Oncocytic adrenal cortical carcinoma

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.

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.

Adrenocortical Carcinoma: Updates of Clinical and Pathological Features after Renewed World Health Organisation Classification and Pathology Staging

Adrenocortical carcinoma (ACC) is a heterogenous group of diseases with different clinical behaviour between adult and paediatric patients. In addition, three histological variants, oncocytic, myxoid and sarcomatoid are noted on the recent World Health Organisation (WHO) classification of ACC. A review of recent literature showed that the different types of ACC have distinctive demographic data, clinical presentation, pathology, biological behaviour, genomic and patients' prognosis. In addition, recent updates of pathology staging for ACC allow refinement of prognostic grouping for planning treatment of the patients with ACC. These advances in genomic, pathology and staging have driven the development of standardisation of pathology reporting. International standardisation of pathological reporting of adrenocortical carcinoma and adaption to local pathology communities provide universal platforms for clinicians and researchers involved in the management of patients with ACC. To conclude, all these advances in the field of pathology will improve development of management strategies including improvement of clinical care, development of prognostic markers and testing of novel therapeutic approaches for patients with adrenocortical carcinoma.

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.

Ultrastructural variability of mitochondrial cristae induced in vitro by bee (Apis mellifera) venom and its derivatives, melittin and phospholipase A2, in isolated rat adrenocortical mitochondria

We tested the ability of bee venom (BV), melittin (Mlt), and phospholipase A2 (PLA) - used in 5 concentrations each (5, 10, 15, 20 and 40 μg/100 μl) - to promote ultrastructural changes and reorganization of cristae in vitro in mitochondria isolated from rat adrenal cortex after a protocol optimized by us. Thus, apart from two control grups (CI and CS), in which the mitochondria were suspended into saline buffer and isolation medium respectively, 15 more groups of mitochondria were constituted, corresponding to the five different doses of the three substance tested (BV5 to M40; M5 to M40 and P5 to P40). The ultrastructural effects were quantified on transmission electron micrographs using a morphometry software. Values of 84.49 nm and 95.45 nm were calculated for median diameters of mitochondrial cristae in two control groups. Large and very large vesicular cristae, many with 2 or 3 membranes, were generated depending on dose among normal cristae in all treated groups. In the BV and Mlt treated groups, after an initial increase (up to 127.27 nm in V15 group and 151.2 nm in M10 group) due to stimulation of cristae fusion, the cristae diameter diminished as the doses increased, mainly by the collapse of the cristae. In the PLA treated groups, the cristae diameter increased continuously from 83.84 nm to 136.01 nm, by stimulated fusion of cristae, only the two largest doses promoting the collapse of cristae in some mitochondria. The highest percentage of abnormal cristae was found in the Mlt treated groups and next in BV treated groups. All substances tested produced pronounced ultrastructural variability of mitochondrial cristae in vitro: they also changed (depending on dose) mitochondrial shapes, generated matrix debris and the highest concentrations of BV and Mlt were responsible for mitochondrial breakdown. These ultrastructural alterations of mitochondrial criste in the presence of the BV molecules suggest a reduced capacity of adrenocortical mitochondria to synthetize steroid hormones consequently to BV envenomations and partially explain the toxic effects of the BV.

Adrenocortical Oncocytoma: Case Report and Review of the Literature

Only 9 oncocytic neoplasms of true adrenal origin have been described to date. It therefore seemed of interest to study the histochemical and ultrastructural features of a non-functioning monolateral adrenocortical oncocytoma which was incidentally detected by ultrasonography and magnetic resonance imaging in a 28-year-old woman. The tumor was round, well encapsulated and weighed 73 g. It consisted of islets of eosinophilic cells, and did not display any sign of necrosis. The proliferation rate (as evaluated by mitotic index and percentage of MIB-1 Ki67 positive cells) was low, and atypic mitoses were absent; some rare cells with nuclear atypias were observed and the capsule was focally invaded by oncocytes. Immunocytochemistry did not show expression of vimentin or cytokeratin. The oncocytes had an abundant cytoplasm packed with mitochondria containing plate-like cristae. Smooth endoplasmic reticulum was virtually absent, while rough endoplasmic reticulum cisternae and free ribosomes were abundant. Although the classic histological approach clearly indicates the benign nature of the tumor, the immunocytochemical and ultrastructural features of oncocytes may suggest their potential for malignant behavior.

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.

Computed tomography and magnetic resonance images of adrenocortical oncocytoma cases

We present two cases of adrenocortical oncocytomas that were well-delineated on multi-detector computed tomography and magnetic resonance imaging. The images showed a well-enhanced large mass with multiple stippled calcifications in a 10-yr-old girl who was consulted due to precocious puberty. A well-enhanced solid mass with necrotic components was incidentally noticed in a 54-yr-old man. These lesions were resected and diagnosed as adrenocortical oncocytomas through immunohistochemical studies and electron microscopy. Adrenocortical oncocytomas are rare disease entities, therefore, we report these interesting, rare adrenocortical oncocytomas here with radiologic findings, and discuss differential diagnosis.

Oncocytic adrenocortical carcinoma in a putty-nosed monkey (Cercopithecus nictitans) with hyperadrenocorticism

Oncocytic adrenocortical tumours are rare in man and have never been described in non-human primates. An oncocytic adrenocortical carcinoma was identified in an 18-year-old female putty-nosed monkey (Cercopithecus nictitans) with hyperadrenocorticism and invasive aspergillosis. Microscopically, the tumour consisted of large cells with abundant eosinophilic, granular cytoplasm containing numerous mitochondria as identified by electron microscopy. Tumour cells had large nuclei with occasional intranuclear cytoplasmic pseudoinclusions. Immunohistochemically, tumour cells expressed vimentin, synaptophysin and neuron-specific enolase, while they were negative for cytokeratin, chromogranin-A, melan-A and S100.

Adrenal oncocytic neoplasm: a systematic review

INTRODUCTION

Oncocytic neoplasms as tumors arising in the adrenal glands are rare, usually considered as nonfunctional and benign. In the current literature, there are extremely limited reports of adrenal oncocytic neoplasms; as to date, only 147 cases have been described. The rarity of the event prompted this study which reviews and presents the incidence, histology, diagnosis and therapy of adrenal oncocytic neoplasms.

MATERIALS AND METHODS

A review by systematic literature search was done using the MEDLINE®/Cochrane libraries from 1950 to date using the medical subject headings 'oncocytoma', 'adrenal gland', 'adrenal oncocytoma', 'adrenal oncocytic neoplasm' and 'adrenal oncocytic carcinoma'.

RESULTS

Adrenal oncocytic neoplasm is a rare disease, usually incidentally detected because only 17% are functional adrenal masses. The typical oncocyte displays abundant granular eosinophilic cytoplasm, due to the accumulation of mitochondria. Computed tomography and magnetic resonance imaging are not able to identify or differentiate benign and malignant oncocytic neoplasms. The mainstay of therapy is adrenalectomy, recently performed by laparoscopy. The prognosis is good for benign tumors, while adrenocortical oncocytic carcinoma has a poor survival rate of only 5 years.

CONCLUSIONS

Adrenal oncocytic neoplasm, a rare and mostly benign tumor, usually presents as an incidental, large adrenal mass; surgery is the mainstay of therapy, by means of laparoscopy which is now the most diffuse approach to adrenalectomy.

Large but benign adrenal mass: Adrenal oncocytoma

Adrenal incidentalomas of more than 4 cm size are usually malignant. We describe a 28-year-old woman with a 7-cm, non-functioning, well-demarcated adrenal mass, which was identified as an oncocytoma on histopathological examination. Therefore, a large, non-functioning, unilateral adrenal mass with preserved tumor outline should invoke the suspicion of oncocytoma, which is invariably a benign tumor.

Adrenal cortical tumors, pheochromocytomas and paragangliomas

Distinguishing adrenal cortical adenomas from carcinomas may be a difficult diagnostic problem. The criteria of Weiss are very useful because of their reliance on histologic features. From a practical perspective, the most useful criteria to separate adenomas from carcinomas include tumor size, presence of necrosis and mitotic activity including atypical mitoses. Adrenal cortical neoplasms in pediatric patients are more difficult to diagnose and to separate adenomas from carcinomas. The diagnosis of pediatric adrenal cortical carcinoma requires a higher tumor weight, larger tumor size and more mitoses compared with carcinomas in adults. Pheochromocytomas are chromaffin-derived tumors that develop in the adrenal gland. Paragangliomas are tumors arising from paraganglia that are distributed along the parasympathetic nerves and sympathetic chain. Positive staining for chromogranin and synaptophysin is present in the chief cells, whereas the sustentacular cells are positive for S100 protein. Hereditary conditions associated with pheochromocytomas include multiple endocrine neoplasia 2A and 2B, Von Hippel-Lindau disease and neurofibromatosis I. Hereditary paraganglioma syndromes with mutations of SDHB, SDHC and SDHD are associated with paragangliomas and some pheochromocytomas.

Imaging appearance of bulk fat within an oncocytic adrenocortical neoplasm, a rare and potentially malignant tumour

Oncocytic adrenocortical neoplasm is a rare adrenal tumour that usually follows a benign clinical course. In some cases, however, these tumours have exhibited malignant behaviour. Here, we present the first published case showing bulk fat within an oncocytic adrenocortical neoplasm on CT and MRI, a finding that mimics fat within an adrenal myelolipoma. The distinction between these entities is important, as the current suggested management of an oncocytic adrenocortical neoplasm is resection with subsequent imaging surveillance.

Abnormal mitochondrial cristae were experimentally generated by high doses of Apis mellifera venom in the rat adrenal cortex

In the present study, Apis mellifera venom (AmV) was tested for its ability to cause ultrastructural changes in mitochondria of rat adrenal cortex in vivo. In order to achieve this goal, different AmV treatments were performed and the effects were quantified on transmission electron micrographs. In a first experimental group, AmV injected for 30 days in low daily doses (700 μg/kg) generated important ultrastructural changes in zona fasciculata. The mitochondrial ultrastructure was not affected, but the diameters of mitochondrial cristae (MC) were reduced (57.066 ± 7.795 nm) as compared to the MC diameters in the corresponding control groups (58.596 ± 6.603 nm, and 58.503 ± 5.708 nm). In adrenal glands collected from rats injected with a single, high dose of AmV (62 mg/kg), many ultrastructural changes were described. Mitochondria with normal, tubular MC (with diameter of 58.711 ± 5.907 nm) were observed in many cells, very close to the values calculated for the corresponding control group (58.639 ± 6.117 nm). However, the striking data reported herein concerned the ability of AmV high doses to promote dramatic alterations in the ultrastructure of these particular mitochondria, similar to those described in certain severe diseases. Thus, several types of abnormal mitochondria were observed, including mitochondria displaying lamellar and/or circular, concentric cristae and mitochondria devoid of cristae. The abnormal circular, concentric MC, with large inner (281.904 ± 158.588 nm) and outer (432.076 ± 230.372 nm) diameters, appeared to be the most stable form of MC in the adrenal cortex after the acute treatment with AmV. Among other ultrastructural aspects, these important changes indicated a high level of cytotoxicity of AmV in adrenocortical cells following in vivo experimental poisoning.

Classification of adrenal cortical tumors: what limits for the pathological approach?

Most adrenocortical tumors are benign; adrenocortical carcinomas are rare but their prognosis is poor and their therapeutics are sparse. In most adrenocortical tumors, the morphological approach in particular by Weiss system, brings sufficient elements to establish the differential diagnosis between a benign and a malignant tumor. But some tumors of Weiss score of 2 or 3 can raise problems: are they benign, malignant or are they of uncertain malignant potential? On the other hand, some Weiss criteria are difficult to evaluate as, for example, sinusoidal invasion. These observations led to the development of other approaches, in particular genetic approaches. These genetics findings already have repercussions for the patients in the development of molecular markers for diagnosis and prognosis and in the future they could help in the development of new morphological approaches, in particular immunohistochemical approaches.

Oncocytic adrenocortical carcinoma

Only 17 cases of oncocytic adrenocortical carcinoma have been reported in the English literature. Here, we report an incidental case of oncocytic adrenocortical carcinoma. The patient was a 69-year-old man with the chief complaint of abdominal pain. Abdominal computed tomography revealed a left adrenal tumor. No hormonal symptoms were observed. The excised tumor was whitish, encapsulated, and 75 x 60 x 45 mm in size. Large polygonal tumor cells were arranged in a generally diffuse architecture and exhibited abundant eosinophilic granular cytoplasm. Nuclear atypia with atypical mitotic figures and capsular and sinusoidal invasions were observed. The tumor cells were immunopositive for vimentin, neuron-specific enolase, and synaptophysin but not for alpha-inhibin, melan A, or p53. Diffuse and strong immunopositivity with an antimitochondrial antibody proved that this tumor was truly oncocytic. Upon review of previous cases of oncocytic adrenocortical tumors, we reconsidered the diagnostic findings of the potential for malignancy.

Adrenocortical oncocytic carcinoma with recurrent metastases: a case report and review of the literature

Background

Adrenal cortex oncocytic carcinoma (AOC) represents an exceptional pathological entity, since only 22 cases have been documented in the literature so far.

Case presentation

Our case concerns a 54-year-old man with past medical history of right adrenal excision with partial hepatectomy, due to an adrenocortical carcinoma. The patient was admitted in our hospital to undergo surgical resection of a left lung mass newly detected on chest Computed Tomography scan. The histological and immunohistochemical study revealed a metastatic AOC. Although the patient was given mitotane orally in adjuvant basis, he experienced relapse with multiple metastases in the thorax twice in the next year and was treated with consecutive resections. Two and a half years later, a right hip joint metastasis was found and concurrent chemoradiation was given. Finally, approximately five years post disease onset, the patient died due to massive metastatic disease. A thorough review of AOC and particularly all diagnostic difficulties are extensively stated.

Conclusion

Histological classification of adrenocortical oncocytic tumours has been so far a matter of debate. There is no officially established histological scoring system regarding these rare neoplasms and therefore many diagnostic difficulties occur for pathologists.

Lesions of the adrenal cortex

CONTEXT

In surgical pathology practice adrenal cortical tumors are rare. However, in autopsy series adrenal cortical nodules are found frequently. These are now being identified more commonly in life when the abdomen is scanned for other disease. It is important to differentiate between benign and malignant lesions as adrenal cortical carcinoma is an aggressive tumor. Molecular genetic investigations are providing new information on both pathogenesis of adrenal tumors and basic adrenal development and physiology.

OBJECTIVE

To provide an overview of current knowledge on adrenal cortical development and structure that informs our understanding of genetic diseases of the adrenal cortex and adrenal cortical tumors.

DATA SOURCES

Literature review using PubMed via the Endnote bibliography tool.

CONCLUSIONS

The understanding of basic developmental and physiologic processes permits a better understanding of diseases of the adrenal cortex. The information coming from investigation of the molecular pathology of adrenal cortical tumors is beginning to provide additional tests for the assessment of malignant potential in diagnosis but the mainstay remains traditional histologic analysis.

Oncocytic adrenal cortical tumor with cytoplasmic inclusions and hyaline globules

Adrenal cortical tumors, particularly oncocytic tumors, have been reported to contain a variety of intracytoplasmic and intramitochondrial inclusions. Oncocytic cortical tumors can also morphologically mimic pheochromocytomas. We report an unusual, partially oncocytic cortical neoplasm with nesting architecture, intranuclear inclusions, and hyaline globules reminiscent of pheochromocytoma, together with numerous, small, brightly eosinophilic, periodic acid-Schiff-positive cytoplasmic inclusions and typical cytoplasmic lipid droplets. Ultrastructural study revealed oncocytes containing numerous mitochondria with intramitochondrial crystals and lipid droplets. Immunohistochemistry and immunoblots were utilized to further characterize the tumor. Immunohistochemistry demonstrated immunoreactivity of both the eosinophilic inclusions and the hyaline globules for adipose differentiation-related protein (ADRP), which is one of a group of proteins associated with storage of neutral lipids in many cell types. Immunoblots confirmed the presence of ADRP and demonstrated an imbalance between ADRP and perilipin, another neutral lipid-associated protein, in tumor tissue compared to normal adrenal cortex. The findings suggest that mitochondrial dysfunction in oncocytic cortical tumors may lead to abnormal processing of proteins related to the lipid-storing functions of the adrenal cortex, resulting in unusual cytoplasmic inclusions and extracellular globules resembling the globules in pheochromocytomas. The finding of ADRP as a constituent of inclusions in adrenal cortical tumors has not been previously reported.

Adrenocortical oncocytic neoplasm presenting with Cushing's syndrome: a case report

Introduction

Oncocytic neoplasms occur in several organs and are most commonly found in the thyroid, kidneys and salivary glands. Oncocytic neoplasms of the adrenal cortex are extremely rare and are usually non-functioning.

Case presentation

We report the case of an adrenocortical oncocytic neoplasm with uncertain malignant potential in a 31-year-old man with Cushing's syndrome. The patient had been operated on following diagnosis of a 7 cm adrenal mass. Following surgery, the Cushing's syndrome resolved. The patient is still alive with no metastases one year after the surgery.

Conclusion

Adrenocortical oncocytic neoplasms must be considered in the differential diagnosis of both functioning and non-functioning adrenal masses.

Subclinical Cushing's syndrome associated with an adrenocortical oncocytoma

Oncocytoma is a neoplasm that can arise in several organs, and it has been more commonly described in the kidney, salivary gland and thyroid. Oncocytoma arising in the adrenal gland is a rare finding. Moreover, functioning adrenocortical oncocytoma is exceptionally rare. A 47-yr-old man was incidentally discovered to have a right adrenal mass. The patient had no clinical features suggestive of increased adrenal function. However, hormonal evaluation showed a disturbed cortisol circadian rhythm, supranormal urinary cortisol excretion, a low level of ACTH, and a lack of suppressibility of cortisol secretion after dexamethasone. Right adrenalectomy was performed, and this revealed a well-circumscribed dark-brown tumor that measured 2.4x2.2 cm. The tumor consisted almost exclusively of large eosinophilic and epitheloid cells whose cytoplasm was packed with eosinophilic granulations, which corresponded to the numerous mitochondria confirmed on electron microscopy. This is a rare case of subclinical Cushing's syndrome that was caused by adrenocortical oncocytoma.

Adrenocortical oncocytoma in a child

Adrenocortical oncocytoma is a rare epithelial tumor only described in adults. We report the case of a 12-year-old female who presented a left adrenal mass with abdominal pain, fatigue, acne vulgaris, and elevation of the androstenedione and total testosterone. She had an adrenalectomy. A diagnosis of adrenocortical oncocytoma was made after detailed histological, immunohistochemical, and ultrastructural studies.

Functioning adrenocortical oncocytoma: the first documented case producing interleukin-6 and review of the literature

Adrenocortical oncocytoma is an extremely rare and predominantly non-functioning tumor. We herein report the first case of an adrenocortical oncocytoma that produces interleukin (IL)-6. A 38-yr-old woman was referred for treatment of a 4-cm adrenal mass. Laboratory test results showed elevated inflammatory parameters. Intriguingly, IL-6 serum level was also high at 30 pg/ml (normal 0-4 pg/ml). The patient underwent laparoscopic right adrenalectomy. Microscopic examination showed that the tumor was an adrenocortical oncocytoma with a unique peripheral lymphoid cuff with germinal centers. Electron microscopy demonstrated that the cytoplasm of the neoplastic cells was packed with numerous abnormal mitochondria. Three observations lead us to consider that this tumor was the primary source of serum IL-6. First, the IL-6 level in blood collected from the right adrenal vein was highest (527 pg/ml) among intra-operative blood samples. Second, neoplastic cells stained positively for IL-6. Third, the serum IL-6 returned to normal levels immediately after surgery.

A diagnostic approach to adrenal cortical lesions

The adrenal gland is not a common specimen in surgical pathology practice as, until recently, adrenal tumors were recognized in life only if associated with hypersecretion of hormones or evidence of malignancy. However, adrenal nodules are not uncommon at autopsy, and the number of these found in life is now increasing as they are identified when the abdomen is scanned for the investigation of other diseases using computed tomography or magnetic resonance imaging. It is therefore becoming increasingly important for the surgical pathologist to be aware of the range of pathology in the gland and to understand how to approach the specimens. This short review will deal with lesions of the adrenal cortex.

Metastatic adrenocortical oncocytoma: a case report

With only 51 cases reported in the literature to date, adrenocortical oncocytoma is an exceedingly rare pathological variant of adrenal neoplasms. The first case of metastatic adrenocortical oncocytoma is reported along with an update of the literature. A role for radiotherapy in the palliative setting is demonstrated.

123I-Methyljodbenzylguanidin- (MIBG-) Szintigraphie

(123)I-metaiodobenzylguanidine (MIBG), a radio-labeled catecholamine analogue, is used for the imaging of pheochromocytoma based on the selective uptake of MIBG by chromaffin tissues. MIBG scintigraphy displays high sensitivity (90%) and specificity (close to 100%). In contrast, the false-positive uptake of MIBG by adrenal cortical carcinoma is rare. Here, we report a metastatic oncocytic adrenal cortical carcinoma with MIBG uptake used for therapeutic purposes.

Adrenocortical Oncocytoma — A Rare Tumor of Undefined Malignant Potential: Report of a Case

Adrenocortical oncocytomas are exceptionally rare. To our knowledge, only 23 cases have been reported in the world literature, most of which were benign and nonfunctioning. We report a case of adrenocortical oncocytoma diagnosed by pathological examination of an extirpated right adrenal mass in a young woman. We discuss this case and review the literature on this unusual entity.

A Giant Oncocytoma Arising from Retroperitoneal Heretopic Adrenal Tissue: A case report and literature review

A 56-year-old male presented with a history of right loin pain of two months duration. Physical examination showed a firm non-tender mass in the left upper quadrant. Blood and urinary investigations including serum Cortisol and urinary cathecholamines were normal. CT scan showed an oval, welldefined, heterogeneous mass measuring 14-10 cm. in the region of the left suprarenal gland(Fig. 1).There was no evidence of infiltration into the surrounding tissue. In view of the size and supra-renal location of the mass it was decided to remove the retroperitoneal tumor and the ipsilateral adrenal gland through a left thoraco-abdominal incision to permit adequate exposure and vascular control.

Case Report: Retroperitoneoscopic Partial Adrenalectomy for Large Adrenocortical Oncocytoma

A young woman had mild hypertension, and on evaluation, a large tumor arising from the right adrenal gland was found. The tumor was hormonally inactive. Retroperitoneoscopic partial adrenalectomy was carried out. The histopathology report described adrenocortical oncocytoma.

Functional oncocytic adrenocortical carcinoma

We present a case of oncocytic adrenocortical carcinoma in a 25-year-old man who presented with persistent hypertension, hypokalemia, and a large right adrenal mass. Clinical workup revealed increased serum aldosterone level, suppressed serum ACTH level and high 24-h urine cortisol. Histologically the tumor showed several features of malignancy and electron microscopy confirmed oncocytic differentiation. This case is reported as the first case of an aldosterone and cortisol-producing malignancy with an oncocytic phenotype.

A case of incidental adrenocortical oncocytoma

BACKGROUND

A 39-year-old female presented with an incidentally discovered left adrenal mass. She denied any history of hypertension, headaches, palpitations, muscle weakness, bruising easily, or fatigue. Physical examination was unremarkable.

INVESTIGATIONS

Physical examination, laboratory analyses, CT scan and MRI.

DIAGNOSIS

Oncocytic adrenocortical tumor, or adrenal oncocytoma.

MANAGEMENT

Adrenalectomy, gross and histopathologic examination, and follow-up radiologic imaging.

Functioning adrenocortical oncocytoma: a case report and review of the literature

Adrenocortical oncocytoma is exceptionally rare. Most of these tumors are benign and nonfunctioning. We report a case of functioning adrenocortical oncocytoma located in the right adrenal gland in a 53-year-old woman who presented with Cushing's syndrome. The tumor was small, with exclusively oncocytic histologic features. A discussion of this case and a review of the literature on this entity is presented.

Oncocytic adrenocortical carcinoma

Oncocytic adrenocortical carcinoma is rare. To our knowledge, only 6 cases have been previously reported. We describe an additional case of oncocytic adrenocortical carcinoma. A 54-year-old man presented with a right subcostal mass. Computed tomography demonstrated a massive tumor in the right abdomen. Because renal or adrenal cancer was suspected, right adrenalectomy and nephrectomy were performed. Histologic examination revealed an oncocytic adrenocortical carcinoma. Five months postoperatively, multiple metastases had developed and were treated with surgical resection, chemotherapy, vascular embolization, and radiotherapy. At last follow-up, the patient was alive with pulmonary and adrenal metastases and undergoing treatment with mitotane.

Adrenocortical oncocytic tumors: report of 10 cases and review of the literature

Ten additional adrenocortical oncocytic tumors are presented: 2 benign oncocytomas, 4 borderline oncocytomas of uncertain malignant potential, and 4 oncocytic carcinomas. Histologically all tumors were entirely or predominantly composed of oncocytes. Immunohistochemically all tumors were immunoreactive for mitochondrial antigen mES-13. Electron microscopy was performed in 8 cases and was confirmatory of the oncocytic cell change. The morphologic parameters of the Weiss system, considered to be predictive of the biologic behavior of conventional (nononcocytic) adrenocortical tumors, are reviewed in the context of their possible application to the oncocytic tumor variant. Proposed major criteria (high mitotic rate, atypical mitoses, venous invasion) and minor criteria (large size and huge weight, necrosis, capsular invasion, sinusoidal invasion) in distinguishing malignant tumors are discussed, and definitional criteria (predominantly cells with eosinophilic and granular cytoplasm, high nuclear grade, diffuse architectural pattern) in common with all types of oncocytic tumors are outlined. The authors' proposed working rules for diagnostic categorization of oncocytic adrenocortical tumors are defined, with the presence of 1 major criterion indicating malignancy, 1 to 4 minor criteria indicating uncertain malignant potential (borderline), and the absence of all major and minor criteria indicative of benignancy. Using these criteria, the diagnosis of malignancy was straightforward in 3 of the 4 cases designated as oncocytic carcinoma (presence of at least 2 major criteria and all the minor criteria), while in 1 case the original diagnosis of benign oncocytoma was reversed to malignant following critical review of the original pathologic material after local tumor recurrence. Tumor recurrence occurred in 2 carcinomas at 8 and 20 months, respectively, and was followed in 1 case by the patient's death. The third patient expired at 6 months from unrelated causes, and the fourth patient is free of disease at the relatively short follow-up interval of 6 months. Regarding the 4 patients with borderline tumors, all are alive with no evidence of disease, with follow-up ranging from 10 to 61 months (mean 38.7 months). The 2 benign tumors have a follow-up of 25 and 30 months, respectively. Diagnostic difficulties are delineated and a complete review of the literature on this topic has also been performed.

Oncocytic adrenocortical carcinomas: a pathological and immunohistochemical study of four cases in comparison with conventional adrenocortical carcinomas

Clinicopathological features of four cases of oncocytic adrenocortical carcinomas were studied. All tumors were large, circumscribed tumors with average size and weight of 11.5 cm and 586 g, respectively. The cut surfaces were yellow or brown and tan with areas of hemorrhage, necrosis, fibrosis, myxoid and cystic change. The tumor cells were exclusively oncocytic with a diffuse or compact and solid arrangement. Nuclear atypia was identified but mitosis was rare. Capsular invasion was identified in all tumors and vascular invasion was identified in one tumor. All tumors were immunoreactive for vimentin and inhibins. Immunoreactivity for pancytokeratin, synaptophysin and S-100 protein was variable and focal. All tumors had low proliferative indices, of less than 1%, and were negative for p53 protein. Ultrastructurally, the cytoplasm of tumor cells showed numerous mitochondria in a compact arrangement. Oncocytic adrenocortical carcinomas showed a similar sex ratio, slightly older mean age, similar left predilection, slightly smaller size and lighter weight compared with the conventional carcinomas. We suggest that most oncocytic adrenocortical carcinomas might be low-grade malignancies with less aggressive histological features compared with conventional carcinomas. However, they should be excised completely because of the likelihood of recurrence and metastasis during the follow-up period.

Adrenocortical oncocytoma

We report the case of an adrenocortical oncocytoma of the left adrenal cortex in a young woman. Physical examination revealed a mass in the left upper quadrant of the abdomen using abdomen ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI), which allowed the identification of a large and inhomogeneous mass between the left kidney and the spleen. The lesion was not endowed of any specific radiologic characteristic nor bysided by any biochemical activity that could allow a radiological presurgical diagnosis. Surgical resection led to the diagnosis of adrenocortical oncocytoma, with no aspects revealing malignant potential.

[Adrenocortical tumours]

Adrenocortical tumours have to be differentiated from cortical hyperplasias, medullary tumours and extra-adrenal tumours or metastases. These diagnoses are mostly possible using routine paraffin sections. In some cases, immunostaining for differing cortical and medullary tumours and metastases are necessary. Adrenal hyperplasias can be congenital or acquired. They are diffuse, micronodular or macronodular and may be inactive or induce a cortical hyperfunction. Very rarely, macronodular hyperplasias may transform into autonomous adenomas. Primary, pigmented adrenocortical disease is a rare, special type of primary adrenal Cushing's syndrome, showing many small tumours with pleomorphic cells and an atrophic surrounding cortical tissue. Adrenal adenomas are mostly unilateral and solitary tumours weighing less than 50 g. Adrenal cortical carcinomas are mostly larger. Like the adenomas, they may be inactive and may induce a hypercortisolism, a hyperandrogenism or (very rarely in carcinomas) a hyperaldosteronism. Differentiating cortical adenomas and carcinomas is difficult in some cases but is possible using a diagnostic algorithm. Myelolipomas are benign, inactive tumours composed of mature fat cells and bone marrow cells. They have to be differentiated from adenomas with myelolipomatous metaplasia. Further, rare primary cortical tumours are mentioned.

Oncocytic adrenocortical carcinoma: a morphologic, immunohistochemical and ultrastructural study of four cases

We present the clinical, histologic, immunohistochemical, and ultrastructural findings of four cases of non-functioning oncocytic adrenocortical carcinomas. The patients' ages ranged from 39 to 71 years. There was no sex predilection. Large yellow-tan tumors (8.5 to 17.0 cm), well demarcated from the adjacent kidney, were seen with a thin rim of normal adrenal gland along one edge. One tumor invaded the inferior vena cava and extended up to the level of the right atrium, and another metastasized to bone. The other two tumors had similar morphologic features and therefore were considered carcinomas. Histologic sections of all four cases showed a diffuse proliferation of polygonal neoplastic cells with large nuclei containing prominent nucleoli and abundant granular and eosinophilic cytoplasm. Occasional mononuclear and binucleated giant cells were noted in one case. There were rare mitotic figures (less than one per 10 high power fields). All tumors were immunoreactive for cytokeratins (AE1/AE3 and CAM5.2). Inhibin was focally expressed by one tumor and its bone metastasis. Ultrastructurally, the cytoplasm of the neoplastic cells was packed with innumerable mitochondria. Cytologic atypia or mitotic rate cannot reliably predict the biologic behavior of oncocytic adrenocortical neoplasms. Large tumor size (4/4), extracapsular extension (3/4), blood vessel invasion (2/4), necrosis (4/4), and metastasis (1/4) are features of malignancy for oncocytic adrenocortical carcinomas. The treatment of these tumors is complete surgical excision.