Difference between revisions of "Adrenal gland"

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'''Adrenal gland''' is a little organ that hangs-out above the kidney.  Pathologists rarely see it.  It uncommonly is affected by tumours.
[[Image:Gray1183.png|thumb|400px|A drawing of the adrenal glands.]]
'''Adrenal gland''' is a little organ that hangs-out above the [[kidney]].  Pathologists rarely see it.  It uncommonly is affected by tumours.


==Anatomy & histology==
==Anatomy & histology==
:''Adrenal cortical rest'' redirects here.
===Anatomy===
*Cortex.
*Medulla.


===Histology===
Note:
Composed for ''cortex'' and medulla''.
*Adrenal tissue may be associated with gonads or between gonads and adrenal gland proper.<ref>{{Cite journal  | last1 = Barwick | first1 = TD. | last2 = Malhotra | first2 = A. | last3 = Webb | first3 = JA. | last4 = Savage | first4 = MO. | last5 = Reznek | first5 = RH. | title = Embryology of the adrenal glands and its relevance to diagnostic imaging. | journal = Clin Radiol | volume = 60 | issue = 9 | pages = 953-9 | month = Sep | year = 2005 | doi = 10.1016/j.crad.2005.04.006 | PMID = 16124976 }}</ref>
*Cortex has three layers - Mnemonic: '''GFR''' (from superficial to deep):
**Zona glomerulosa - salt (e.g. aldosterone)
***eosinophilic cytoplasm???
***Normally discontinuous layer.
**Zona fasciculata - sugar (e.g. cortisol)
***Clear cytoplasm - '''key feature'''.
***Largest part of the cortex ~ 70%.
***Cells in cords/nests???
**Zona reticularis - steroid (e.g. dehydroepiandrosterone).
***Marked eosinophilia of cytoplasm - '''key feature'''.
***Granular/reticular cytoplasm.
*Medulla - produces epinephrine


==Benign==
===Microscopic===
*Spironolactone bodies<ref>{{cite journal |author=Kovacs K, Horvath E, Singer W |title=Fine structure and morphogenesis of spironolactone bodies in the zona glomerulosa of the human adrenal cortex |journal=J. Clin. Pathol. |volume=26 |issue=12 |pages=949-57 |year=1973 |month=December |pmid=4131694 |pmc=477936 |doi= |url=http://jcp.bmj.com/cgi/pmidlookup?view=long&pmid=4131694}}</ref>
It is composed of a ''cortex'' and a ''medulla''.
**location: zona glomerulosa (where aldosterone is produced)
**appearance: eosinophilic spherical laminated whorls.
**etiology: long-term use of spironolactone.


==Adenomas==
====Cortex====
Radiology<ref>URL: [http://emedicine.medscape.com/article/376240-overview http://emedicine.medscape.com/article/376240-overview].</ref>
It has three layers - mnemonic: '''GFR''' (from superficial to deep):
*radiologists are good at identifying adenomas, as they are usually lipid rich and have a characteristic low HU signal.
#Zona glomerulosa - salt (e.g. aldosterone).
#*Eosinophilic cytoplasm. (???)
#*Layer normally discontinuous.
#Zona fasciculata - sugar (e.g. cortisol).
#*Clear cytoplasm - '''key feature'''.
#*Largest part of the cortex ~ 70%.
#*Cells in cords/nests. (???)
#Zona reticularis - steroid (e.g. dehydroepiandrosterone).
#*Marked eosinophilia of cytoplasm - '''key feature'''.
#*Granular/reticular cytoplasm.


Treatment is excision if...<ref name=pmid10870039>PMID 10870039.</ref><ref name=pmid19035218>PMID 19035218.</ref>
Note:
*Lesions >30 mm.
*Normal cortex may not be completely encapsulated, i.e. the adrenal capsule may have defects.<ref>{{Ref_H4P4|1236}}</ref>
*Hormonally active.
**In other words: the cortex may "spill" into the surrounding fat.
*Non-incidental finding. (???)


===Hyperplasia vs. adenoma===
====Medulla====
*Hyperplasia is multifocal.<ref>IAV. 18 February 09.</ref>
It consists of two cell types:<ref name=Ref_PBoD8_1159>{{Ref PBoD8|1159}}</ref>
#Chromaffin cells.
#*Arise of neural crest.
#Sustentacular cells (supporting cells).


Produce ''NED'': norepinephrine, epinephrine, dopamine.


==Neoplasms==
=====Images=====
===Benign neoplasms===
<gallery>
Image:Adrenal_gland_(medulla).JPG | Adrenal medulla. (WC)
Image:Adrenal_cortical_carcinoma_-_low_mag.jpg | Adrenal cortex & medulla (right of image), and tumour (left of image). (WC/Nephron)
</gallery>
<gallery>
Image:Adrenal rest - epididymis -- low mag.jpg | Adrenal rest - low mag. (WC/Nephron)
Image:Adrenal rest - epididymis -- intermed mag.jpg | Adrenal rest - intermed. mag. (WC/Nephron)
Image:Adrenal rest - epididymis -- high mag.jpg | Adrenal rest - high mag. (WC/Nephron)
</gallery>


==Adrenal cortical adenoma==
=====www=====
===Epidemiology===
*[http://www.webpathology.com/image.asp?case=78&n=5 Adrenal medulla (webpathology.com)].
*Often an incidental finding.
 
===IHC===
Adrenal cortex:<ref name=pmid18579979>{{Cite journal  | last1 = De Padua | first1 = M. | last2 = Rajagopal | first2 = V. | title = Myxoid adrenal adenoma with focal pseudoglandular pattern. | journal = Indian J Med Sci | volume = 62 | issue = 5 | pages = 199-203 | month = May | year = 2008 | doi =  | PMID = 18579979 }}</ref>
*Chromogranin A -ve.
*Synaptophysin +ve.
*Alpha-inhibin +ve.
*Vimentin +ve.
*Melan A +ve.
*AE1/AE3 -ve.
*RCC -ve (0 +ve of 63 cases<ref name=pmid21490444>{{Cite journal  | last1 = Sangoi | first1 = AR. | last2 = Fujiwara | first2 = M. | last3 = West | first3 = RB. | last4 = Montgomery | first4 = KD. | last5 = Bonventre | first5 = JV. | last6 = Higgins | first6 = JP. | last7 = Rouse | first7 = RV. | last8 = Gokden | first8 = N. | last9 = McKenney | first9 = JK. | title = Immunohistochemical distinction of primary adrenal cortical lesions from metastatic clear cell renal cell carcinoma: a study of 248 cases. | journal = Am J Surg Pathol | volume = 35 | issue = 5 | pages = 678-86 | month = May | year = 2011 | doi = 10.1097/PAS.0b013e3182152629 | PMID = 21490444 }}</ref>).
*EMA -ve (0 +ve of 63 cases<ref name=pmid21490444/>).
 
A panel that may be useful for [[adrenal cortical adenoma|adenoma]] versus [[adrenal cortical carcinoma|carcinoma]]:<ref name=pmid26317117>{{Cite journal  | last1 = Kovach | first1 = AE. | last2 = Nucera | first2 = C. | last3 = Lam | first3 = QT. | last4 = Nguyen | first4 = A. | last5 = Dias-Santagata | first5 = D. | last6 = Sadow | first6 = PM. | title = Genomic and immunohistochemical analysis in human adrenal cortical neoplasia reveal beta-catenin mutations as potential prognostic biomarker. | journal = Discoveries (Craiova) | volume = 3 | issue = 2 | pages =  | month =  | year =  | doi = 10.15190/d.2015.32 | PMID = 26317117 }}
</ref><ref name=pmid11196463>{{Cite journal  | last1 = Arola | first1 = J. | last2 = Salmenkivi | first2 = K. | last3 = Liu | first3 = J. | last4 = Kahri | first4 = AI. | last5 = Heikkilä | first5 = P. | title = p53 and Ki67 in adrenocortical tumors. | journal = Endocr Res | volume = 26 | issue = 4 | pages = 861-5 | month = Nov | year = 2000 | doi =  | PMID = 11196463 }}</ref>
*Beta-catenin, p53, reticulin, inhibin, melan A, Ki-67.
 
==Clinical==
Patients getting a bilateral adrenalectomy get pre-treatment with steroids.<ref>URL:
[http://www3.interscience.wiley.com/cgi-bin/fulltext/119909358/PDFSTART http://www3.interscience.wiley.com/cgi-bin/fulltext/119909358/PDFSTART]. Accessed on: 21 August 2010.</ref>


Pathologic/clinical:  
Adrenal insufficiency is an immediate danger post-op.<ref>URL: [http://ats.ctsnetjournals.org/cgi/content/full/62/5/1516 http://ats.ctsnetjournals.org/cgi/content/full/62/5/1516]. Accessed on: 21 August 2010.</ref>
*May be hormonally active.


===Histology===
=Benign=
Classic features:
The section covers non-neoplastic pathologies of the adrenal gland. These uncommonly come to the pathologist.
*Well-defined cell borders.
*Clear cytoplasm.
*May have foci of necrosis/degeneration and nuclear atypia.


In aldosterone producing tumours:
*Adrenal incidentalomas<ref>{{Cite journal  | last1 = Aljabri | first1 = KS. | last2 = Bokhari | first2 = SA. | last3 = Alkeraithi | first3 = M. | title = Adrenal hemangioma in a 19-year-old female. | journal = Ann Saudi Med | volume = 31 | issue = 4 | pages = 421-3 | month =  | year =  | doi = 10.4103/0256-4947.76411 | PMID = 21293064 }}</ref>
*May extend outside of the capsule (should not be diagnosed as ''adrenal cortical carcinoma''.
**Adrenal tumors
*No atrophy of non-hyperplastic cortex.
**Greater than 1 cm
**Identified on imaging performed for other indications
*Found in up to 10% of patients undergoing abdominal imaging.
*Management problematic
** Guidelines incorporate lesion size, functional status and imaging features.
**Resection is generally advocated for
***Functioning lesions.
***Radiographic features suggestive of malignancy.
***Growth during observation.
==Stress response==
*In fetuses - fat content increases due to stress<ref name=pmid964978>{{cite journal |author=Becker MJ, Becker AE |title=Fat distribution in the adrenal cortex as an indication of the mode of intrauterine death |journal=Hum. Pathol. |volume=7 |issue=5 |pages=495–504 |year=1976 |month=September |pmid=964978 |doi= |url=}}</ref> -- see: ''[[Fetal_autopsy#Adrenal_fetal_fat_pattern]]''.
*In newborns/children/adults - fat content decreases due to stress.


In cortisol producing tumours:
==Spironolactone bodies==
*Atrophy of the non-hyperplastic cortex (due to feedback inhibition from the [[pituitary gland]]).
{{Main|Spironolactone bodies}}


==Pheochromocytoma==
==Hemorrhagic adrenalitis==
*[[AKA]] ''Waterhouse-Friderichsen syndrome''.
===General===
===General===
*Considered to be a [[paraganglioma]].<ref>EP P.327.</ref>
*Classically thought to be only due to ''Neisseria meningitidis''; however, more recently also associated with ''Staphylococcus aureus'',<ref name=pmid16177250>{{cite journal |author=Adem PV, Montgomery CP, Husain AN, ''et al.'' |title=Staphylococcus aureus sepsis and the Waterhouse-Friderichsen syndrome in children |journal=N. Engl. J. Med. |volume=353 |issue=12 |pages=1245–51 |year=2005 |month=September |pmid=16177250 |doi=10.1056/NEJMoa044194 |url=}}</ref> and ''Streptococcus pneumoniae''.<ref name=pmid14747454>{{cite journal |author=Hamilton D, Harris MD, Foweraker J, Gresham GA |title=Waterhouse-Friderichsen syndrome as a result of non-meningococcal infection |journal=J. Clin. Pathol. |volume=57 |issue=2 |pages=208–9 |year=2004 |month=February |pmid=14747454 |pmc=1770213 |doi= |url=}}</ref>


===Clinical===
===Gross===
*Paroxysms (i.e. episodic) tachycardia, headache, anxiety.
Features:
*Massive haemorrhage within the substance of the adrenal gland.


===Epidemiology===
DDx (autopsy):
*Tumour arises from medulla
*Post-mortem changes.
*Literally means "dusky" (pheo) "colour" (chromo) - dull appearance on gross


===Histology===
===Microscopic===
Features:
Features:
*Architecture:
*Massive haemorrhage within the substance of the adrenal gland.
**Cell nests, ''auf deutsch'': Zellballen (literally 'Cell balls').
***Useful for differentiating from ACC.
*Nuclei.
**+/-Pleomorphism.
**Nucleoli may be prominent (not signif. prognostically).
*Cellular morphology.
**Polygonal cells.
*Cytoplasm.
**Basophilic, granular.
*Other.
**Haemorrhagic.


==Ganglioneuroma==
Image: [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1770213/figure/f1/ Haemorrhage in adrenal (nih.gov)].
Micro.<ref>[need ref]</ref>
*disordered fibrinous material
*ganglion cells.
**large cells with large nucleus.
***prominent nucleolus.


==Myelolipoma==
<gallery>
Image:Adrenal WaterhouseFriderichse EColiSepsis LP PA.JPG|Adrenal hemorrhage -low power - E. coli sepsis (SKB)
Image:Adrenal WaterhouseFriderichse EColiSepsis MP PA.JPG|thumb|Adrenal hemorrhage - medium power - E. coli sepsis (SKB)
</gallery>


==Adenomatoid tumour==
==Adrenal cytomegaly==
*[[AKA]] ''adrenocortical cytomegaly''.
*[[AKA]] ''adrenal gland with cytomegaly''.


===Malignant neoplasms===
===General===
==Adrenocortical carcinoma (ACC)==
May be associated with:<ref>URL: [http://www.humpath.com/?adrenal-cytomegaly http://www.humpath.com/?adrenal-cytomegaly]. Accessed on: 3 January 2012.</ref>
Epi.
*[[Beckwith-Wiedemann syndrome]].
*Prognosis sucks.
* Prematurity.
* Rh-incompatibility.<ref name=pmid4336262>{{Cite journal  | last1 = Aterman | first1 = K. | last2 = Kerenyi | first2 = N. | last3 = Lee | first3 = M. | title = Adrenal cytomegaly. | journal = Virchows Arch A Pathol Pathol Anat | volume = 355 | issue = 2 | pages = 105-22 | month =  | year = 1972 | doi =  | PMID = 4336262 |URL = http://www.springerlink.com/content/v06w5250415jr818/ }}</ref>


===Microscopic===
===Microscopic===
Features:
Features:
*Very pleomorphic nuclei.
*Large cells in the adrenal cortex.<ref name=pmid4336262/>
*High mitotic rate.
 
*Atypical mitoses.
==Addison disease==
*Eosinophilic cytoplasm.
===General===
*Chronic adrenocortical insufficiency.
 
Clinical:
*Brown skin - due POMC (a precursor of ACTH and melanocyte stimulating hormone (MSH)).<ref name=Ref_PBoD8_1157>{{Ref PBoD8|1157}}</ref>
**POMC presence implies the [[pituitary gland]] intact.
*Hypotension.
*Nausea and vomiting.
 
DDx:<ref name=Ref_PBoD8_1155>{{Ref PBoD8|1155}}</ref>
*Autoimmune.
*[[Tuberculosis]].
*[[HIV|AIDS]].
*Malignancy.
 
Notes:
*Secondary adrenocortical insufficiency (due to pituitary pathology):<ref name=Ref_PCPBoD8_585>{{Ref PCPBoD8|585}}</ref>
**No hyperpigmentation (as no POMC).
**Aldosterone usu. normal.
 
===Microscopic===
Features:<ref name=Ref_PBoD8_1157>{{Ref PBoD8|1157}}</ref>
*Atrophy adrenal cortex - specifically zona fasciculata and zona reticularis.
 
Notes:
*There is preservation of zona glomerulosa and medulla.
 
=Benign neoplasms=
 
==Adrenal hemangioma==
Radiographic incidentalomas but may be large and calcified raising a radiographic ddx of adrenal cortical carcinoma.
*Rare.
*40 and 70 years.
*2:1 female-to-male ratio
<gallery>
Image:Adrenal Hemangioma LP CTR.jpg|Adrenal hemangioma - low power (SKB)
Image:Adrenal Hemangioma MP CTR.jpg|Adrenal hemangioma - medium power (SKB)
</gallery>
 
==Adrenal cortical adenoma==
{{Main|Adrenal cortical adenoma}}
 
==Pheochromocytoma==
{{Main|Pheochromocytoma}}
 
==Adrenal ganglioneuroma==
{{Main|Ganglioneuroma}}
 
===General===
*May be retroperitoneal.
*Multiple ganglioneuromas may be due to [[multiple endocrine neoplasia IIb]].
 
===Gross===
*Solid.
*White.
*Firm.
*Well-circumscribed.
*May be nodular.


==Malignant pheochromoctyoma==
DDx (gross):
*Like the description in ''benign neoplasms''.
*[[Leiomyoma]].
*Differentiated from benign pheochromocytoma by mets - often aided by radiologic report.
*Features useful for differentiating benign from malignant:<ref>EP P.259.</ref>
**Marked nuclear atypia.
**Invasion:
***Capsular.
***Vascular.
**Necrosis.
**Cellular monotony.
**Mitoses:
***Rate.
***Atypical mitosis.


==Neuroblastoma==
Images:
Epi:  
*[http://commons.wikimedia.org/wiki/File:Adrenal_ganglioneuroma_02.JPG Adrenal ganglioneuroma (WC)].
*Usually paediatric population.
*[http://www.webpathology.com/image.asp?n=2&Case=84 Ganglioneuroma (webpathology.com)].


===Microscopic===
===Microscopic===
*Small round cell tumour.
Features:
*Ganglion cells - '''key feature'''.
**Large cells with large nucleus.
***Prominent nucleolus.
*Disordered fibrinous material.


Images:
*[http://commons.wikimedia.org/wiki/File:Ganglion_high_mag.jpg Ganglion - benign (WC)].
==Adrenal myelolipoma==
{{Main|Adrenal myelolipoma}}
==Adenomatoid tumour==
See: ''[[Uterine_tumours#Adenomatoid_tumour|Adenomatoid tumours (uterine tumours)]]''.
=Malignant neoplasms=
==Adrenocortical carcinoma==
*[[AKA]] ''adrenal cortical carcinoma''.
*Abbreviated ''ACC''.
{{Main|Adrenocortical carcinoma}}
==Neuroblastoma==
{{Main|Neuroblastoma}}


==Angiosarcoma==
=See also=
?
*[[Small round cell tumours]].


==References==
=References=
{{reflist|2}}
{{reflist|2}}


[[Category:Endocrine pathology]]
[[Category:Endocrine pathology]]
[[Category:Genitourinary pathology]]
[[Category:Genitourinary pathology]]

Latest revision as of 18:21, 6 March 2018

A drawing of the adrenal glands.

Adrenal gland is a little organ that hangs-out above the kidney. Pathologists rarely see it. It uncommonly is affected by tumours.

Anatomy & histology

Adrenal cortical rest redirects here.

Anatomy

  • Cortex.
  • Medulla.

Note:

  • Adrenal tissue may be associated with gonads or between gonads and adrenal gland proper.[1]

Microscopic

It is composed of a cortex and a medulla.

Cortex

It has three layers - mnemonic: GFR (from superficial to deep):

  1. Zona glomerulosa - salt (e.g. aldosterone).
    • Eosinophilic cytoplasm. (???)
    • Layer normally discontinuous.
  2. Zona fasciculata - sugar (e.g. cortisol).
    • Clear cytoplasm - key feature.
    • Largest part of the cortex ~ 70%.
    • Cells in cords/nests. (???)
  3. Zona reticularis - steroid (e.g. dehydroepiandrosterone).
    • Marked eosinophilia of cytoplasm - key feature.
    • Granular/reticular cytoplasm.

Note:

  • Normal cortex may not be completely encapsulated, i.e. the adrenal capsule may have defects.[2]
    • In other words: the cortex may "spill" into the surrounding fat.

Medulla

It consists of two cell types:[3]

  1. Chromaffin cells.
    • Arise of neural crest.
  2. Sustentacular cells (supporting cells).

Produce NED: norepinephrine, epinephrine, dopamine.

Images

  • Adrenal medulla. (WC)

  • Adrenal cortex & medulla (right of image), and tumour (left of image). (WC/Nephron)

  • Adrenal rest - low mag. (WC/Nephron)

  • Adrenal rest - intermed. mag. (WC/Nephron)

  • Adrenal rest - high mag. (WC/Nephron)

www

IHC

Adrenal cortex:[4]

  • Chromogranin A -ve.
  • Synaptophysin +ve.
  • Alpha-inhibin +ve.
  • Vimentin +ve.
  • Melan A +ve.
  • AE1/AE3 -ve.
  • RCC -ve (0 +ve of 63 cases[5]).
  • EMA -ve (0 +ve of 63 cases[5]).

A panel that may be useful for adenoma versus carcinoma:[6][7]

  • Beta-catenin, p53, reticulin, inhibin, melan A, Ki-67.

Clinical

Patients getting a bilateral adrenalectomy get pre-treatment with steroids.[8]

Adrenal insufficiency is an immediate danger post-op.[9]

Benign

The section covers non-neoplastic pathologies of the adrenal gland. These uncommonly come to the pathologist.

  • Adrenal incidentalomas[10]
    • Adrenal tumors
    • Greater than 1 cm
    • Identified on imaging performed for other indications
  • Found in up to 10% of patients undergoing abdominal imaging.
  • Management problematic
    • Guidelines incorporate lesion size, functional status and imaging features.
    • Resection is generally advocated for
      • Functioning lesions.
      • Radiographic features suggestive of malignancy.
      • Growth during observation.

Stress response

Spironolactone bodies

Main article: Spironolactone bodies

Hemorrhagic adrenalitis

  • AKA Waterhouse-Friderichsen syndrome.

General

  • Classically thought to be only due to Neisseria meningitidis; however, more recently also associated with Staphylococcus aureus,[12] and Streptococcus pneumoniae.[13]

Gross

Features:

  • Massive haemorrhage within the substance of the adrenal gland.

DDx (autopsy):

  • Post-mortem changes.

Microscopic

Features:

  • Massive haemorrhage within the substance of the adrenal gland.

Image: Haemorrhage in adrenal (nih.gov).

  • Adrenal hemorrhage -low power - E. coli sepsis (SKB)

  • Adrenal hemorrhage - medium power - E. coli sepsis (SKB)

Adrenal cytomegaly

  • AKA adrenocortical cytomegaly.
  • AKA adrenal gland with cytomegaly.

General

May be associated with:[14]

Microscopic

Features:

  • Large cells in the adrenal cortex.[15]

Addison disease

General

  • Chronic adrenocortical insufficiency.

Clinical:

  • Brown skin - due POMC (a precursor of ACTH and melanocyte stimulating hormone (MSH)).[16]
  • Hypotension.
  • Nausea and vomiting.

DDx:[17]

Notes:

  • Secondary adrenocortical insufficiency (due to pituitary pathology):[18]
    • No hyperpigmentation (as no POMC).
    • Aldosterone usu. normal.

Microscopic

Features:[16]

  • Atrophy adrenal cortex - specifically zona fasciculata and zona reticularis.

Notes:

  • There is preservation of zona glomerulosa and medulla.

Benign neoplasms

Adrenal hemangioma

Radiographic incidentalomas but may be large and calcified raising a radiographic ddx of adrenal cortical carcinoma.

  • Rare.
  • 40 and 70 years.
  • 2:1 female-to-male ratio

  • Adrenal hemangioma - low power (SKB)

  • Adrenal hemangioma - medium power (SKB)

Adrenal cortical adenoma

Main article: Adrenal cortical adenoma

Pheochromocytoma

Main article: Pheochromocytoma

Adrenal ganglioneuroma

Main article: Ganglioneuroma

General

Gross

  • Solid.
  • White.
  • Firm.
  • Well-circumscribed.
  • May be nodular.

DDx (gross):

Images:

Microscopic

Features:

  • Ganglion cells - key feature.
    • Large cells with large nucleus.
      • Prominent nucleolus.
  • Disordered fibrinous material.

Images:

Adrenal myelolipoma

Main article: Adrenal myelolipoma

Adenomatoid tumour

See: Adenomatoid tumours (uterine tumours).

Malignant neoplasms

Adrenocortical carcinoma

  • AKA adrenal cortical carcinoma.
  • Abbreviated ACC.
Main article: Adrenocortical carcinoma

Neuroblastoma

Main article: Neuroblastoma

See also

References

  1. ↑ Barwick, TD.; Malhotra, A.; Webb, JA.; Savage, MO.; Reznek, RH. (Sep 2005). "Embryology of the adrenal glands and its relevance to diagnostic imaging.". Clin Radiol 60 (9): 953-9. doi:10.1016/j.crad.2005.04.006. PMID 16124976.
  2. ↑ Mills, Stacey E. (2012). Histology for Pathologists (4th ed.). Lippincott Williams & Wilkins. pp. 1236. ISBN 978-1451113037.
  3. ↑ Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson; Aster, Jon (2009). Robbins and Cotran pathologic basis of disease (8th ed.). Elsevier Saunders. pp. 1159. ISBN 978-1416031215.
  4. ↑ De Padua, M.; Rajagopal, V. (May 2008). "Myxoid adrenal adenoma with focal pseudoglandular pattern.". Indian J Med Sci 62 (5): 199-203. PMID 18579979.
  5. ↑ 5.0 5.1 Sangoi, AR.; Fujiwara, M.; West, RB.; Montgomery, KD.; Bonventre, JV.; Higgins, JP.; Rouse, RV.; Gokden, N. et al. (May 2011). "Immunohistochemical distinction of primary adrenal cortical lesions from metastatic clear cell renal cell carcinoma: a study of 248 cases.". Am J Surg Pathol 35 (5): 678-86. doi:10.1097/PAS.0b013e3182152629. PMID 21490444.
  6. ↑ Kovach, AE.; Nucera, C.; Lam, QT.; Nguyen, A.; Dias-Santagata, D.; Sadow, PM.. "Genomic and immunohistochemical analysis in human adrenal cortical neoplasia reveal beta-catenin mutations as potential prognostic biomarker.". Discoveries (Craiova) 3 (2). doi:10.15190/d.2015.32. PMID 26317117.
  7. ↑ Arola, J.; Salmenkivi, K.; Liu, J.; Kahri, AI.; Heikkilä, P. (Nov 2000). "p53 and Ki67 in adrenocortical tumors.". Endocr Res 26 (4): 861-5. PMID 11196463.
  8. ↑ URL: http://www3.interscience.wiley.com/cgi-bin/fulltext/119909358/PDFSTART. Accessed on: 21 August 2010.
  9. ↑ URL: http://ats.ctsnetjournals.org/cgi/content/full/62/5/1516. Accessed on: 21 August 2010.
  10. ↑ Aljabri, KS.; Bokhari, SA.; Alkeraithi, M.. "Adrenal hemangioma in a 19-year-old female.". Ann Saudi Med 31 (4): 421-3. doi:10.4103/0256-4947.76411. PMID 21293064.
  11. ↑ Becker MJ, Becker AE (September 1976). "Fat distribution in the adrenal cortex as an indication of the mode of intrauterine death". Hum. Pathol. 7 (5): 495–504. PMID 964978.
  12. ↑ Adem PV, Montgomery CP, Husain AN, et al. (September 2005). "Staphylococcus aureus sepsis and the Waterhouse-Friderichsen syndrome in children". N. Engl. J. Med. 353 (12): 1245–51. doi:10.1056/NEJMoa044194. PMID 16177250.
  13. ↑ Hamilton D, Harris MD, Foweraker J, Gresham GA (February 2004). "Waterhouse-Friderichsen syndrome as a result of non-meningococcal infection". J. Clin. Pathol. 57 (2): 208–9. PMC 1770213. PMID 14747454. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1770213/.
  14. ↑ URL: http://www.humpath.com/?adrenal-cytomegaly. Accessed on: 3 January 2012.
  15. ↑ 15.0 15.1 Aterman, K.; Kerenyi, N.; Lee, M. (1972). "Adrenal cytomegaly.". Virchows Arch A Pathol Pathol Anat 355 (2): 105-22. PMID 4336262.
  16. ↑ 16.0 16.1 Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson; Aster, Jon (2009). Robbins and Cotran pathologic basis of disease (8th ed.). Elsevier Saunders. pp. 1157. ISBN 978-1416031215.
  17. ↑ Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson; Aster, Jon (2009). Robbins and Cotran pathologic basis of disease (8th ed.). Elsevier Saunders. pp. 1155. ISBN 978-1416031215.
  18. ↑ Mitchell, Richard; Kumar, Vinay; Fausto, Nelson; Abbas, Abul K.; Aster, Jon (2011). Pocket Companion to Robbins & Cotran Pathologic Basis of Disease (8th ed.). Elsevier Saunders. pp. 585. ISBN 978-1416054542.
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