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Presented by Dr. Argani and prepared by J. Stephen Nix
This is a 73 year old male with bilateral adrenal enlargement and a history of an ACTH-producing tumor
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1. Question
This is a 73 year old male with bilateral adrenal enlargement and a history of an ACTH-producing tumor
Correct
Answer: B
Histologic Description: The background adrenal shows the changes consistent with ACTH-dependent hyperplasia; specifically, there is depletion of the lipid-rich zona fasciculata, and instead there is a prominent zona reticularis characterized by cells with granular eosinophilic cytoplasm and occasional pigment. Admixed within this hyperplasia are small nests of primitive small round cells which have mitotic activity and demonstrate nuclear molding, consistent with metastatic small cell carcinoma. This patient had a history of small cell carcinoma of the lung which was ACTH secreting. The patient underwent adrenalectomy with the thought that the bilateral adrenals would demonstrate only cortical hyperplasia. The small foci of metastatic small cell carcinoma were an unsuspected finding.
Differential Diagnosis: Adrenal cortical hyperplasia does not typically demonstrate a prominent lymphoid reaction. Even if this were present, the primitive chromatin and nuclear molding of the small cell carcinoma is different than that of lymphoid tissue. Medullary hyperplasia would feature nests of epithelioid cells with clear or granular purple cytoplasm, which is different than the cortical hyperplasia seen in this case. Cortical adenoma would be a discrete lesion in a background of normal adrenal. Neither of the latter two diagnoses account for the metastatic small cell carcinoma component of this case.
Incorrect
Answer: B
Histologic Description: The background adrenal shows the changes consistent with ACTH-dependent hyperplasia; specifically, there is depletion of the lipid-rich zona fasciculata, and instead there is a prominent zona reticularis characterized by cells with granular eosinophilic cytoplasm and occasional pigment. Admixed within this hyperplasia are small nests of primitive small round cells which have mitotic activity and demonstrate nuclear molding, consistent with metastatic small cell carcinoma. This patient had a history of small cell carcinoma of the lung which was ACTH secreting. The patient underwent adrenalectomy with the thought that the bilateral adrenals would demonstrate only cortical hyperplasia. The small foci of metastatic small cell carcinoma were an unsuspected finding.
Differential Diagnosis: Adrenal cortical hyperplasia does not typically demonstrate a prominent lymphoid reaction. Even if this were present, the primitive chromatin and nuclear molding of the small cell carcinoma is different than that of lymphoid tissue. Medullary hyperplasia would feature nests of epithelioid cells with clear or granular purple cytoplasm, which is different than the cortical hyperplasia seen in this case. Cortical adenoma would be a discrete lesion in a background of normal adrenal. Neither of the latter two diagnoses account for the metastatic small cell carcinoma component of this case.
