Difference between revisions of "Adrenal cortical adenoma"

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{{ Infobox diagnosis
| Name      = {{PAGENAME}}
| Image      = Primary aldosteronism (1) adrenocortical adenoma.jpg
| Width      =
| Caption    = Adrenal cortical adenoma. [[H&E stain]].
| Synonyms  =
| Micro      =
| Subtypes  =
| LMDDx      = adrenal cortical nodule, [[adrenal cortical hyperplasia]], [[adrenal cortical carcinoma]]
| Stains    =
| IHC        = [[calretinin]], inhibin
| EM        =
| Molecular  =
| IF        =
| Gross      =
| Grossing  =
| Site      = [[adrenal gland]]
| Assdx      =
| Syndromes  =
| Clinicalhx =
| Signs      =
| Symptoms  =
| Prevalence = relatively common
| Bloodwork  =
| Rads      = adrenal mass, HU<10
| Endoscopy  =
| Prognosis  = benign
| Other      =
| ClinDDx    =
| Tx        = followup or surgical excision
}}
'''Adrenal cortical adenoma''', also '''adrenocortical adenoma''' and '''adrenal adenoma''', is a relatively common benign pathology of the [[adrenal gland]].
'''Adrenal cortical adenoma''', also '''adrenocortical adenoma''' and '''adrenal adenoma''', is a relatively common benign pathology of the [[adrenal gland]].


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*Can be a cause of [[hypertension]].<ref name=pmid18584586/>
*Can be a cause of [[hypertension]].<ref name=pmid18584586/>


*Radiologists are good at identifying adenomas, as they are usually lipid rich and have a characteristic low HU signal.<ref>URL: [http://emedicine.medscape.com/article/376240-overview http://emedicine.medscape.com/article/376240-overview].</ref>
*Radiologists are good at identifying adenomas, as they are usually lipid rich and have a characteristic low HU signal (<10 HU<ref name=pmid24636681>{{Cite journal  | last1 = Tenenbaum | first1 = F. | last2 = Lataud | first2 = M. | last3 = Groussin | first3 = L. | title = [Update in adrenal imaging]. | journal = Presse Med | volume = 43 | issue = 4 Pt 1 | pages = 410-9 | month = Apr | year = 2014 | doi = 10.1016/j.lpm.2014.02.002 | PMID = 24636681 }}</ref>).
**Microadenomas may be missed.<ref name=pmid18584586/><ref name=pmid20881759>{{Cite journal  | last1 = Fujiwara | first1 = M. | last2 = Murao | first2 = K. | last3 = Imachi | first3 = H. | last4 = Yoshida | first4 = K. | last5 = Muraoka | first5 = T. | last6 = Ohyama | first6 = T. | last7 = Kushida | first7 = Y. | last8 = Haba | first8 = R. | last9 = Kakehi | first9 = Y. | title = Misdiagnosis of two cases of primary aldosteronism owing to failure of computed tomography to detect adrenal microadenoma. | journal = Am J Med Sci | volume = 340 | issue = 4 | pages = 335-7 | month = Oct | year = 2010 | doi = 10.1097/MAJ.0b013e3181e95587 | PMID = 20881759 }}</ref>
**Microadenomas may be missed.<ref name=pmid18584586/><ref name=pmid20881759>{{Cite journal  | last1 = Fujiwara | first1 = M. | last2 = Murao | first2 = K. | last3 = Imachi | first3 = H. | last4 = Yoshida | first4 = K. | last5 = Muraoka | first5 = T. | last6 = Ohyama | first6 = T. | last7 = Kushida | first7 = Y. | last8 = Haba | first8 = R. | last9 = Kakehi | first9 = Y. | title = Misdiagnosis of two cases of primary aldosteronism owing to failure of computed tomography to detect adrenal microadenoma. | journal = Am J Med Sci | volume = 340 | issue = 4 | pages = 335-7 | month = Oct | year = 2010 | doi = 10.1097/MAJ.0b013e3181e95587 | PMID = 20881759 }}</ref>


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*May have foci of [[necrosis]]/degeneration and nuclear atypia.
*May have foci of [[necrosis]]/degeneration and nuclear atypia.


Note:
*In aldosterone producing tumours:
**May extend outside of the capsule (should ''not'' be diagnosed as ''[[adrenal cortical carcinoma]]'').
**No atrophy of non-hyperplastic cortex.
**May show spironolactone bodies if hypertension treated with spironolactone prior to surgery.
DDx:
*Adrenal cortical nodule.<ref name=Ref_EP200>{{Ref EP|200}}</ref>
*[[Adrenal cortical hyperplasia]].
**Hyperplasia is multifocal.<ref>IAV. 18 February 2009.</ref>
*[[Adrenal cortical carcinoma]] - see ''Weiss criteria'' below.
====Weiss criteria====
The diagnosis of ''adrenal cortical carcinoma'' requires three of the following:<ref name=pmid20551521>{{cite journal |author=Jain M, Kapoor S, Mishra A, Gupta S, Agarwal A |title=Weiss criteria in large adrenocortical tumors: a validation study |journal=Indian J Pathol Microbiol |volume=53 |issue=2 |pages=222–6 |year=2010 |pmid=20551521 |doi=10.4103/0377-4929.64325 |url=}}</ref><ref name=pmid6703192>{{Cite journal  | last1 = Weiss | first1 = LM. | title = Comparative histologic study of 43 metastasizing and nonmetastasizing adrenocortical tumors. | journal = Am J Surg Pathol | volume = 8 | issue = 3 | pages = 163-9 | month = Mar | year = 1984 | doi =  | PMID = 6703192 }}</ref>
#High nuclear grade.
#High mitotic rate; >5/50 HPF (@ 40X obj.) - definition suffers from [[HPFitis]].
#Atypical mitoses.
#Cleared cytoplasm in <= 25% of tumour cells.
#Sheeting (diffuse architecture) in >= 1/3 of tumour cells.
#Necrosis in nests.
#Venous invasion.
#Adrenal sinusoid invasion; [[lymphovascular space invasion]] within the [[adrenal gland]].
#Capsular invasion.
===Images===
<gallery>
<gallery>
Image: Adrenal CorticalAdenoma DSCN5001 PA.JPG|Adrenal Cortical Adenoma (SKB)
Image: Adrenal CorticalAdenoma DSCN5001 PA.JPG|Adrenal Cortical Adenoma (SKB)
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</gallery>
</gallery>


Note:  
==IHC==
*In aldosterone producing tumours:
Features:<ref name=pmid11893039>{{cite journal |authors=Jorda M, De MB, Nadji M |title=Calretinin and inhibin are useful in separating adrenocortical neoplasms from pheochromocytomas |journal=Appl. Immunohistochem. Mol. Morphol. |volume=10 |issue=1 |pages=67–70 |date=March 2002 |pmid=11893039 |doi=10.1097/00129039-200203000-00012 |url=}}</ref>
**May extend outside of the capsule (should ''not'' be diagnosed as ''[[adrenal cortical carcinoma]]'').
*[[Calretinin]] +ve.
**No atrophy of non-hyperplastic cortex.
*Inhibin +ve.
**May show spironolactone bodies if hypertension treated with spironolactone prior to surgery.
 
Note:
*Calretinin and inhibin in combination are useful for adrenal versus [[pheochromocytoma]].<ref name=pmid11893039/>
 
==Sign out==
<pre>
Adrenal Gland, Right, Adrenalectomy:
- Adrenal cortical adenoma.  
</pre>
 
===Microscopic===
<pre>
The sections show a benign adrenal gland with an expanded cortex.
Clearing of the cytoplasm is present in the cortex.


DDx:
None of the following are present in the cortex:
*Adrenal cortical nodule.<ref name=Ref_EP200>{{Ref EP|200}}</ref>
High nuclear grade, high mitotic rate (mitotic activity 1/50 HPF,
*[[Adrenal cortical hyperplasia]].
where 1 HPF~=0.2376 mm*mm), atypical mitoses, sheeting, necrosis,
**Hyperplasia is multifocal.<ref>IAV. 18 February 2009.</ref>
sinusoidal invasion, venous invasion, capsular invasion.
*[[Adrenal cortical carcinoma]].
</pre>


==See also==
==See also==
Line 58: Line 127:


==References==
==References==
{{Refist|1}}
{{Reflist|2}}


[[Category:Adrenal gland]]
[[Category:Adrenal gland]]
[[Category:Diagnosis]]
[[Category:Diagnosis]]

Latest revision as of 14:38, 1 June 2020

Adrenal cortical adenoma
Diagnosis in short

Adrenal cortical adenoma. H&E stain.
LM DDx adrenal cortical nodule, adrenal cortical hyperplasia, adrenal cortical carcinoma
IHC calretinin, inhibin
Site adrenal gland
Prevalence relatively common
Radiology adrenal mass, HU<10
Prognosis benign
Treatment followup or surgical excision

Adrenal cortical adenoma, also adrenocortical adenoma and adrenal adenoma, is a relatively common benign pathology of the adrenal gland.

General

Epidemiology:

  • Often an incidental finding.

Pathologic/clinical:

  • Radiologists are good at identifying adenomas, as they are usually lipid rich and have a characteristic low HU signal (<10 HU[2]).
    • Microadenomas may be missed.[1][3]

Indications for excision:[4][5]

  • Lesions >30 mm.
  • Hormonally active.
  • Non-incidental finding. (???)
  • Adrenal vein sampling (AVS) suggestive of adenoma.[1]

Notes:

  • Cushing disease is due to the ACTH over-production by the pituitary.
  • In cortisol producing tumours (Cushing syndrome): atrophy of the non-hyperplastic cortex (due to feedback inhibition from the pituitary gland).

Microscopic

Classic features:

  • Well-defined cell borders.
  • Clear cells (abundant, finely vacuolated cytoplasm)
  • Polygonal pink cells.
  • Most of the nuclei are bland, central and round.
  • May have foci of necrosis/degeneration and nuclear atypia.

Note:

  • In aldosterone producing tumours:
    • May extend outside of the capsule (should not be diagnosed as adrenal cortical carcinoma).
    • No atrophy of non-hyperplastic cortex.
    • May show spironolactone bodies if hypertension treated with spironolactone prior to surgery.

DDx:

Weiss criteria

The diagnosis of adrenal cortical carcinoma requires three of the following:[8][9]

  1. High nuclear grade.
  2. High mitotic rate; >5/50 HPF (@ 40X obj.) - definition suffers from HPFitis.
  3. Atypical mitoses.
  4. Cleared cytoplasm in <= 25% of tumour cells.
  5. Sheeting (diffuse architecture) in >= 1/3 of tumour cells.
  6. Necrosis in nests.
  7. Venous invasion.
  8. Adrenal sinusoid invasion; lymphovascular space invasion within the adrenal gland.
  9. Capsular invasion.

Images

  • Adrenal Cortical Adenoma (SKB)

  • Adrenal Cortical Adenoma (SKB)

  • Adrenal Cortical Adenoma (SKB)

  • Adrenal Cortical Adenoma (SKB)

  • Adrenal Cortical Adenoma - Medium power (SKB)

  • Adrenal Cortical Adenoma - High power. Abundant clear cytoplasm. Round, regular nuclei. (SKB)

  • Adrenal Cortical Adenoma - Some pleomorphism - Medium power (SKB)

  • Adrenal cortical adenoma with fat - "lipoadenoma" (SKB)

IHC

Features:[10]

Note:

Sign out

Adrenal Gland, Right, Adrenalectomy: 
- Adrenal cortical adenoma.

Microscopic

The sections show a benign adrenal gland with an expanded cortex.
Clearing of the cytoplasm is present in the cortex.

None of the following are present in the cortex:
High nuclear grade, high mitotic rate (mitotic activity 1/50 HPF, 
where 1 HPF~=0.2376 mm*mm), atypical mitoses, sheeting, necrosis, 
sinusoidal invasion, venous invasion, capsular invasion.

See also

References

  1. ↑ 1.0 1.1 1.2 Myint, KS.; Watts, M.; Appleton, DS.; Lomas, DJ.; Jamieson, N.; Taylor, KP.; Coghill, S.; Brown, MJ. (Jun 2008). "Primary hyperaldosteronism due to adrenal microadenoma: a curable cause of refractory hypertension.". J Renin Angiotensin Aldosterone Syst 9 (2): 103-6. doi:10.3317/jraas.2008.015. PMID 18584586.
  2. ↑ Tenenbaum, F.; Lataud, M.; Groussin, L. (Apr 2014). "[Update in adrenal imaging].". Presse Med 43 (4 Pt 1): 410-9. doi:10.1016/j.lpm.2014.02.002. PMID 24636681.
  3. ↑ Fujiwara, M.; Murao, K.; Imachi, H.; Yoshida, K.; Muraoka, T.; Ohyama, T.; Kushida, Y.; Haba, R. et al. (Oct 2010). "Misdiagnosis of two cases of primary aldosteronism owing to failure of computed tomography to detect adrenal microadenoma.". Am J Med Sci 340 (4): 335-7. doi:10.1097/MAJ.0b013e3181e95587. PMID 20881759.
  4. ↑ Luton, JP.; Martinez, M.; Coste, J.; Bertherat, J. (Jul 2000). "Outcome in patients with adrenal incidentaloma selected for surgery: an analysis of 88 cases investigated in a single clinical center.". Eur J Endocrinol 143 (1): 111-7. PMID 10870039.
  5. ↑ Liu, XK.; Liu, XJ.; Dong, X.; Kong, CZ. (Jun 2008). "[Clinical research about treatment for adrenal incidentalomas]". Zhonghua Wai Ke Za Zhi 46 (11): 832-4. PMID 19035218.
  6. ↑ Thompson, Lester D. R. (2006). Endocrine Pathology: A Volume in Foundations in Diagnostic Pathology Series (1st ed.). Churchill Livingstone. pp. 200. ISBN 978-0443066856.
  7. ↑ IAV. 18 February 2009.
  8. ↑ Jain M, Kapoor S, Mishra A, Gupta S, Agarwal A (2010). "Weiss criteria in large adrenocortical tumors: a validation study". Indian J Pathol Microbiol 53 (2): 222–6. doi:10.4103/0377-4929.64325. PMID 20551521.
  9. ↑ Weiss, LM. (Mar 1984). "Comparative histologic study of 43 metastasizing and nonmetastasizing adrenocortical tumors.". Am J Surg Pathol 8 (3): 163-9. PMID 6703192.
  10. ↑ 10.0 10.1 Jorda M, De MB, Nadji M (March 2002). "Calretinin and inhibin are useful in separating adrenocortical neoplasms from pheochromocytomas". Appl. Immunohistochem. Mol. Morphol. 10 (1): 67–70. doi:10.1097/00129039-200203000-00012. PMID 11893039.
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