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Presented by Peter Illei, M.D. and prepared by Amy Duffield, M.D., Ph.D.
Case 6: This 47 y.o. patient was diagnosed with stage IV colon cancer.
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1. Question
Week 376: Case 6
This 47 y.o. patient was diagnosed with stage IV colon cancer with liver metastases 2 years ago and was treated with chemotherapy. His follow up scans detected a 6 cm periaortic mass and a 3.5 cm adrenal mass. The images show both masses. The periartic tumor was only positive for inhibin. The patient also had bilateral orchiectomy for Leydig cell tumor in the past.images/12_15_08 6A.jpg
images/12_15_08 6B.jpg
images/12_15_08 6C.jpg
images/12_15_08 6D.jpg
images/12_15_08 6E.jpgCorrect
Answer: Adrenal cortical adenoma and metastatic Leydig cell tumor in lymph node
Histology: The adrenal mass is confined within the cortex and consists of predominantly clear cells with low nuclear grade and very low mitotic activity (<4 per 50 hpf). No necrosis, atypical mitotic figures, venous or sinusoidal invasion are identified. These findings are consistent with an adrenal cortical adenoma.
The periartic tumor is well circumscribed and exhibits diffuse and sinusoidal architecture. The tumor cells have distinct cell borders, pink eosinophilic cytoplasm and round to oval nuclei and small nucleoli. There is an increased mitotic activity (12 per 50 hpf). No necrosis or venous invasion is identified. Histologically, the differential diagnosis includes an adrenal (both medulla and cortex), renal, and hepatic neoplasm, as well as a metastatic Leydig cell tumor. The tumor in the periaortic mass biopsy and the retroperitoneal mass resection are morphologically similar. Immunostains reveal that the neoplastic cells of this retroperitoneal mass are positive for Inhibin and negative for Melan A/Mart-1, caltretinin, cytokeratin (AE1/3, CAM 5.2), HMB45, S100, chromogranin, Heppar-1, and RCC.Discussion: This staining pattern favors a Leydig cell tumor, however, an adrenal cortical neoplasm cannot be entirely excluded. In view of the patient's clinical history of bilateral orchiectomy for Leydig cell tumor, the findings are consistent with metastatic Leydig cell tumor.
Incorrect
Answer: Adrenal cortical adenoma and metastatic Leydig cell tumor in lymph node
Histology: The adrenal mass is confined within the cortex and consists of predominantly clear cells with low nuclear grade and very low mitotic activity (<4 per 50 hpf). No necrosis, atypical mitotic figures, venous or sinusoidal invasion are identified. These findings are consistent with an adrenal cortical adenoma.
The periartic tumor is well circumscribed and exhibits diffuse and sinusoidal architecture. The tumor cells have distinct cell borders, pink eosinophilic cytoplasm and round to oval nuclei and small nucleoli. There is an increased mitotic activity (12 per 50 hpf). No necrosis or venous invasion is identified. Histologically, the differential diagnosis includes an adrenal (both medulla and cortex), renal, and hepatic neoplasm, as well as a metastatic Leydig cell tumor. The tumor in the periaortic mass biopsy and the retroperitoneal mass resection are morphologically similar. Immunostains reveal that the neoplastic cells of this retroperitoneal mass are positive for Inhibin and negative for Melan A/Mart-1, caltretinin, cytokeratin (AE1/3, CAM 5.2), HMB45, S100, chromogranin, Heppar-1, and RCC.Discussion: This staining pattern favors a Leydig cell tumor, however, an adrenal cortical neoplasm cannot be entirely excluded. In view of the patient's clinical history of bilateral orchiectomy for Leydig cell tumor, the findings are consistent with metastatic Leydig cell tumor.
