A 72-year old man suffered a car crash and died. At autopsy, he was noted to have a 4 cm right adrenal mass with a dark variegated cut surface. I thought it was likely yet another pheochromocytoms, but no. It turned out to be a bit of a zebra.
Here’s the gross pic:
On histology, it was an unencapsulated mucoid tumor with scattered areas of hemorrhage and necrosis:
There were broad areas of necrosis:
Here’s a description of the cellular component from one review:
At higher magnification, the tumor cells were arranged in trabeculae, clusters, or cords floating in a prominent myxoid stromal background… The individual tumor cells were either small with angulated and hyperchromatic nuclei and small or inconspicuous nucleoli or large and pleomorphic with polygonal shape, eosinophilic cytoplasm, vesicular nuclei, and prominent nucleoli… The myxoid stroma was characterized by pools, lakes, or microcysts of loose mucoid material.
Weissferdt, A., Phan, A., Suster, S. and Moran, C.A., 2013. Myxoid adrenocortical carcinoma: a clinicopathologic and immunohistochemical study of 7 cases, including 1 case with lipomatous metaplasia. American journal of clinical pathology, 139(6), pp.780-786.
A couple of publications describe lipomatous metaplasia, but I didn’t see it here. In my case there was scattered hemorrhage and some hemosiderin.
This is an unusual type of adrenocrotical tumor, making up about 1% of the cases. It’s supposed to be fairly aggressive, though I didn’t see any metastases. I’d never seen one before. Just goes to show that even after years of doing this stuff, there’s always something new to see.
Some more pics:
I used to hate adrenal “neoplasms” when I was doing surg. path. full time. Morphology was tough and the behavior was always kind of a definite maybe. As in ” It’s supposed to be fairly aggressive, though I didn’t see any metastases.” Some surgeons never caught on that morphology was not predictive of behavior in many tumors. One example is “benign metastasizing leiomyoma” of the lung etc. I don’t miss it. HOW IS YOUR WIFE?
She’s struggling along. She has two months left of her chemotherapy. Sigh.
You don’t see lipomatous transformation in the 3rd image from the bottom? It’s a question of ignorance, not a challenge of your diagnosis.
Al in WV
Eh, maybe. I wasn’t being too particular since this case was a little autolyzed by the time I got it. I get fairly conservative the more decomposed a body is…