Composite adrenal medullary tumor: A rare cause of hypertension in a young male

Mixed cortico-medullary adrenal carcinoma in children: looks are deceptive!!

Background

Mixed cortico-medullary adrenal carcinoma (MCMAC) is an extremely rare entity with scarce literature on its cytomorphology.

Case presentation

A 2-year-old girl presented with abdominal pain for 3 days and a past history of fever with significant weight loss. On examination, a non-tender left hypochondrial firm mass and an enlarged left supraclavicular node were found. Twenty-four-hour urinary levels of VMA were marginally high. Contrast-enhanced computed tomography of the abdomen showed a suprarenal heterogeneous mass encasing major vessels. Aspiration cytology of both mass and node showed similar features comprising a predominant population of singly scattered large cells with moderate cytoplasm, eccentric nucleus and prominent nucleolus in a necrotic background. Tumour cells expressed Synaptophysin and Melan-A. In view of increasing respiratory distress, debulking surgery was performed, and histopathology of the specimen revealed the presence of both malignant medullary and cortical components supported by immunohistochemistry making a final diagnosis of MCMAC. The patient succumbed to death in the postoperative period. The cytology slides were reviewed and were seen to show a dual cell population.

Conclusion

Coexistent malignant cortical and medullary tumour of the adrenal gland is the first case reported in the paediatric age group in the literature with only three previous case reports in adults.

Composite pheochromocytoma/paraganglioma-ganglioneuroma: analysis of SDH and ATRX status, and identification of frequent HRAS and BRAF mutations

INTRODUCTION

Composite pheochromocytoma/paraganglioma (CP) is a rare neoplasm with most cases presented as single reports. Little is known about its pathogenesis and relationship with ordinary pheochromocytoma (PCC) or paraganglioma (PGL). Our study is aimed at analyzing the status of SDH and ATRX and identifying novel genetic changes in CP.

METHODS

Eighteen CP cases were collected. SDH and ATRX status was screened by immunohistochemistry. Targeted region sequencing (TRS) was successfully performed on formalin-fixed paraffin-embedded tissues in two cases within 3 years. Based on the TRS result, Sanger sequencing of BRAF and HRAS was performed in fifteen cases (including the two cases with TRS performed), with three cases excluded due to the limited amount of tissue.

RESULTS

Histopathologically, all the cases were composite PCC/PGL-ganglioneuroma (GN). The GN components were either closely admixed or juxtaposed with the PCC/PGL components, with a highly variable percentage (10-80%). All cases stained positive for SDHB and ATRX. HRAS and BRAF mutations were identified during TRS. In the subsequent Sanger sequencing, 20.0% (3/15) harbored BRAF mutations (K601E and K601N) and 46.7% (7/15) harbored HRAS mutations (Q61R, Q61L, G13R). The mutation rates were both significantly higher than reported in ordinary PCC/PGL.

CONCLUSIONS

We demonstrated that composite PCC/PGL-GN might be a unique entity with frequent HRAS and BRAF mutations rather than genetic changes of SDH and ATRX. Our findings revealed the possible pathogenesis of composite PCC/PGL-GN and provided clues for potential treatment targets.

Composite Pheochromocytoma Presenting as Severe Lactic Acidosis and Back Pain: A Case Report

Pheochromocytoma is a rare, catecholamine secreting tumor arising from chromaffin cells. Presentation of this tumor is highly variable, the most common being hypertension, tachycardia, sweating, and headache. Lactic acidosis and back pain are rare complications of this tumor. We report a 51-year-old gentleman with composite pheochromocytoma, which is rarer than pheochromocytoma, presenting as severe back pain and lactic acidosis.

A rare and easily misdiagnosed tumor of the urinary bladder: primary composite pheochromocytoma

BACKGROUND

Composite pheochromocytoma, which is a tumor composed of ordinary pheochromocytoma and other components, is extremely rare in bladder. We present a case of this rarely seen tumor in bladder, and discuss the clinical features, behavior, pathologic findings, essentials of diagnosis and prognosis of this tumor after literature review.

METHODS

Specimens from a 55-year-old woman with primary composite pheochromocytoma in bladder were analyzed by immunohistochemical (IHC) and fluorescence in situ hybridization (FISH). Clinicopathological characteristics were also collected and discussed. Then, we searched and reviewed literatures related with composite pheochromocytoma that were published in PubMed over the last 80 years.

RESULTS

B-mode ultrasound scanner and Magnetic Resonance Imaging (MRI) detected a papillary and infiltrative tumor mass in the irregularly thickened posterior walls of the urinary bladder. Histologically, the tumor showed evidence of big ganglion-liked cells and small round cells in cystoscopy biopsy and typical "Zellballen" structure in gross specimen. On PubMed, a total of 58 cases of composite pheochromocytoma has been reported during 1933-2017.

CONCLUSION

Composite pheochromocytoma in urinary bladder, which has distinctive clincopathologic features, is an extremely rare disease and can only be diagnosed by pathologists. Diagnosis is difficult before histopathological examination and should be considered in patients with no risk factors for usual bladder tumor. The rate of metastasis and death is higher in cases where the second component is not ganglioneuroma. Fortunately, treatment of this type of tumor remains the same as pheochromocytoma. Patients with localized tumors have an extremely favorable prognosis.

Expression of Extracellular Signal-regulated Kinase 5 and Ankyrin Repeat Domain 1 in Composite Pheochromocytoma and Ganglioneuroblastoma Detected Incidentally in the Adult Adrenal Gland

Composite pheochromocytoma (cPC) is extremely rare, arising in the adrenal medulla as a mixture of PC and other tumors of neural origin. We herein report on a case of adrenal incidentaloma post-operatively diagnosed as cPC with ganglioneuroblastoma (GNBL). The PC component had 7 points on the PASS, a Ki-67 index of 5.1%, a focal absence of sustentacular cells, and no genetic aberrations in succinate dehydrogenase subunit B. The GNBL component exhibited no N-myc amplification. Tumor cells of both components were stained positively for extracellular signal-regulated kinase 5 and ankyrin repeat domain 1. The aberrant activation of growth signaling may play a role in the marginal malignancy of cPC.

Paragangliomas: update on differential diagnostic considerations, composite tumors, and recent genetic developments

Recent developments in molecular genetics have expanded the spectrum of disorders associated with pheochromocytomas (PCCs) and extra-adrenal paragangliomas (PGLs) and have increased the roles of pathologists in helping to guide patient care. At least 30% of these tumors are now known to be hereditary, and germline mutations of at least 10 genes are known to cause the tumors to develop. Genotype-phenotype correlations have been identified, including differences in tumor distribution, catecholamine production, and risk of metastasis, and types of tumors not previously associated with PCC/PGL are now considered in the spectrum of hereditary disease. Important new findings are that mutations of succinate dehydrogenase genes SDHA, SDHB, SDHC, SDHD, and SDHAF2 (collectively "SDHx") are responsible for a large percentage of hereditary PCC/PGL and that SDHB mutations are strongly correlated with extra-adrenal tumor location, metastasis, and poor prognosis. Further, gastrointestinal stromal tumors and renal tumors are now associated with SDHx mutations. A PCC or PGL caused by any of the hereditary susceptibility genes can present as a solitary, apparently sporadic, tumor, and substantial numbers of patients presenting with apparently sporadic tumors harbor occult germline mutations of susceptibility genes. Current roles of pathologists are differential diagnosis of primary tumors and metastases, identification of clues to occult hereditary disease, and triaging of patients for optimal genetic testing by immunohistochemical staining of tumor tissue for the loss of SDHB and SDHA protein. Diagnostic pitfalls are posed by morphological variants of PCC/PGL, unusual anatomic sites of occurrence, and coexisting neuroendocrine tumors of other types in some hereditary syndromes. These pitfalls can be avoided by judicious use of appropriate immunohistochemical stains. Aside from loss of staining for SDHB, criteria for predicting risk of metastasis are still controversial, and "malignancy" is diagnosed only after metastases have occurred. All PCCs/PGLs are considered to pose some risk of metastasis, and long-term follow-up is advised.

Composite pheochromocytoma-ganglioneuroma of the adrenal gland: A case report with immunohistochemical study

Composite tumors of the adrenal medulla consisting of pheochromocytoma and ganglioneuroma are rare tumors accounting for less than 3% of all sympathoadrenal tumors. These tumors display more than one line of differentiation in which normal and neoplastic chromaffin cells are capable of differentiating into ganglion cells under the influence of nerve growth factors. To the best of our knowledge, we report the second case with a composite tumor of the adrenal medulla in a normotensive patient from India.