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Presented by Jonathan Epstein, M.D. and prepared by Angelique W. Levi, M.D.
Case 1: 39 year old female with hypokalemia and a 2.5 cm. (9 gram) adrenal mass.
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Question 1 of 1
1. Question
Week 9: Case 1
39 year old female with hypokalemia and a 2.5 cm. (9 gram) adrenal mass.
Correct
Answer: Adrenal cortical adenoma (Conn’s syndrome with hyperaldosteronemia)
Histology: There is a single nodule arising within the adrenal gland. The lesion is well circumscribed and lacks necrosis. The lesion consists of nests of cells with abundant xanthomatous pale cytoplasm. Nuclei are uniform with visible nucleoli. Mitotic figures are not easily identifiable. Separating the nests is a thin uniform vascular pattern. The surrounding adrenal gland is histologically unremarkable without any other nodularity.
Discussion: Distinction of adrenal cortical adenoma from carcinoma may be difficult in well differentiated cases. Tumors weighing more than 100 grams in adults are typically malignant. Necrosis >2 high power fields and broad fibrous bands are also useful histological signs of carcinoma. High nuclear grade, mitoses (>1 per 10 high power field), atypical mitoses, diffuse growth, vascular/capsular invasion, clear cells <25% of tumor are also good discriminates. Nodular hyperplasia consists of multiple nodules of cortical cells with intervening atrophic cortical tissue. Pheochromocytoma characteristically has very amphophilic granular cytoplasm rather than the pale to clear xanthomatous cytoplasm seen in adrenal cortical lesions.
Incorrect
Answer: Adrenal cortical adenoma (Conn’s syndrome with hyperaldosteronemia)
Histology: There is a single nodule arising within the adrenal gland. The lesion is well circumscribed and lacks necrosis. The lesion consists of nests of cells with abundant xanthomatous pale cytoplasm. Nuclei are uniform with visible nucleoli. Mitotic figures are not easily identifiable. Separating the nests is a thin uniform vascular pattern. The surrounding adrenal gland is histologically unremarkable without any other nodularity.
Discussion: Distinction of adrenal cortical adenoma from carcinoma may be difficult in well differentiated cases. Tumors weighing more than 100 grams in adults are typically malignant. Necrosis >2 high power fields and broad fibrous bands are also useful histological signs of carcinoma. High nuclear grade, mitoses (>1 per 10 high power field), atypical mitoses, diffuse growth, vascular/capsular invasion, clear cells <25% of tumor are also good discriminates. Nodular hyperplasia consists of multiple nodules of cortical cells with intervening atrophic cortical tissue. Pheochromocytoma characteristically has very amphophilic granular cytoplasm rather than the pale to clear xanthomatous cytoplasm seen in adrenal cortical lesions.
