the tumor was suggestive but not diagnostic of this entity. However, electron microscopic evaluation of the neoplasm revealed prominent basal lamina and interdigitating cellular processes characteristic of a schwannoma. The diagnosis of schwannoma was further supported by the demonstration of S-100 protein, type IV (basement membrane) collagen, and laminin immunoreactivity by immunohistochemical techniques. The use of these special studies to arrive at the diagnosis in this case and in the larger context in the diagnosis of rare adrenal and periadrenal tumors of uncertain origin is fully discussed.

Histopathology of the human adrenal cortex

The morphological features of the adult human adrenal cortex are described with particular respect to changes induced by alterations in function of the hypothalamo-pituitary axis. The occurrence of nodules in the normal and hyperplastic cortex (Cushing's and Conn's syndromes) is discussed in relation to the diagnostic problems that they still pose. Explanations based on the normal mechanisms of functional zonation in the cortex are provided for the different cell types which comprise cortical neoplasms associated with various syndromes of hypercorticalism (Cushing's, adrenogenital and Conn's syndromes), together with morphological and functional criteria to distinguish adenomas from carcinomas.

Non-functioning adrenocortical adenoma in culture. Quantitative and morphological observations

This report describes the morphological responses of unstimulated and stimulated non-functioning adrenocortical adenoma in culture. The removed adrenocortical adenoma was composed mainly of clear-type cells and partially had a small area of cholesterol granuloma. These adenoma cells had many lipid droplets and round to long rod-shaped mitochondria with tubular or tubulo-lamellar cristae which were similar to those in Cushing's adenoma. The non-functioning adrenocortical adenoma cells which were incubated in vitro under ACTH (10 mIU/ml) and angiotensin II (10(-6) M/ml) stimulation, were examined by phase contrast microscopy, transmission and scanning electron microscopy, and the content of cortisol and aldosterone in the culture medium was measured by radioimmunoassay. As a result of exposure of ACTH, the cultured cells revealed the retraction response and production of cortisol and aldosterone. After administration of ACTH for many days, the cultured cells showed characteristic changes in sER and mitochondria. The sER were markedly developed and packed tightly into a network of dilated tubules. Mitochondria were larger and more numerous than in the unstimulated cells. The mitochondria appeared to be entwined by the tubules of the sER. Lipid droplets decreased in number.

Adrenal adenocarcinomas: histologic grading and survival

Thirty-eight patients with adrenal adenocarcinoma were reviewed. Two of 23 males and 8 of 15 females had a functioning tumor (P less than 0.005). The most striking finding in this review was the variation in survival according to histologic grade. The median survival from histologic diagnosis was for grade I tumors 54 months, for grade II tumors 26 months, for grade III tumors 1 month. The difference in survival between patients with grade I or II tumors and those with grade III tumors was significant (P less than 0.001). The majority of the patients with grade III tumors were admitted with clinical evidence of disseminated disease and died within 1 month. Among the patients with well-differentiated tumors, five who received surgical treatment of their recurrence had a median survival of 51 months, whereas seven patients who received no surgical treatment had median survival of 20 months following first recurrence (0.05 less than P less than 0.10).

Crystals and alpha-1-antitrypsin-reactive globoid inclusions in an islet cell tumor of the pancreas

An islet cell tumor of the pancreas with unusual light microscopic, ultrastructural, and immunocytochemical features is reported. In addition to secretory granules and positive immunostaining for pancreatic polypeptide, the tumor contained globoid intracytoplasmic inclusions by light and electron microscopy, which correlated with a positive immunoreaction for alpha-1-antitrypsin, and Reinke-like crystals.

Adrenal cortical carcinoma. A study of 77 cases

Seventy-seven patients with histologically proven adrenal cortical carcinoma seen at the University of Texas M. D. Anderson Hospital (1950-1981) were studied. Thirty-nine were women (mean age at diagnosis, 36.6 years), and 38 were men (mean age at diagnosis, 48.3 years). On presentation, 41 of 74 had abdominal symptoms (55.4%) and 25 of 74 had an abdominal mass (33.8%). Twenty-six patients (33.8%) were found to have clinically functional disease (18 women, 8 men). At diagnosis, 26 (33.8%) had clinical or radiologic signs of distant metastases. Preoperative radiologic studies yielded an abnormal intravenous pyelogram in 42 of 51 (82%), an abnormal abdominal ultrasound in eight of nine (88.9%), abnormal computerized tomography in 10 of 10 (100%), and abnormal arteriogram in 18 of 19 (94.7%). Surgery for localized or regional disease was associated with a disease-free interval of at least 2 years in 16 of 34 patients (47%). The use of op'DDD, abdominal radiotherapy, and systemic chemotherapy produced demonstrable effects in nine of 47 (19.1%), two of nine (22.2%), and three of 26 (11.5%), respectively. Distant metastases occurred in 60 patients, commonly in lung, liver, peritoneal and pleural surfaces, lymph nodes, and bone. Analysis of survival data showed a 5-year survival of approximately 30%. The authors concluded that early diagnosis and radical surgery offer the only prospects of long-term survival and the possibility of cure.