Adrenal cortical carcinoma

ADRENAL CORTICAL CARCINOMA
  • Malignant tumor arising from adrenal cortical cells
  • Age – more common in 4th and 5th decades but can occur at any age
  • Sex – Slight female predilection
  • Left gland is involved more than right
  • These tumors can be functional or non functional
  • Signs and symptoms –
    • Abdominal or flank pain, discomfort or fullness
    • weight loss, intermittent fever
    • Hypoglycemia or hypocalcemia due to hormones
    • DIC or hemorrhagic shock due to rupture of tumor
  • Gross : Bulky tumors measuring 3 to 40 cms
    • Cut section: Coarsely lobulated appearance with soft bulging nodules ranging from yellow-orange to tan. Areas of hemorrhage, necrosis and cystic change can be present
  • Microscopy:
    • Architectural patterns – 
      • Trabecular pattern with anastomosing columns separated by delicate fibrovascualar septa with sinusoids
      • Nesting or alveolar pattern
      • Solid or diffuse pattern
      • Mixture of these patterns
    • Tumor cells
      • Usually have acidophilic cytoplasm which is lipid depleted
      • Oncocytic cells with abundant granular eosinophilic cytoplasm
      • Occasional Lipofuscin pigment may be seen in cytoplasm
      • Few cells may show lipid droplets
      • Intracytoplasmic hyaline globules may be present
      • Nuclear pleomorphism may be present. Hyperchromatic nuclei, multilobated nuclei, nuclei with prominent nucleoli and nuclear pseudoinclusions may be present
    • Stromal changes 
      • Myxoid stroma
      • Foci of calcifications 
      • Metaplastic bone formation
      • Lipomatous or myelolipomatous change
  • Grades 
    • Low grade – 20 or less /50 high power field
    • High grade – More than 20/ 50 high power field
  • Immunohistochemistry 
    • Cytokeratin – negative (rarely positive)
    • Vimentin – positive
    • Melan A, Inhibin, Calretinin – Positive
  • Metastasis 
    • Both lymphatic and hematogenous
    • common sites of metastasis are liver, lung, retroperitonium, lymphnodes and bones
    • Inferior vena cavae invasion producing obstruction producing edema of lower limbs and ascites
Prognosis 
  • Features associated with recurrence and metastasis are 
    • Mitotic rate of 6 or more/ 50 high power feild
    • Atypical mitosis
    • Invasion of vascular structures
Reference: Ernest E.Lack. Tumors of the adrenal glands and extraadrenal paraganglia. AFIP Atlas of tumor pathology Series 4.

 

Adrenal Cortical carcinoma: Tumor cells arranged in trabecular and anastomosing cords (H&E,X50)

 

Adrenal Cortical carcinoma: Tumor cells arranged in trabecular and anastomosing cords (H&E,X100)

 

Adrenal cortical carcinoma: Anastomosing cords of tumor cells (H&E,X100)

 

Adrenal cortical carcinoma: Tumor cells arranged in cords and trabeculae separated by delicate sinusoids (H&E,X100)

 

Adrenal cortical carcinoma: Tumor cells arranged in cords and trabeculae separated by delicate sinusoids (H&E,X400)

 

Adrenal cortical carcinoma: Alveolar pattern of arrangement of tumor cells (H&E,X100)

 

Adrenal cortical carcinoma: Tumor cells on theleft top and normal adrenal tissue in right bottom (H&E,X100)

 

Adrenal cortical carcinoma: Tumor cells with compact eosinophilic cytoplasm and hyperchromatic nuclei (H&E,X100)

 

Adrenal cortical carcinoma: Tumor cells having hyperchromatic pleomorphic nuclei and with eosinophilic cytoplasm (H&E,X400)

 

Adrenal cortical carcinoma: Tumor cells having eosinophilic cytoplasm. Some cells have lipid vacuoles in cytoplasm (H&E,X400)

 

Adrenal cortical carcinoma: Oncocytic tumor cells with abundant eosinophilic cytoplasm (on right) (H&E,X100)

 

Adrenal cortical carcinoma: Oncocytic tumor cells with abundant eosinophilic cytoplasm (H&E,X100)

 

Adrenal cortical carcinoma: Oncocytic tumor cells with abundant eosinophilic cytoplasm (H&E,X100)

 

Adrenal cortical carcinoma: Oncocytic tumor cells with abundant eosinophilic cytoplasm (H&E,X400)

 

 

Adrenal Cortical carcinoma: Tumor cells showing perivascular arrangement (Left) (H&E,X100)

 

Adrenal Cortical carcinoma: Perivascular arrangement of tumor cells (H&E,X50)

 

Adrenal Cortical carcinoma: Perivascular arrangement of tumor cells with myxoid stroma (H&E,X50)

 

Adrenal Cortical carcinoma: Perivascular arrangement of tumor cells with myxoid stroma (H&E,X100)

 

Adrenal cortical carcinoma: Tumor cells with pleomorphic nuclei and with pseudoinclusions (H&E,X400)

 

Adrenal Cortical carcinoma: Tumor cells showing clear cytoplasm due to lipid content (H&E,X100)

 

Adrenal Cortical carcinoma: Tumor cells with eosinophilic cytoplasm. Left top shows glandular pattern of arrangement (H&E,X400)

 

Adrenal Cortical carcinoma: Tumor with areas of necrosis (bottom) (H&E,X50)

 

Adrenal Cortical carcinoma: Metaplastic bone formation in tumor (H&E,X100)

 

Adrenal Cortical carcinoma: Tumor cells arranged in cords having pleomorphic hyperchromatic nuclei (H&E,X 100)

 

Adrenal Cortical carcinoma: Tumor cells arranged in cords having pleomorphic hyperchromatic nuclei (H&E,X 400)

 

Adrenal Cortical carcinoma: Tumor tissue (on left) with normal adrenal cortical tissue (H&E,X100)

 

Adrenal Cortical carcinoma: Tumor tissue (on top) with normal adrenal cortical tissue (bottom) (H&E,X100)