Functional plurihormonal adrenal oncocytoma: case report and literature review

Androgen producing oncocytic adrenocortical tumor in a 3.7-year-old female

Summary

We report a 3.7-year-old female who presented with clinical features of premature adrenarche. Workup revealed significantly elevated androgen levels and advanced bone maturation, prompting abdominal imaging that identified a 6.0 cm adrenal mass. She underwent unilateral adrenalectomy, and subsequent histopathology revealed a benign oncocytic adrenocortical adenoma. Post-adrenalectomy, androgen levels returned to pre-pubertal levels. A review of the literature on pediatric oncocytic adrenocortical neoplasms (OANs) is presented, and we add our case to the growing data of this rare disease in the pediatric population.

Learning points

A high index of suspicion is necessary when encountering a prepubertal child with clinical signs of hyperandrogenism and advanced bone age. Oncocytic adrenocortical neoplasms are rare in children and are often benign, although they can be malignant or of uncertain malignant potential. Adrenalectomy is necessary for histopathological diagnosis and definitive treatment. Pediatric oncocytic adrenocortical neoplasms are typically associated with elevated androgens; however, they can have a variety of other abnormal hormonal profiles at presentation. Return to normal hormonal levels is common post-adrenalectomy.

Oncocytic adrenocortical neoplasm with undetermined malignant potential and autonomous cortisol secretion

Increasing incidence of adrenal incidentalomas with hypercortisolemia not associated with overt features of Cushing's syndrome has led to the evolution of the term autonomous cortisol secretion. Oncocytic adrenocortical neoplasms (OANs) are rare adrenal cortex neoplasms with only 250 reported cases worldwide. We present a woman in her 30s with menometrorrhagia, weight gain and increasing abdominal girth who was found to have a large right adrenal mass on abdominal CT scan. Serum cortisol was not suppressed after 1 mg dexamethasone (31.5 µg/dL) and adrenocorticotrophic hormone was not detectable (<1.0 pg/mL). She underwent right adrenalectomy under glucocorticoid coverage. Hypertension, weight, visceral adiposity and menometrorrhagia improved postoperatively. Histopathology with immunohistochemistry showed OAN with undetermined malignant potential. These kinds of tumours can only be definitively diagnosed postsurgically using the Lin-Weiss-Bisceglia system. Although they have better prognosis compared with adrenocortical carcinomas and do not require chemotherapy, patients should be closely monitored to identify recurrence promptly.

Pediatric Adrenocortical Oncocytoma presenting as Cushing's Syndrome and Peripheral Precocious Puberty: A Case Report and Review of Literature

Oncocytic adrenocortical tumours (OATs) or oncocytomas are extremely rare and are usually benign and nonfunctional. We report the case of a 4-year-old male with a right-sided, functional oncocytic adrenocortical adenoma, who presented with precocious puberty and Cushing's syndrome. After work-up, the patient underwent laparoscopic adrenalectomy. The excised adrenal mass weighed 21 g and measured 3.5 cm in maximum dimension. Histological examination demonstrated no features suggestive of aggressive biological behaviour. The patient had no features of recurrent or metastatic disease and had prepubertal testosterone levels with suppressed hypothalamic-pituitary-adrenal axis twelve months after the surgery. A discussion of this case and a review of the literature on functional OATs in the pediatric population are presented.

Case Report: A Virilizing Adrenal Oncocytoma

A 64-year-old female was admitted to our clinic with a 9-cm-sized adrenal mass. The patient's main symptom was hirsutism, which included thinning scalp hair and excessive hair growth over her torso and arms. Upon investigation, elevated values of testosterone, androsterone D4, and DHEA-S were found. Contrast-enhanced abdominal CT and MRI scans revealed a heterogenous large mass (diameter 9 × 8.5 cm) with focal calcifications, necrotic areas, and a clear distinction from the adjacent structures. The patient underwent a right adrenalectomy. The histological examination of the tumor revealed a borderline adrenocortical oncocytoma. The patient had an uncomplicated postoperative course and was discharged on postoperative day 8. Similar cases reported in the literature are also being reviewed in this case report.

Laparoscopic resection of an adrenal oncocytic neoplasm: Report of a case and review of the literature

•

Oncocytic adrenal neoplasms are rare and mostly benign lesions.

•

Preoperative determination of malignancy remains difficult.

•

Surgical excision planification is based on preoperative investigations.

Introduction

Oncocytic adrenal neoplasms are rare and mostly benign lesions. Available literature supports indication for a surgical resection, but criteria to predict aggressive behavior are unreliable, thus making decision of surgical approach (laparotomy versus laparoscopy), and extent of resection, difficult to define.

Presentation of case

This is the case of a 46-year-old male, with an incidental finding of a 10 cm asymptomatic tumor in the left adrenal gland identified by MRI, performed in the setting of the initial assessment of liver steatosis. Adrenal hormone levels were in the normal range, thus, a CT-guided needle biopsy was performed and showed an adrenocortical oncocytic neoplasm. A laparoscopic left adrenalectomy was performed sparing the adjacent left kidney. Histological examination of the resected tumor showed a 10 cm oncocytic adrenocortical neoplasm of uncertain malignant potential with negative resection margins. A follow-up MRI was scheduled at six months after surgery, and no recurrence was found.

Conclusions

Although rare, oncocytic neoplasms should be included in the differential diagnosis of adrenal “incidentalomas”. Determination of their malignant potential is difficult in the preoperatory setting. Final diagnosis is based on histological analysis of the whole surgical specimen. Laparoscopic complete excision with negative resection margins is feasible and safe.

[Cushing's syndrome due to bilateral oncocytic adrenal tumor]

Cushing&rsquo;s syndrome accounts for approximately 20&ndash;30% of endogenous hypercortisolism cases, and adrenal involvement can be either unilateral or bilateral. Cushing&rsquo;s syndrome due to bilateral adrenal tumors is extremely rare. Adrenal oncocytomas are another rare cause of endogenous hypercortisolism: about 13 cases are described in the literature. Oncocytomas are rare epithelial neoplasms, characterized by abnormally excessive accumulation of defective mitochondria in the cytoplasm of cells, and make up 1.8% of all adrenal neoplasms. We describe a 58-year old patient with Cushing&rsquo;s syndrome and bilateral adrenal tumors. Multispiral computed tomography of the adrenals showed signs suspicious of lipid-poor atypical adenomas or malignant tumors. Surgical treatment was the method of choice, and the larger tumor was excised first. Due to the absence of remission of endogenous hypercortisolism the excision of the second tumor was performed. Morphological and immunohistochemical examination confirmed the diagnosis of bilateral oncocytic adrenocortical tumors with uncertain malignant potential. Cases of bilateral hormone-producing adrenal oncocytomas have not been described in the literature.

A rare combination of giant right retroperitoneal schwannoma and right adrenal oncocytoma as an incidental finding

Adrenal oncocytomas and retroperitoneal schwannomas are two groups of very rare tumors with distinct histologic features. Both tumors are usually incidentally found and are mostly benign. Optimal management is usually with surgical resection. We report a unique case of a 74-year-old woman who was incidentally found to have these two exceptionally rare tumors at the same time. She was successfully managed with surgical resection of the retroperitoneal schwannoma and adrenalectomy for the adrenal oncocytoma and both diagnoses were confirmed with histopathology and immunochemistry.

Functional plurihormonal adrenal oncocytoma: case report and literature review

We present a 27-year-old woman with an adrenal oncocytoma. This is a very rare entity. We provide a review of the clinical, biochemical and pathological features of cases reported in the literature.