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PubMed1993

Primary adrenocortical nodular dysplasia presented as adrenal adenoma by functional scintigraphy.

This is a report of a case of a 12-year-old boy with Cushing's syndrome in which high doses of dexamethasone failed to suppress glucocorticoid secretion. Neither CT nor MRI (morphologic studies) revealed any adrenal abnormality. Functional images with NP-59 (I-131 beta-iodomethyl-norcholesterol) clearly revealed intense unilateral uptake in the right adrenal gland. A right adrenalectomy was performed, and the pathologic diagnosis was primary adrenocortical nodular dysplasia. One year later, the cushingoid signs had virtually disappeared and urinary steroid excretion and serum cortisol levels were within the normal range. Nevertheless, primary adrenocortical nodular dysplasia is essentially a bilateral disease. In this case, a remission in the adrenocortical hyperfunction was observed. Although there was confusion in the etiological diagnosis, functional scintigraphy correctly indicated the status of adrenal function.

Adenoma↗
PubMed1978

Adrenal cortical tumors with low attenuation coefficients: a pitfall in computed tomography diagnosis.

Four cases of adrenal tumors with unusually low attenuation coefficients are reported. The tumors presented with values ranging from 8 to 17 EMI units (EU: 500 scale) instead of the expected 30 to 40 EU range of the remainder of our adrenal tumors. Two of these patients had primary aldosteronism and two had Cushing's syndrome. An unusually high lipid content may be responsible for the lucent appearance.

Adrenal Cortex Neoplasms↗
PubMedDate not supplied

Artificial paravertebral widening for percutaneous CT-guided adrenal biopsy.

A percutaneous adrenal biopsy under CT guidance is described. The biopsy was performed after injection of physiologic saline solution into the paravertebral space, creating a wider pathway for needle insertion. This technique has been previously reported for biopsy of thoracic lesions, but in our case it was used for biopsy of a relatively inaccessible adrenal lesion. This artificial window that is formed by displacing the pleura laterally allows a direct and potentially safer access route to the retroperitoneum, avoiding puncture of pleura, diaphragm, and abdominal structures.

Adenoma↗
PubMed1993

Endothelin in ectopic ACTH-secreting bronchial carcinoid tumors.

The presence of immunoreactive endothelin (ir-ET) in the tumor tissues of two cases of ectopic ACTH-secreting bronchial carcinoid tumors was studied by radioimmunoassay. The cross-reaction with big ET-1, ET-2, and ET-3 was 5%, 6%, and 6%, respectively. Tumor tissue ir-ET concentrations in two ectopic ACTH-secreting bronchial carcinoid tumors were 920 and 3,370 fmol/g wet weight, which were much higher than those in pheochromocytomas (146 +/- 70 fmol/g wet weight; n = 12, mean +/- SD), adrenocortical tumors (115 +/- 105 fmol/g wet weight, n = 14), and normal parts of adrenal glands (82 +/- 31 fmol/g wet weight, n = 12). High-performance liquid chromatography of the tumor tissue extract showed that the ir-ET was mainly eluted in the position of ET-1. Plasma levels of ir-ET in these two cases were not elevated (1.2 and 1.7 pmol/L). The findings of the present study suggest that ET-1 has local pathophysiologic roles in the tumor tissues of ectopic ACTH-secreting bronchial carcinoid tumors.

Adrenal Cortex Neoplasms↗
PubMed1985

Adrenal scintigraphy with 75Se selenonorcholestenol: a review.

We have reviewed 58 patients on whom adrenal scintigraphy has been performed using 75Se selenonorcholestenol. For 15 patients whose adrenal function was biochemically normal, the upper limit of normal of the 7 day adrenal uptake test was 0.45%, considerably higher than the generally accepted value of 0.3%. There is evidence from this group of patients that stress and obesity might account for uptakes in the range 0.3-0.45%. The sensitivity of the uptake test is poor, with 7 out of 23 patients with Cushing's syndrome having uptakes within the normal range. Scintigraphy of such patients may still be useful in differentiating between unilateral and bilateral adrenal involvement.

Adrenal Cortex↗
PubMed2002

Usefulness of CT scan, MRI and radiocholesterol scintigraphy for adrenal imaging in Cushing's syndrome.

The aim of this study was to evaluate the sensitivity and accuracy of computed tomography (CT) scanning, 75Se-selenomethyl-norcholesterol scintigraphy (SNS) and magnetic resonance imaging (MRI) in patients with Cushing's syndrome (CS) undergoing adrenalectomy. A series of 67 patients with CS due to benign adrenal disease was reviewed. There were 11 (16.4%) men and 56 (83.6%) women, with an overall median age of 44 years (range 19-69 years). Prior to surgery all patients underwent both CT and SNS, and 58 (86.6%) underwent adrenal MRI. Thirty-five (52.2%) of the patients (group A) had histologically confirmed unilateral adrenal involvement (33 patients with a solitary adrenocortical adenoma, and two with unilateral nodular cortical hyperplasia), while 32 (47.8%) of the patients (group B) had CS caused by bilateral adrenal involvement, including two patients with multinodular adrenal hyperplasia. The sensitivity, specificity and accuracy of adrenal imaging in group A were 97.1%, 100% and 98.5% for SNS, 94.3%, 68.7% (P<0.05, chi2 test) and 82.1% for CT scan, and 92.3%, 60.0% (P<0.05) and 64.3% (P<0.05) for MRI, respectively. In group B the sensitivity, specificity and accuracy were 100%, 97.2% and 98.5% for SNS, 64.5% (P<0.05), 97.2% and 82.1% for CT scan, and 60.0% (P<0.05), 92.3% and 35.7% (P<0.05) for MRI, respectively. In conclusion, SNS represents the most sensitive and specific adrenal imaging study and should be used in all patients with confirmed biochemical diagnosis of CS undergoing adrenalectomy. The sensitivity and specificity of CT scan and MRI are similar, but the latter shows a lower accuracy, especially in patients with bilateral adrenal involvement.

Adrenal Cortex Neoplasms↗
PubMed1976

Pregnancy complicated by Cushing's syndrome.

A case of Cushing's syndrome occurring during the eighth month of pregnancy was presented. Steroid values and the results of dexamethasone suppression tests were markedly abnormal. Urinary steroid excretion reverted toward normal following delivery and prior to the removal of a large adrenal cortical adenoma.

Adenoma↗
PubMed1988

Estrogen-secreting adrenal tumor responsive to ACTH: localization by adrenal venous sampling.

In a 48-year-old man with gynecomastia but no other signs of feminization, routine evaluation revealed only minimally elevated serum estrogens. The diagnosis of an estrogen-secreting adrenal tumor was suggested by CT and confirmed by adrenal venous sampling. This tumor was found to be ACTH-responsive. Results in this patient are compared with those in normal volunteers, in whom adrenal venous sampling failed to localize estrogen secretion and in whom ACTH did not increase estrogens.

Adrenal Cortex Neoplasms↗
PubMed2003

The role of calretinin, inhibin, melan-A, BCL-2, and C-kit in differentiating adrenal cortical and medullary tumors: an immunohistochemical study.

Morphologic distinction between adrenal cortical and medullary tumors can be difficult. Previous studies have shown inhibin, melan-A, and BCL-2 to be useful markers for adrenal cortical tumors. We have recently observed a high level of calretinin expression in normal adrenal cortex but not the medulla and therefore evaluated its diagnostic application for adrenal tumors in comparison with inhibin, melan-A, and BCL-2. C-kit is a transmembrane tyrosine kinase receptor. Immunodetection of c-kit expression has been recently used for tumor diagnosis, and c-kit-positive tumors can potentially benefit from kit kinase inhibitor treatment. Although c-kit expression was reported in adrenal medulla and pheochromocytoma, it has not been evaluated in adrenal cortical tumors. In this study, 28 adrenal cortical tumors (12 carcinomas, 16 adenomas), 20 pheochromocytomas, and 20 extraadrenal paragangliomas were evaluated for calretinin, inhibin, melan-A, BCL-2, and c-kit expression by standard immunohistochemical assays on paraffin sections. The percentage of immunoreactivity in adrenal cortical tumors was as follows: calretinin, 96%; melan-A, 89%; inhibin, 92%; BCL-2, 20%; and c-kit, 5%. Normal adrenal medulla did not stain for c-kit but was positive for BCL-2. Eighty-six percent of pheochromocytomas stained for BCL-2 and none for calretinin, with the exception of the ganglioneuromatous areas in composite pheochromocytomas (n = 5). Extraadrenal paragangliomas showed reactivity with calretinin in 25%, melan-A in 5%, inhibin in 16%, BCL-2 in 38%, and c-kit in 8% of the cases. Our results indicate that calretinin is the most sensitive among all the adrenal markers tested. Like melan-A and inhibin, calretinin is also a very specific marker in differentiating cortical from medullary adrenal tumors. In addition, calretinin can be used to confirm a composite pheochromocytoma. BCL-2 does not appear to be useful in differentiating adrenal cortical from medullary tumors. C-kit is not useful in the diagnosis of adrenal tumors, and kit kinase inhibitor might have a limited role in the treatment of adrenal tumors and paraganglioma because of the low frequency of c-kit expression in these tumors.

Adrenal Cortex Neoplasms↗
PubMed1976

Conn's syndrome. A follow-up of thirteen surgically treated cases.

Thirteen patients were followed for 4-46 months after removal of an aldosterone producing adenoma. Normotension was achieved in all cases but two in whom moderate diastolic hypertension was easily managed on diuretic therapy. All were cured of hypokalemia and symptoms related to low plasm potassium. Persistaent selective hypoaldosteronism was seen in one patient. A gratifying regression of symptoms and signs related to arterial hypertension was seen. Medical treatment with aldosterone antagonists may "cure" the patient to the same extent as surgery. The present results encourage the use of surgical treatment in these young patients since a life-long drug therapy--with its attendant problems--is the only alternative.

Adenoma↗
PubMed1981

Adrenocortical tumour in untreated congenital adrenocortical hyperplasia associated with inadequate ACTH suppressibility.

Data are presented concerning a 60-year-old woman with untreated congenital adrenocortical hyperplasia due to 21-hydroxylase deficiency, who presented with a tumour of the left adrenal gland. Steroid excretion was partly suppressed with dexamethasone. After removal of the tumour, the excretion of several steroid fractions decreased substantially, but suppression by dexamethasone remained inadequate. Preoperatively, plasma ACTh was elevated in the afternoon and decreased only slightly after dexamethasone administration. After surgery, cortisol secretion decreased markedly, whereas ACTH dysregulation became more prominent. Negative feedback failure precluded the use of normal suppressive therapy with low doses of glucocorticosteroids and led to the therapeutic removal of the right adrenal gland, which showed histological signs of nodular hyperplasia.

Adenoma↗
PubMed1984

Recovery of adrenal function after treatment of adrenocortical carcinoma with o,p'-DDD.

The adrenolytic agent, 2,2-bis[2-chlorophenyl-4-chlorophenyl] 1,1 dichloroethane (o,p'-DDD), was used over a 20-month period following surgery in a 2 3/12-year-old girl for treatment of adrenocortical carcinoma. The child remained free of disease and was maintained on glucocorticoid and mineralo-corticoid supplements for 7 years. Hormonal evaluation was undertaken at 9 9/12 years of age to determine remaining adrenal steroidogenic capacity. Following discontinuation of both hydrocortisone and 9 alpha-fludrocortisone, she remained stable and asymptomatic. Immediately after discontinuing 9 alpha-fludrocortisone, the adrenal glomerulosa was able to respond to stimulation by the renin-angiotensin system as shown by the ability to achieve renal sodium conservation on a restricted sodium intake (less than 10 mEq/d for 5 d). The response of the adrenal fasciculata to ACTH stimulation showed a slower recovery. Baseline levels of cortisol were in the low normal range, but there was no increase in plasma cortisol or urinary 17-hydroxysteroids following stimulation with ACTH. The responses of cortisol, deoxycorticosterone, and corticosterone to ACTH stimulation gradually improved to achieve normal stimulated levels 18 months after stopping medications. Serum testosterone and delta 4-androstenedione were initially increased for level of puberty, while levels of dehydroepiandrosterone were prepubertal. Testosterone and delta 4-androstenedione did not suppress with dexamethasone (2 mg/d for 2 d; 4 mg/d for 2 d), and dehydroepiandrosterone decreased only slightly. However, administration of norethindrone (Norlutin) (10 mg orally, three times a day for 3 d) resulted in suppression while human chorionic gonadotrophin (hCG; 5000 U i.m. daily for 3 d) produced stimulation of testosterone, delta 4-androstenedione and dehydroepiandrosterone. Thus the androgens were felt be predominantly of ovarian origin. Dehydroepiandrosterone rose to low normal levels by 18 months after discontinuation of hydrocortisone. We thus demonstrate for the first time that both the adrenal glomerulosa and fasciculata have the capacity to recover normal function following treatment with o,p'-DDD. Further, we suggest that early exposure to excess adrenal androgens may result in mild alteration of gonadal function.

Adenocarcinoma↗
PubMed1994

Clonal analysis of human adrenocortical carcinomas and secreting adenomas.

OBJECTIVES: Adrenocortical tumours in man are characterized mainly on biochemical, anatomical and histological grounds which establish their secretory pattern and, with some uncertainty, their benign or malignant nature. To study further these tumours and eventually to shed some light on their pathogenesis, we determined their clonal composition. METHODS: Clonal composition was determined by X-chromosome inactivation analysis on tumour and leucocyte DNA using three markers: M27 beta, phospho-glycero-kinase (PGK) and hypoxanthine-phosphoribosyl transferase (HPRT) with 88, 33 and 27% heterozygosity rates respectively. PATIENTS: Clonal analysis was performed on 25 tumours from 19 heterozygous female patients: four had a carcinoma, 14 had a single secreting adenoma, and one had autonomous bilateral macronodular hyperplasia with Cushing's syndrome (seven adenomas examined). RESULTS: The malignant tumours had patterns indicative of monoclonality. The single adenomas displayed contrasting results with patterns indicative of monoclonality in eight cases, and patterns indicative of polyclonality in six cases; monoclonal adenomas were larger and had a higher prevalence of nuclear pleomorphism than the apparently polyclonal adenomas. In the patient with bilateral macronodular hyperplasia, different clonal patterns were present in different adenomas: whereas a clear monoclonal pattern was observed in the three adenomas of the right gland, in which the active X-allele was not always the same, in two interpretable adenomas of the left gland, a moderately skewed pattern suggested a partial monoclonal component. CONCLUSIONS: These data show that adrenocortical carcinomas are monoclonal and suggest that adenomas may arise from a single cell or from more than one cell under the putative action of local growth factors. In adenomas, which until now had appeared homogeneous, this genetic heterogeneity may reflect different pathophysiological mechanisms or it may represent different stages of a common multistep process exceptionally occurring in a single patient with bilateral macronodular hyperplasia.

Adenoma↗
PubMed1994

Augmented 17 alpha-hydroxyprogesterone response to ACTH stimulation as evidence of decreased 21-hydroxylase activity in patients with incidentally discovered adrenal tumours ('incidentalomas').

OBJECTIVE: Recent studies have indicated that the syndrome of congenital adrenal hyperplasia due to 21-hydroxylase deficiency is closely associated with the development of benign adrenocortical tumours. Tumour formation is thought to be a consequence of ACTH hypersecretion which results from the lack of glucocorticoid synthesis. The aim of this study was to evaluate 21-hydroxylase activity in patients with an incidentally discovered adrenal mass ('incidentaloma') without a history of congenital adrenal hyperplasia. DESIGN: A prospective study of 52 patients admitted to a single hospital. PATIENTS: Fifty-two consecutive subjects (mean age 56.0 years, range 24-81 years) with an incidentally discovered adrenal tumour were studied. MEASUREMENTS: The 21-hydroxylase reserve was assessed by intravenous bolus administration of 1-24 ACTH (tetracosactrin) with measurement of basal and stimulated serum 17 alpha-hydroxyprogesterone (17-OHP) concentrations. Impaired 21-hydroxylase activity was defined as an exaggerated 17-OHP response, with a 17-OHP increment exceeding 7.9 nmol/l. Basal and stimulated cortisol concentrations, and basal ACTH were also measured. RESULTS: Baseline levels of 17-OHP were normal in 44 and elevated in 8 subjects. In 37 patients (71.2%), the 17-OHP increment following ACTH administration exceeded 7.9 nmol/l, demonstrating mildly decreased 21-hydroxylase activity. In these subjects, the peak serum 17-OHP correlated with the tumour diameter. In the patients with apparently normal 21-hydroxylase activity, no significant correlation was found between 17-OHP concentrations and tumour size. All patients had a stimulated serum cortisol above 550 nmol/l reflecting intact adrenal glucocorticoid reserve. There were no other differences between the group with exaggerated and the group with normal 17-OHP increment. The tumours were removed from two women with augmented 17-OHP responses and this was followed by normalization of 17-OHP dynamics. CONCLUSIONS: Biochemical evidence for partial 21-hydroxylase defiency is a common finding in patients with an adrenal incidentaloma, even in the absence of a congenital adrenal hyperplasia history. Exaggerated 17-OHP increment is not accompanied by decreased adrenal glucocorticoid reserve. Normalization of the 17-OHP response after surgical treatment suggests that the phenomenon results from reduced 21-hydroxylase activity in the tumour, which retains ACTH responsiveness.

17-alpha-Hydroxyprogesterone↗
PubMed1984

An unusual variant of multiple endocrine neoplasia syndrome: a case report.

A case of multiple endocrine neoplasia syndrome (MEN) in a 57-year-old woman with multiple endocrine tumours involving the pancreas, parathyroid and thyroid glands is reported. An unusual feature was the presence of collision tumours in the pituitary and adrenal. In the pituitary there were adenomas and a meningioma whereas in the adrenal there was a carcinoma along with a myelolipoma. Such collision tumours in the pituitary and adrenal as components of MEN syndrome have not been previously described.

Adenoma↗
PubMed1995

Incidentally detected adrenal tumours (incidentalomas): histological heterogeneity and differentiated therapeutic approach.

OBJECTIVES: To find a differentiated therapeutical approach to incidentalomas. DESIGN: Prospective study of incidentalomas: their histology, hormonal activity, and growth if primarily non-operated. SETTING: Admissions to an academic tertiary care centre because of incidentaloma. PATIENTS: Thirty-eight female, 25 male, 27-85 years old. INTERVENTIONS: Ultrasound, computed tomography and adrenal scintigraphy when appropriate; investigations to exclude malignancy giving metastasis into the adrenal gland; ACTH, cortisol, aldosterone, renin activity, androgene, catecholamine measurements; surgery or follow-up. MAIN OUTCOME MEASURES: Rate of malignancy; linkage of tumour size to probability of malignancy; prevalence of tumours with subtle hormone excess. RESULTS: Cortical adenomas occurred in 13/31, metastases in 7/31 of the histologically confirmed cases. In 10/31 cases, the computed tomography indicated a size that was smaller than the pathological size (mean = 20 mm). 20.6% of all incidentalomas and 61.5% of the 13 operated corticol adenomas showed subtle hormonal activity. Twenty-seven incidentalomas < 30 mm were followed-up (3-41 months; mean 18 months) and showed growth in only one case. Sensitivity, specificity, and predictive value (PV) of a tumour > or = 30 mm to indicate malignancy were: 1.0, 0.56 and 0.27, respectively. The PV of a < 30 mm tumour to exclude malignancy was 1.0. CONCLUSIONS: Oncological screening tests are necessary in all incidentalomas. Tumours > or = 30 mm should be operated but smaller ones can be followed-up, because they are usually benign and rarely show progressive growth. Cortical adenomas with subtle hormonal overproduction and hypertension, diabetes or osteoporosis should be operated, irrespective of their size, but in the absence of relevant clinical symptoms they can be followed-up.

Adrenal Cortex Hormones↗