|
|
|
|
|
|
|
| Adrenal
gland cancer vs. adenoma |
| |
|
As with thyroid gland masses, adrenal gland masses are often discovered incidentally during CT or MRI exams for other reasons. and are then termed adrenal incidentalomas . Most cortical tumors are straight-forwardly
adenomas or carcinomas.
When to biopsy5? In a chinese study, the ratio of malignant to benign climbed to 1 in 8 (12.5%) at the 4CM size4. And, pre-biopsy features concerning for
malignant behavior are irregular margins, image heterogeneity, contrast enhancement, intermediate T2 intensity, soft tissue density CT, and associated enlarged nodes4.
An adenoma is said to be thoroughly encapsulated2.
When one is left in a sort of "indeterminate tumor" situation,
it is possibly time for not only expert pathologist consultation
but tertiary level clinical oncologist consultation: do we have
more to gain by treating as a low grade cancer or by just following?
Incidentally, when recording weight, there is "specimen
weight" and there is "tumor weight" (a recent case was only 25% adenoma, 75% of total specimen weight being organizing intra-adenoma hemorrhage
[LMC-05-575]).
Cortical lesions under 50 grams are generally cured by excision;
most carcinomas weigh 10 grams [about 3CM diameter] or more2. "Except
for the cases situated at the two extremes, it may be more honest
and accurate to designate the tumors as adrenocortical neoplasms
followed by an estimate of the risk of the tumor recurring or
metastasizing on the basis of all the evaluable parameters, the
list of which is likely to increase further in the next few years2."
IHC is another line of evidence
in cortical lesions. Renal cell carcinoma metastatic to the adrenal
tends to be EMA positive, while adrenal cortical primaries tend to be
EMA negative. We have a current (4/21/05) case...LMC-05-3324...of
Conn's syndrome with the removed gland hyperplastic & with
a dominant 1.0 cm nodule and lots of extra-glandular, peri-adrenal
cellularity of cortical cells exactly similar to those in the
gland (and the extra-glandular, peri-adrenal cellularity is vimentin
positive & LMW-keratin negative)! Benign & malignant cortical tumors can be vimentin, keratin, and neurofilment positive; and adenoma and carcinoma are MELAN A
positive3. Adenomata have a Ki-67 of 8% or less; cortical ca. has a Ki-67 over 8% & tending to be about 20%3. |
Weiss is the Favored System:
| system/criteria of Weiss
(best2): |
- Venous invasion (smooth muscle in wall)
- Mitotic rate > 5/50
HPF
- Atypical mitotic figures
- high
Fuhrman nuclear grade
- Diffuse architecture (≥ 33% of tumor)
- Necrosis
- Eosinophilic tumor cell cytoplasm (≥ 75% of tumor cells)
- Sinusoidal invasion (no smooth muscle in wall)
- Capsular invasion
- these, above, are most highly
correlated with recurrence or metastasis
|
|
| system/criteria of Hough: |
|
Numeric sum of the following (a
group of 41 tumors): a mean of 2.91 when subsequent malignant behavior;
a mean of 1.00 when indeterminate; a mean 0.17 when benign: |
Criteria |
Numeric value |
| Histologic
Criteria |
|
- Diffuse growth pattern
|
0.92 |
- Vascular invasion
|
0.92 |
- Tumor cell necrosis
|
0.69 |
- Broad fibrous bands
|
1.00 |
- Capsular invasion
|
0.37 |
- Mitotic index (1/10 HPF or more)
|
0.60 |
- Pleomorphism (moderate/marked)
|
0.39 |
| Non-histologic Criteria |
|
- Tumor mass (≥ 100 g)
|
0.60 |
- Urinary 17-ketosteroids (10 mg/g creatinine/24 hours)
|
0.50 |
- Response to ACTH (17-hydroxysteroids increased two times after 50
µg ACTH IV)
|
0.42 |
- Cushing's syndrome with virilism, virilism alone, or no clinical
manifestations
|
0.42 |
- Weight loss (10 lb/3 months)
|
2.00 |
|
|
| system/criteria of Van
Slooten: |
|
If numeric
sum of the following is 8 or higher, correlates highly with subsequent malignant behavior
(a group of 45 cases with 10 year follow up): |
- Extensive regressive changes (necrosis, hemorrhage,
fibrosis, calcification)
|
5.7 |
- Loss of normal structure
|
1.6 |
- Nuclear atypia (moderate/marked)
|
2.1 |
- Nuclear hyperchromasia (moderate/marked)
|
2.6 |
- Abnormal nucleoli
|
4.1 |
- Mitotic activity (2/10 HPFs)
|
9.0 |
- Vascular or capsular invasion
|
3.3 |
|
|
References:
- Weidner, Noel, The Difficult Diagnosis in Surgical Pathology,
944 pages (in EBS's office); 1996.
-
Rosai J, Rosai AND Ackerman's Surgical
Pathology, 9th Ed., p. 1118-1142, 2004.
-
Ronald A. DeLellis , MD, Pathologist-in-Chief @ Lifespan Academic Med. Ctr in Providence, Rhode Island. He has served on key committees, including the WHO Project on Classification of Endocrine Tumoprs. He was a speaker at The Second International Course in Applied Immunohistochemistry and Molecular Pathology (Santa Barbara, Calif. 1/28/08-2/1/08).
-
comprehensive e-Medicine website overview HERE.
-
American College of Radiology (2000) biopsy appropriateness criteria guidelines HERE.
-
-
UMCCC Endocrine Oncology Program is one of the only fully-integrated, interdisciplinary clinics (as of early 2010) for adrenal patients in the world HERE (& I'd guess Mayo).
(posted
20 December 2003; latest addition 29 March 2010)
|
|
|
© Copyright
1999 - 2006, all rights reserved, Pathology Associates Of Lexington,
P.A. |
| |