title: Diagnostic dilemmas in enlarged and diffusely hemorrhagic adrenal glands.
abstract: We have noted an increasing number of cases of enlarged adrenal glands where the underlying diagnosis was masked by a diffusely hemorrhagic process. We identified from our database 59 cases (32 consults, 27 routine) of adrenal glands with diffuse (>25%) hemorrhage received between 2000 and 2014. Fifty-three adrenalectomies and 6 biopsies were identified. The diagnoses after central review were 41 adrenocortical adenomas, 1 nodular adrenocortical hyperplasia with associated myelolipoma, 1 benign adrenocortical cyst, and 10 nonneoplastic adrenal glands with hemorrhage. A definitive diagnosis for the 6 biopsies was precluded by the sample size. The adrenocortical adenomas (size, 1-13 cm; 25%-95% hemorrhage) showed clear cell change in the neoplastic area (10%-80% of the tumor), 19 showed focal calcification (1 with ossification), 11 showed areas of papillary endothelial hyperplasia, 10 showed scattered lymphoplasmacytic inflammation, 6 showed benign cortical tissue extending beyond the adrenal capsule into soft tissue, 1 showed necrosis in the form of ghost cells, 2 showed lipomatous change, and 6 were associated with incidental benign lesions (1 cortical cyst, 1 schwannoma, and 4 myelolipomas). Twenty-four of the adrenocortical adenomas were consults where the referring pathologist had trouble classifying the lesion. Of the 10 nonneoplastic adrenals (4.5-22 cm; 40%-80% hemorrhage), 2 were consults. In summary, pathologists have difficulties recognizing adrenocortical adenomas in the setting of a massively enlarged and hemorrhagic adrenal gland. Although there is a correlation between adrenocortical malignancy and size, hemorrhage into nonmalignant adrenal glands can result in markedly enlarged adrenals.
authors.affiliation: The Department of Pathology, The Johns Hopkins Medical Institutions, Baltimore, MD 21231.
authors.forename: Mairo L
authors.initials: ML
authors.lastname: Diolombi
authors.affiliation: The Department of Pathology, The Johns Hopkins Medical Institutions, Baltimore, MD 21231.
authors.forename: Francesca
authors.initials: F
authors.lastname: Khani
authors.affiliation: The Department of Pathology, The Johns Hopkins Medical Institutions, Baltimore, MD 21231; The Department of Urology, The Johns Hopkins Medical Institutions, Baltimore, MD 21231; The Department of Oncology, The Johns Hopkins Medical Institutions, Baltimore, MD 21231. Electronic address: jepstein@jhmi.edu.
authors.forename: Jonathan I
authors.initials: JI
authors.lastname: Epstein
mesh_terms: D000306:Adrenal Cortex Neoplasms / Q000473:pathology; D000307:Adrenal Gland Diseases / Q000473:pathology*; D000310:Adrenal Gland Neoplasms / Q000473:pathology*; D000311:Adrenal Glands / Q000473:pathology*; D018246:Adrenocortical Adenoma / Q000473:pathology; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001706:Biopsy; D003560:Cysts / Q000473:pathology; D016208:Databases, Factual; D003937:Diagnosis, Differential; D005260:Female; D006470:Hemorrhage / Q000473:pathology*; D006801:Humans; D006984:Hypertrophy; D008297:Male; D008875:Middle Aged; D018209:Myelolipoma / Q000473:pathology; D009336:Necrosis; D011237:Predictive Value of Tests; D011379:Prognosis; D047368:Tumor Burden
keywords: Adrenal cortical adenoma; Hemorrhage; Myelolipoma; Nonneoplastic adrenal gland; Vascular lesions