Difference between revisions of "Adrenal cortical adenoma"

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Adrenal cortical adenoma (view source)

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#redirect [[Adrenal_gland#Adrenal_cortical_adenoma]]
{{ 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]].


==General==
Epidemiology:
*Often an incidental finding.
Pathologic/clinical:
*May be hormonally active.
*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 (<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>
Indications for excision:<ref name=pmid10870039>{{Cite journal  | last1 = Luton | first1 = JP. | last2 = Martinez | first2 = M. | last3 = Coste | first3 = J. | last4 = Bertherat | first4 = J. | title = Outcome in patients with adrenal incidentaloma selected for surgery: an analysis of 88 cases investigated in a single clinical center. | journal = Eur J Endocrinol | volume = 143 | issue = 1 | pages = 111-7 | month = Jul | year = 2000 | doi =  | PMID = 10870039 }}
</ref><ref name=pmid19035218>{{Cite journal  | last1 = Liu | first1 = XK. | last2 = Liu | first2 = XJ. | last3 = Dong | first3 = X. | last4 = Kong | first4 = CZ. | title = [Clinical research about treatment for adrenal incidentalomas] | journal = Zhonghua Wai Ke Za Zhi | volume = 46 | issue = 11 | pages = 832-4 | month = Jun | year = 2008 | doi =  | PMID = 19035218 }}</ref>
*Lesions >30 mm.
*Hormonally active.
*Non-incidental finding. (???)
*Adrenal vein sampling (AVS) suggestive of adenoma.<ref name=pmid18584586>{{Cite journal  | last1 = Myint | first1 = KS. | last2 = Watts | first2 = M. | last3 = Appleton | first3 = DS. | last4 = Lomas | first4 = DJ. | last5 = Jamieson | first5 = N. | last6 = Taylor | first6 = KP. | last7 = Coghill | first7 = S. | last8 = Brown | first8 = MJ. | title = Primary hyperaldosteronism due to adrenal microadenoma: a curable cause of refractory hypertension. | journal = J Renin Angiotensin Aldosterone Syst | volume = 9 | issue = 2 | pages = 103-6 | month = Jun | year = 2008 | doi = 10.3317/jraas.2008.015 | PMID = 18584586 }}</ref>
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:
*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>
Image: Adrenal CorticalAdenoma DSCN5001 PA.JPG|Adrenal Cortical Adenoma (SKB)
Image: Adrenal CorticalAdenoma DSCN5002 PA.JPG|Adrenal Cortical Adenoma (SKB)
Image: Adrenal CorticalAdenoma DSCN5004 PA.JPG|Adrenal Cortical Adenoma (SKB)
Image: Adrenal CorticalAdenoma DSCN5005 PA.JPG|Adrenal Cortical Adenoma (SKB)
Image: Adrenal CorticalAdenoma MP CTR.jpg|Adrenal Cortical Adenoma - Medium power (SKB)
Image: Adrenal CorticalAdenoma HP CTR.jpg|Adrenal Cortical Adenoma - High power.  Abundant clear cytoplasm.  Round, regular nuclei. (SKB)
Image: Adrenal CorticalAdenoma MP PA.JPG|Adrenal Cortical Adenoma - Some pleomorphism - Medium power (SKB)
Image: Adrenal LipoAdenoma MP PA.JPG|Adrenal cortical adenoma with fat - "lipoadenoma" (SKB)
</gallery>
==IHC==
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>
*[[Calretinin]] +ve.
*Inhibin +ve.
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.
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.
</pre>
==See also==
*[[Adrenal gland]].
==References==
{{Reflist|2}}
[[Category:Adrenal gland]]
[[Category:Diagnosis]]
[[Category:Diagnosis]]
Michael
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