Radioisotopic study of the adrenal glands using 131I-19-iodocholesterol

Scintigraphy of the adrenal gland with 131I-19-iodocholesterol has recently been added to radiological techniques in adrenal imaging and has been used successfully to demonstrate anatomical and functional disorders of the adrenals in a variety of clinical situations. A review of the authors' experience stresses the diagnostic value of this method. Radiological findings and results of scintillation imaging are complementary: their comparison improves and clarifes indications for scintigraphy. Hyperadrenal cortical diseases always gave satisfactory scintigrams, the most interesting results being obtained in adrenal cortical hyperplasia and unilateral hyperfunctioning adenomas. In these cases the evaluation of the response to stimulation or suppression tests was very useful. On the other hand scintigraphy was less valuable in demonstrating malignant and non malignant tumours.     

Collision tumors of the adrenal gland: demonstration and characterization at MR imaging

PURPOSE: To evaluate the magnetic resonance (MR) imaging findings in collision tumors of the adrenal gland. MATERIALS AND METHODS: MR images obtained in 104 patients with a known primary malignant tumor and an adrenal mass were reviewed to find adrenal glands that contained two contiguous but histologically distinct masses. The findings in such cases were correlated with histopathologic findings. RESULTS: In two (2%) cases, both MR and histopathologic findings showed a mass within the adrenal gland that consisted of contiguous adrenal adenoma and metastasis, which represented a collision tumor. The adenomatous component in each tumor showed a (quantitative) decrease in signal intensity relative to that of the liver (79% and 61%) on opposed-phase images, whereas the metastatic component showed an increase in signal intensity (50% and 15%). Similarly, the adrenal lesion-to-spleen signal intensity ratio on opposed-phase images was lower for the adenomatous component in each (0.39 and 0.43) than for the metastatic component (1.17 and 0.90). CONCLUSION: MR imaging can demonstrate and enable characterization of the separate components of collision tumors within the adrenal gland. These findings can be crucial in planning and guiding subsequent percutaneous needle biopsy and patient care.     

Telomeric fusions in cultured human fibroblasts as a source of genomic instability

Adrenal myelolipomas are rare benign tumours that may be identified on routine imaging studies. The association of myelolipomas with obesity, hypertension and malignant tumours has been reported. We describe a giant intra-adrenal myelolipoma in a 40-year-old woman that is the largest asymptomatic tumour of this type documented in the past 10 years. To avoid unnecessary and extensive treatment, the distinction of benign from malignant adrenal tumours or extra-medullary haematopoietic tumour is important, particularly when a small, inactive adrenal mass is found incidentally.     

Adrenalectomy and radical nephrectomy due to renal carcinoma

BACKGROUND: Surgery remains the only effective treatment for renal carcinoma. According the current surgical procedure, both the neoplastic kidney with its perirenal tissue and the Gerota fascia with adrenal gland must be removed. In the last years, the utility of routine adrenalectomy for kidney cancer surgery has been questioned and some authors now recommend this procedure just in selected cases. METHODS: In order to provide a contribution to this debate, 350 cases of nephrectomy after renal carcinoma have been reviewed. In all, 185 adrenalectomy have been performed and neoplastic involvement of adrenal gland has been identified just in 9 cases (4.9%), suggesting a rarity of tumor progression to adrenal gland at the time of surgery. RESULTS: Moreover, neoplastic involvement of adrenal gland has been shown in just 3 cases at preoperatively CT scan. CONCLUSIONS: The conclusion is drawn that adrenal gland may be retained in surgery for radical nephrectomy after renal carcinoma. Adrenalectomy may be recommended in doubtful cases, especially in upper pole localization and in large tumours.     

Imaging of small renal tumors

The increased incidence of detection of small renal tumours, less than or equal to 3 cm in diameter, is related to the generalization and improvement of radiological techniques. Many asymptomatic renal tumours are discovered by ultrasonography and computed tomography. Medical imaging is now able to identify simple cysts (morphological characters, absence of blood supply), angiomyolipomas (demonstration of the fatty contingent) and other solid renal tumours (tumour enhancement on computed tomography). Plain, followed by postcontrast CT looking for contrast enhancement of the lesions is the examination of choice in this context. MRI with Gadolinium injection looking for neoplastic enhancement can be useful in doubtful cases. Medical imaging is able to reliably demonstrate the vascular nature of solid lesions, but cannot distinguish between renal cancer, oncocytoma or another benign solid tumour. Medical imaging allows precise preoperative mapping when partial nephrectomy is envisaged.     

Vascularization of the adrenal cortex: its possible involvement in the regulation of steroid hormone release

This review examines the morphology of the adrenal gland with particular reference to the adrenal vasculature. It examines the possibility that variability in adrenal gland responsiveness may be attributable to neural or hormonal modulation of adrenal blood flow. Changes in the rate of blood flow through the adrenal cortex would be expected to play an important role in the regulation of steroid hormone release. It would affect both the delivery of the major stimulant (ACTH) and the removal of the end product from the steroidogenic cells (the glucocorticoids). In the past, interest in this area has concentrated on the regulation of arterial blood flow, rather than the regulation of venous drainage. The current review examines the concept of vascular damming, and attempts to link the morphological features of the gland with experimental data associated with glucocorticoid release. It is postulated that regulation of venous drainage, via the vascular dam, plays an important role in the storage of the secretory product during the animals' inactive phase, and in the initial rapid rise in plasma levels of the glucocorticoids seen in response to stress or injection of ACTH.     

Direct effects of stress on adrenocortical function

The adrenal gland plays a pivotal role in the stress response since this response involves the hypothalamic-pituitary-adrenal axis (HPAA) and the sympatho-adrenomedullary system (SAMS) as its two principal components. An important relation between the immune system and the other stress response systems is also centered on the adrenal gland. It is well known that the cortex secretes glucocorticoids while the medulla secretes epinephrine, two of the major effects of the stress response. Some other aspects, however, also deserve special consideration: The paracrine effects of the cortical secretion on the medullary cells through the special irrigation system of the gland and reciprocally the influence of the medulla upon the cortex, either by direct close contact or by local innervation. The influence of vascular events also needs to be considered as well as the existence of some local hormonal axis such as those resulting from the local production of renin or CRH in adrenal cells. Some other cells such as mast cells, macrophages and endothelial cells seem to play a role in the regulation of the adrenal cortex and hence in the tuning of the stress response. Stressors stimulate the release of CRH from the hypothalamic paraventricular nucleus inducing the secretion of ACTH from the pituitary and that of corticosteroids from the adrenal cortex. Through the activation of the sympathetic system the adrenal can be stimulated even before adequate levels of ACTH are reached. In conditions of chronic stress the adrenal cortex undergoes an adaptation that allows the hypersecretion of glucocorticoids to occur even without the increment of ACTH.     

Multiple endocrine neoplasia-type medullary thyroid carcinoma in three generations of a family

The familial accumulation of a multiple endocrine neoplasia (MEN) type 2a medullary thyroid carcinoma, is described based on the retrospective analysis of a family history. The proband was characterized by medullary carcinoma (MC) combined with phaeochromocytoma, her child had been shown to suffer from MC. In the third generation of the family C-cell hyperplasia and bilateral adrenal hyperplasia occurred. It is shown that in order to arrive at a correct decision as regards the therapy to be used, modern laboratory tests (serum calcitonin, CEA-analysis) and diagnostic imaging methods (ultrasound, computer tomography, magnetic resonance imaging, positron emission tomography, metaiodobenzylguanidine scintigraphy) should be used. It is emphasized that the available therapeutic means (surgery, radiotherapy, nuclear medicine) have to be carefully selected and, if necessary, combined. In medullary thyroid carcinoma associated tumours in other endocrine organs should be expected to occur. Family screening using blood chemical and genetic tests are recommended in asymptomatic cases, since their surgical treatment can in this way lead to complete recovery.     

Morphological changes in adrenals from victims of suicide in relation to altered apoptosis

Endocrine dysfunction may cause psychiatric symptoms and, vice versa, psychiatric diseases may lead to endocrine alterations. The adrenal as the end organ of both the hypothalamic-pituitary-adrenocortical and sympatho-adrenal axes is subject to the functional changes of the stress system. Thus, increased adrenal gland weight was observed previously in victims of violent suicide. This study was designed to analyze the morphological and morphodynamic changes of adrenals from suicide victims. We investigated 30 adrenals obtained from 15 suicide victims using immunohistochemistry and a computerized video system. In addition, apoptosis and cell proliferation were analyzed. We found a significant enlargement of the adrenal cortex to 158.8% (SD = 29.8%, p < 0.01) that was restricted to the two inner zones only (zona reticularis, 161.6 +/- 35.3%; zona fasciculata, 186.4 +/- 34.4%). This increase in adrenocortical size correlated with a decrease in the number of apoptotic cells within the zona fasciculata. In conclusion, these results clearly demonstrate chronic structural adrenal changes in suicide victims. The adrenal gland mirrors the functional changes of the stress system which leaves an imprint on the morphology of the gland.     

Lipoma of the superficial lobe of the parotid gland. A case report

We report the case of a patient with a lipoma of the superficial lobe of the right parotid gland. Lipomas of the parotid gland are very rare. They are said to constitute one to two percent of all parotid tumours. Only six cases were found in the recent literature. Preoperative diagnosis is difficult when the physical examination reveals a renitent, well-localized and painless mass. However, magnetic resonance imaging is now the imaging modality of choice to facilitate the diagnosis, but the diagnosis can only be confirmed by histological examination of the tumour. We discuss the value of superficial parotidectomy, while some authors suggest an enucleation of lipomas of the superficial lobe of parotid.     

Age-related changes of electrocardiographic wave

OBJECTIVE: Cystic tumors of the adrenal gland are uncommon, but are being increasingly more frequently diagnosed during routine radiological evaluation as "incidentalomas". We discuss the differential diagnosis, therapeutic approach and the existing controversies concerning the management of this tumor type. METHODS: Two additional cases of adrenal pseudocyst in two women aged 47 and 38 years are presented. In one case the tumor was discovered incidentally, whereas the other case presented with acute pain arising from intracystic hemorrhage. RESULTS: The fist patient had a cystic tumor of 8 cm with some inner walls. Fine needle aspiration biopsy revealed a benign cystic lesion of the right adrenal gland. At laparotomy, an 8.5 x 4.5 cm multiloculated cystic lesion was excised. The second patient presented with abdominal pain due to intracystic hemorrhage. A Doppler US did not disclose any vessel inside the lesion. We performed a lumbotomy and excised a 7.5 x 6 cm cystic tumor located in the right adrenal gland. Both lesions were diagnosed as adrenal pseudocyst; the second case was a hemorrhagic one. CONCLUSIONS: The therapeutic approach in adrenal cystic tumors can be based upon the radiological and cytological findings since malignant cystic tumors are uncommon. A clear liquid and a negative cytology practically discard malignant tumors. Furthermore, cystic adenocarcinomas are usually large and the cystic liquid is cloudy with abundant cellularity. Surgical treatment is justified in the symptomatic, big or complex tumors (mixed, non-homogeneous).     

HIV infection among women of reproductive age

PURPOSE: To report on an exceptional case of spontaneous, idiopathic, unilateral adrenal gland rupture that caused massive retroperitoneal hemorrhage. METHODS AND RESULTS: US and CT were performed in a patient who presented with acute abdominal pain. Urgent adrenalectomy was required to prevent the blood loss from continuing. The CT findings were correlated with the histological findings. CONCLUSION: CT proved to be an accurate imaging modality by which to diagnose adrenal hemorrhage. The absence of irregular tissue enhancement showed that neoplasia was not the underlying cause of the hematoma.     

Radiology in primary hyperaldosteronism

Autonomous hypersecretion of aldosterone (primary hyperaldosteronism) is caused by either hyperplasia (usually bilateral) or an adenoma (frequently unilateral) of the adrenal cortex. Systemic hypertension due to an aldosteronoma is a potentially curable condition through surgical extirpation of the offending organ. In our experience with 37 patients clinically suspected to have primary hyperaldosteronism, radiological methods contributed significantly in preoperative diagnosis. These included (1) selective bilateral adrenal vein catheterization and blood sample collection, (2) adrenal venography, and (3) radioisotope adrenal scan. Unilateral hyperfunction could be accurately detected by the aldosterone assays from the collected samples. When adrenal venography was technically satisfactory, a nodule or aggregate of nodules measuring at least 7 mm and located on the margin of the gland or 1.5 cm or more in diameter when located in the center of the gland were readily identified. Enlarged adrenal gland on venography, in itself, was not a dependable index of a hyperfunctioning gland. Presence of a higher uptake on one side on the radioisotope adrenal scan did not always indicate the hyperfunctioning gland, but lack of lateralization of adrenal hyperfunction was more accurately predicted on the radioisotope scan than by venography. Four histopathological patterns were recognized in the surgically removed adrenal glands, but no correlation between these patterns and clinical behavior or postoperative course was found.     

Metastasis and invasion of hepatocellular carcinoma mimicking a right adrenal tumor

A 60-year-old man presented with a large right adrenal mass. Adrenal primary carcinoma invading the liver and retrohepatic inferior vena cava was suspected after preoperative imagings, which included ultrasonography, computed tomography, selective hepatic and adrenal angiography, and magnetic resonance imaging. An en bloc resection of the right kidney, right adrenal gland, posterior hepatic segment, and laterodorsal of the vena cava was performed using an active veno-venous bypass. The defect of the inferior vena cava was closed using a 6 x 10 cm patch of horse pericardium. The cut surface of the resected specimens revealed a smaller necrotic intrahepatic tumor as well as a large extrahepatic tumor which involved the right adrenal gland and extended continuously to the liver, mimicking an adrenal tumor. As the histological features of the two tumors disclosed the same moderately differentiated hepatocellular carcinoma with a trabecular or pseudoglandular pattern, a huge mass of the right adrenal gland with invasion into the right lobe of the liver, which mimicked a primary adrenal tumor, was diagnosed as metastatic hepatocellular carcinoma from a primary hepatic tumor.     

Adrenal incidentaloma: proposal for a correct treatment

BACKGROUND: The incidence of unsuspected adrenal masses (incidentalomas) based on CT-scan results to be higher than in the past. The aim for our study was to establish some guidelines for an appropriate management. METHODS: From 1986 to 1995, 61 patients with no history or clinical findings suggestive of adrenal mass or adrenal hyperfunction were discovered by radiologic examination to have an incidentaloma larger than 1 cm. In each patient basal biochemical evaluations were obtained to exclude the presence of adrenal cortical or medullary dysfunction. There were 28 men and 33 (54.1%) women, with a mean age of 53 years (range 16-74). 19 patients underwent CT-guided fine-needle biopsy to exclude metastatic tumors. Furthermore in 29 patients 75-Se-selenomethyl-norcholesterol was performed and 17 were studied by MRI. RESULTS: At CT-scan mean lesion diameter was 5.48 +/- 3.76 cm (range 2-23); 32 adrenal masses were right sided and 3 (4.9%) were bilateral. 17 patients had concordant scintigraphic imaging pattern, 6 bilateral uptake and 6 had discordant imaging. CT-guided FNAB showed malignancy in 9. Adrenalectomy was performed in 45 patients according to a score calculated by 4 parameters: age of the patients, size of the mass, scintigraphic pattern, MR imaging. Twenty-four had a score greater than 9 and in the remaining 21 patients in spite of a score lower than 10 adrenalectomy was performed based on: 1) increased size at CT scan follow-up (15 pts); 2) either suspected primitive malignant neoplasm at CT-guided FNAB or history of malignancy (6 pts); 3) elevated 24-hour dopamine (4 pts). In 12 (26.7%) patients a malignant tumor was found. There were not any statistically significant differences (p > 0.05) between the age of the patients with malignant neoplasms and those with benign masses, and between the size of the masses, which were 7.58 +/- 5.93 cm (range 2-23) and 5.03 +/- 2.81 cm (range 3-17) respectively. The difference in scores between the patients with malignant masses (12.17 +/- 2.95) and those with benign ones (9.09 +/- 1.33) was statistically significant (p < 0.01). CONCLUSIONS: Since adrenal incidentaloma have a malignancy rate higher than the other adrenal tumors, it is crucial to outlinesome criteria to sort out the patients at risk for whom adrenalectomy is to be warranted. Based on our results we believe that patients with a score > 9 should undergo adrenalectomy.     

Direct inhibitory effect of uremic toxins and polyamines on proliferation of VERO culture cells

Steroidogenic tumors are derived from cells of male and female reproductive tracts, adrenal glands, central nervous system, and, to a lesser degree, from the liver and pituitary gland. The symptoms caused by these tumors are related to their secretory products. Because enzymatic pathways are shared by both adrenal- and gonadal-derived tissues, and the conversion of some of these steroids occurs in the adipose tissue, positive identification of many lesions cannot be based on peripheral blood hormone levels alone, but require complex protocols to improve diagnostic accuracy. Furthermore, these tumors often are smaller than the size limit of conventional imaging modalities and thus demand more precise imaging techniques. Although diagnosis and localization may be challenging, the rewards of a positive prognosis, with complete reversal of symptoms, are more likely to occur with early detection and treatment. This article is a review of the clinical syndromes associated with pediatric steroidogenic tumors; suggested strategies to facilitate their diagnosis, localization, and treatment are provided.     

Psychosomatic obstetrics and gynecology in the next millennium: some thoughts and observations

Diagnostic pitfalls exist when benign salivary gland diseases are mistakenly classified as malignant, with consequences for treatment and prognosis. Examples are necrotizing sialometaplasia, metaplastic Warthin tumour and sclerosing polycystic sialadenopathy. The proper diagnosis is of eminent importance to distinguish cases of primary tumours that have developed in salivary glands or their lymph nodes from cases of extraglandular tumours with metastases in these glands or their nodes. In these cases clinical data and additional immunocytochemical methods are necessary to clarify the exact diagnosis, especially when the primary salivary gland tumours have a structure largely identical to the metastases (e.g. squamous cell carcinoma). Nasopharyngeal or cervical chordomas can be mistaken for pleomorphic adenoma or mucinous adenocarcinoma. The initial stage of malignant MALT lymphomas in association with Sj?gren's syndrome demands identification of clonal rearrangement for therapeutic implication. The diagnostic criteria for proper classification are analysed in detail.     

Regulation of immunoreactive androgen receptor in the adrenal gland of the adult rat

The androgen receptor (AR) was measured by an immunoblot assay in adult tissues of both male and female rats. Relatively high levels of AR were detected in tissues of the male urogenital tract and in the adrenal glands and gonads of both sexes. Another group of tissues, including the male levator ani/bulbocavernosus muscles, preputial gland, scrotal skin, and vagina, had low, but detectable, levels of AR. In a third group of tissues, including the uterus, kidney, spleen, liver, gut, heart, lung, pituitary, and hypothalamus, AR was undetectable. In some androgen target tissues, such as the penis, androgens cause an apparent disappearance of AR from the tissue, and in other tissues, such as the ventral prostate, androgen therapy increases the amount of detectable AR. We compared the effect of androgen on AR levels in the adrenal gland and ventral prostate, tissues that differ markedly in their trophic responses to androgen. Castration appeared to have no effect on the amount of detectable AR in the adrenal gland, whereas it caused a profound decrease in AR levels in the ventral prostate. By contrast, 7 days after hypophysectomy, AR levels declined in both the adrenal gland and the ventral prostate. The effects of hypophysectomy plus castration were similar to those of hypophysectomy alone. Administration of ACTH to hypophysectomized rats for 7 days did not reverse the effects of hypophysectomy on adrenal AR, nor did treatment with levothyroxine, dexamethasone, rat GH, or rat PRL. Treatment of hypophysectomized rats with 5alpha-dihydrotestosterone for 7 days caused a dramatic increase in the amount of detectable AR in both the ventral prostate and the adrenal gland, but had a trophic effect only in the ventral prostate. These findings suggest that the amount of immunoreactive AR detected in both the adrenal gland and the ventral prostate is enhanced by androgens: testicular androgens in the case of the ventral prostate and adrenal androgen in the case of the adrenal glands.     

Diagnosis and prognosis of salivary gland tumors. An interpretation of new revised WHO classification

An exact morphological classification of salivary gland tumours is necessary for international comparison of clinical tumour studies. The basis is formed by the TNM system for determining tumour stage ("staging") and the WHO classification as the underlying principle of identifying the pathohistological tumour state and cellular tumour differentiation ("grading"). The second, revised edition of the WHO classification of salivary gland tumours differs from the first in that the exact definition of a considerably greater number of tumour entities is given and in the consideration of additional factors concerning prognosis and therapy. In the present interpretation of salivary gland tumours, not only are solitary tumour entities defined, but new findings are also considered concerning immunohistochemical tumour markers, proliferation markers (Ki-67 resp. MIB 1, AgNORs, PC-NA), oncogenes and cell receptors as well as cytogenetic alterations as prognostic factors. In particular the new tumour entities of adenomas (myoepithelial adenoma, basal cell adenoma, canalicular adenoma) and carcinomas (acinic cell carcinoma, mucoepidermoid carcinoma, polymorphous low-grade adenocarcinoma, salivary duct carcinoma, myoepithelial carcinoma) are characterized. In addition, the tumour-like lesions and differential diagnostic aspects are mentioned and a general review about new prognostic factors is presented.     

Laparoscopic adrenalectomy

Between June and September 1993, laparoscopic adrenalectomy was indicated in five patients (three women, two men; aged 25-50 years). Three had a phaeochromocytoma, two had an adenoma (Conn's syndrome). Four of the five tumours were localized to the right adrenal gland, one to the left. Tumour diameter ranged from 3 to 5 cm. The laparoscopic procedure was successful in four of the patients (three right, one left). In the fifth case the operations had to be completed by conventional surgery, because of non-controllable haemorrhage. Duration of operation ranged between 165 and 360 min for right adrenalectomy and was 135 min for the left one. Rapid convalescence, lower dose of pain-killing drug required, short hospital stay and good cosmetic results characterized the postoperative course after the laparoscopic procedure. This technique thus opens up new perspectives for adrenal surgery.