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Adrenal gland

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IntroductionEdit

Adrenal glands are removed for enlargements, most of which are neoplastic—most commonly adrenal cortical adenoma, less commonly pheochromocytoma or adrenal cortical carcinoma.

Usually the questions to be answered are therefore:

  • Is the lesion cortical or medullary?
  • Is it benign or malignant?
  • Is it confined to the gland?


Fresh HandlingEdit

Note: Adrenalectomy specimens are friable and may be damaged by excessive handling in the fresh state, but they may not fix well if placed intact in formalin. Additionally, the weight of the specimen will be altered by fixation. A good compromise is to perform the first two steps on the fresh specimen, then fix the specimen before handling it further or taking sections.

  1. If a mass is present, or if the surrounding soft tissue is abnormal (e.g., grossly involved by tumor), ink the outer surface.
  2. Serially section through the specimen at 2–3-mm intervals, stopping short ofmaking complete cuts. If no mass is present and significant amounts of peri-adrenal soft tissue are present, the soft tissue should be dissected away and the exact weight and size of the gland measured. Weight is an important feature in assessing hyperplastic glands as well as tumors. Normal glands weigh 4–6 g.
    1. If a mass is present, and only a small amount of peri-adrenal soft tissue is present, the entire specimen may be weighed.
    2. If large amounts of soft tissue are present, take sections demonstrating margins and possible soft tissue invasion. Noninvolved soft tissue may then be removed before weighing.
  3. Describe any lesion present including size, capsule (benign lesions are usually well encapsulated, malignant lesions may lack a capsule or invade into soft tissue), color (similar to normal cortex, brown, yellow/white, or red/brown), and relationship to normal adrenal gland. Adenomas and carcinomas arise from the cortex. Pheochromocytomas arise from the medulla.
  4. Describe the nonlesional portion of the gland (color: golden yellow cortex, inner band of reddish zona reticularis, with a central pearly gray medulla), average thickness of gland (normal is 0.7 cm), presence or absence of nodularity.
  5. Carefully section through any adjacent soft tissue to search for additional tumor nodules or lymph nodes.


Grossing InEdit

  1. Once the specimen has been thoroughly described, take sections:
    1. Cortical lesion less than 3 cm: Submit in toto.
    2. Cortical lesion greater than 3 cm: Submit one block per 0.5 cm.
    3. Medullary lesion: 6-8 sections, including one of interface of neoplasm with normal gland.
    4. Normal gland: One section.


Sample DictationEdit

The specimen is received fresh, labeled with the patient’s name and medical record number and designated “right adrenal”, and consists of an adrenalectomy specimen measuring ___ x ___ x ___ cm. The specimen is surrounded by fat ranging from ___ to ___ cm in thickness and weighs ___ grams after trimming. There is a ___ x ___ x ___ cm ovoid well-circumscribed bright yellow lesion arising from the cortex; the lesion is firm and lacks necrosis or hemorrhage. The lesion appears to compress the adjacent cortex, which is homogeneous and atrophic and measures ___ cm in thickness. The medulla is an unremarkable narrow gray band. A single ___ cm lymph node is found in the adjacent soft tissue.



Review and SignoutEdit

1. Adrenal gland, right/left, ___ grams, adrenalectomy:

-Adrenal cortical adenoma, ___ cm.
-Adrenal cortical carcinoma, ___ cm, confined to adrenal gland and completely excised, see note.
-Pheochromocytoma, ___ cm, confined to adrenal gland and completely excised, see note.


Here are the criteria used to define cortical adenoma/carcinoma/adrenocortical neoplasm of unknown malignant potential:

Original Weiss criteria for malignancyEdit

AJSP 1984;8:163 , modified as indicated below. Each is scored 0 when absent and 1 when present. 3 or more of these factors are required for a diagnosis of adrenocortical carcinoma:

  1. Nuclear grade III or IV based on criteria of Fuhrman
  2. >5 mitotic figures/50 HPF (40x objective), counting 10 random fields in area of greatest number of mitotic figures on 5 slides with greatest number of mitoses
  3. Presence of atypical mitotic figures (abnormal distribution of chromosomes or excessive number of mitotic spindles)
  4. Clear or vacuolated cells comprising 25% or less of tumor
  5. Diffuse architecture (more than 1/3 of tumor forms patternless sheets of cells; trabecular, cord, columnar, alveolar or nesting is not considered to be diffuse
  6. Microscopic necrosis
  7. Venous invasion (veins must have smooth muscle in wall; tumor cell clusters or sheets forming polypoid projections into vessel lumen or polypoid tumor thrombi covered by endothelial layer)
  8. Sinusoidal invasion (sinusoid is endothelial lined vessel in adrenal gland with little supportive tissue; consider only sinusoids within tumor)
  9. Capsular invasion (nests or cords of tumor extending into or through the capsule with a stromal reaction); either incomplete or complete

Note: above criteria may not apply to childhood tumors.


Modified Weiss criteriaEdit

(using 1 if above factor is present in tumor, 0 otherwise):

2x mitotic rate score + 2x clear cytoplasm score + abnormal mitoses + necrosis + capsular invasion (score of 3 or more suggests malignancy, AJSP 2002;26:1612)


PASS scoreEdit

For pheochromocytoma, report the PASS score (Pheochromocytoma of the Adrenal gland Scaled Score). In its initial description, a PASS of <4 accurately identified all histologically benign and clinically benign tumors. A PASS of >=4 correctly identified all tumors that were histologically malignant, even though 17 of the 50 patients did not develop malignant clinical behavior. However, all of the patients who had clinically aggressive neoplasms were identified by a PASS of >=4.

Feature Score if present (no. of points assigned)
Large nests or diffuse growth (>10% of tumor volume) 2
Central (middle of large nests) or confluent tumor necrosis (not degenerative change) 2
High cellularity 2
Cellular monotony 2
Tumor cell spindling (even if focal) 2
Mitotic figures >3/10 HPF 2
Atypical mitotic figure(s) 2
Extension into adipose tissue 2
Vascular invasion 1
Capsular invasion 1
Profound nuclear pleomorphism 1
Nuclear hyperchromasia 1
Total 20

Useful immunohistochemistryEdit

To distinguish cortical from medullary lesions (either because pathology is confusing, or because clinical diagnosis is incongruous), the following stains are helpful:

  • Cortical origin:
    • Inhibin
    • Calretinin
  • Medullary origin:
    • S100
    • Chromogranin
    • Melan A can give confusing results and is not recommended.


ReferencesEdit

Grossing and sample dictation: Lester, Manual of Surgical Pathology, 2nd ed., pp. 201–202. PASS score: Thompson LDR, Am. J. Surg. Path. 26(5) 551-566 (2002).



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