3.2.3 Adrenal Pathology

Question 1

How would this person look without Cushing’s?

Answer 1

Question 2

What is the rule of 10s in regards to pheochromocytoma?

Answer 2

Question 3

Chromaffin cells release what? What are chromaffin cells innervated by?

Answer 3

Epinephrine

Pre-ganglionic fibers that release acetylcholine

Question 4

What are some of the sources of adrenal hyperfunction?

Answer 4

Question 5

What are the important anatomical features of the adrenal gland?

Answer 5

Cortex - Steroid hormones

Medulla - Catecholamines

Question 6

What are the main causes of Addison’s disease (5)?

Answer 6

Granulomatous inflammation

Metastatic carcinoma

Amylodosis

Surgical removal

Idiopathic

Question 7

What are the specific lab findings associated with pheochromocytoma?

Answer 7

Elevated metanephrines and chromogranin A

Elevated urinary catecholamines

Presence of adrenal mass on CT

Question 8

What is the arrow pointing to in this cell?

Answer 8

Adrenal medulla, ganglion cells (black arrow), Trichrome, 40x. The remaining cells are the small clusters of pheochromocytes.

Question 9

Endocrine hyperfunction is usually due to what?

Answer 9

Increased tropic hormone

Neoplasms

Exogeneous artificial hormones

Question 10

What is the clinical triad associated with pheochromocytoma?

Answer 10

Clinical triad - Headache, sweating, and heart palpitations

If hypertension is also found it raises the probability of pheochromocytoma to 90%

Question 11

What is this an image of?

Answer 11

Adrenal gland - normal

Slide photo: Normal adrenal, trichrome stain. Note that the thin zona glomerulosa can easily be seen under the capsule, even at low power. The lipid-rich zona fasciculata is also discernible. The zona reticularis has less fat, and the medulla can be clearly separated from it.

Question 12

What lung neoplasm commonly leads to Cushing’s Syndrome?

Answer 12

Small cell carcinoma

Question 13

What is this an image of? Go ahead an identify the layers TANNER!

Answer 13

Question 14

What are the two main acute causes of adrenal hypofuction?

Answer 14

Waterhouse-Friedrichson syndrome

Steroid withdrawl

Question 15

What is this an image of?

Answer 15

Diffuse hyperplasia

Diffuse hyperplasia is found in 60% to 70% of cases of Cushing syndrome.

Question 16

Adrenal gland hypofunction is typically due to?

Answer 16

Inflammation

Surgical excision

Circulating defect

Congenital enzyme defect

Neoplasm compressing normal gland

Question 17

What are the characteristics of Cushing’s Syndrome?

Answer 17

Increased mineralcorticoids - Salt and water retention and potassium depletion

Increased glucocorticoids - obesity, hyperglycemia, decreased protein, euphoria

Increased androgens - hirsutism, acne, amenorrhea, and polycythemia

Question 18

What is the differenct between the two figures in this image?

Answer 18

Left is normal

RIght is atrophied (Sheehan syndrome)

Question 19

What in Conn’s syndrome?

Answer 19

Mineralcorticoid-secreting adenoma often in the glomerulosa

Question 20

How will Addison’s disease present in clinic?

Answer 20

Increased skin pigmentation

Hypotension

Loss of Libido

Hyponatremia

Hyperkalemia (Na and K are due to overlap of glucocorticoid and mineralcorticoid)

Hypoglycemia

Question 21

What is this an image of?

Answer 21

Pheochromocytoma

Note the small amount of normal adrenal. The tumor at the top of the slide is separated from it by a fibrous pseudocapsule, which is often a sign of a benign prognosis.

Question 22

What is this an image of?

Answer 22

Pheochromocytoma

You can see the fine capillaries surrounding nests of cells (zellballen), most easily seen in the middle of the photomicrograph . There is mild atypia, meaning that the nuclei are of different size, shape, and darker blue color (more DNA) as compared to normal.

Question 23

What is this an image of?

Answer 23

Anaplasia in adrenal carcinoma.

Atypical cells with big blue nuclei

Question 24

How would you treat pheochromocytoma?

Answer 24

Surgical removal

Pre-surgical preparation with alpha and beta blockers

Question 25

What is this an image of?

Answer 25

Primary hyperplasia ## Footnote Primary adrenal neoplasms, such as adrenal adenoma and carcinoma, and primary cortical hyperplasia are responsible for about 10% to 20% of cases of endogenous Cushing syndrome. This form of Cushing syndrome is also designated ACTH-independent Cushing syndrome or adrenal Cushing syndrome because the adrenals function autonomously. The biochemical sine qua non of adrenal Cushing syndrome is elevated serum levels of cortisol with low levels of ACTH

Question 26

What is this an image of?

Answer 26

**Adrenal, carcinoma.** Note necrosis, evident grossly. The carcinomas associated with Cushing syndrome, by contrast, **tend to be larger than the adenomas**. These tumors are **unencapsulated masses** frequently exceeding 200 to 300 gm in weight, having all of the anaplastic characteristics of cancer, as will be detailed later. With functioning tumors, both benign and malignant, the adjacent adrenal cortex and that of the contralateral adrenal gland are atrophic, owing to suppression of endogenous ACTH by high cortisol levels.

Question 27

What is this an image of?

Answer 27

This would be a classic example of what a **pheochromocytoma** should look like on the national boards. Look for expansion of the gray-brown medulla, which is normally quite thin. You can see the lipid-rich adrenal cortex around it.

Question 28

What is this an image of?

Answer 28

Waterhouse-Friedrichson syndrome (Most commonly caused by Nesseria Meningitis) Infarction of the adrenal gland

Question 29

What is this image of and what causes it?

Answer 29

Sheehan syndrome - caused by ischemic necrosis due to blood loss

Question 30

What is this an image of?

Answer 30

Pheochromocytoma

Question 31

What is this an image of?

Answer 31

Cortical Adenoma