Adrenal Flashcards
Deficiency of 21-hydroxylase: Laboratory finding.
Elevated 17-hydroxyprogesterone.
Congenital lipoid adrenal hyperplasia: Definition.
Severest form of congenital adrenal hyperplasia: All gonadal and adrenal cortical steroids are markedly underproduced.
Congenital lipoid adrenal hyperplasia: Genes (2).
StAR (steroidogenic acute regulatory) protein.
P-450scc.
Classic presentation of congenital adrenal hyperplasia in females:
A. Newborn.
B. Older (3).
A. Virilization.
B. Postpubertal: Oligomenorrhea, hirsutism, acne.
Classic presentation of congenital adrenal hyperplasia in males:
A. Newborn.
B. Older (3).
A. Salt-losing crisis.
B. Prepubertal: Precocious puberty.
Non-classic presentation of congenital adrenal hyperplasia (3).
Newborns: Normal.
Around puberty: Virilization.
Pregnancy: May present with adrenal insufficiency.
Congenital adrenal hyperplasia: Histopathology (3).
All three cortical layers are thickened, but especially the zona reticularis.
Loss of zonation.
Lipid-poor cells.
Congenital lipoid adrenal hyperplasia: Histopathology.
Cholesterol-overloaded cells with rupture and cholesterol esters.
Congenital adrenal hyperplasia: Complication.
Adrenal cortical adenoma or carcinoma.
Congenital adrenal hyperplasia: Effect on adrenal medulla.
Glucocorticoid deficiency can impair development of the medulla, resulting in epinephrine deficiency and hypoglycemia.
Autoimmune adrenal insufficiency:
A. Frequency.
B. Antibodies (3).
A. Accounts for 75-90% of cases of primary adrenal insufficiency.
B. 21-hydroxylase, 17-hydroxylase, P-450scc.
Primary vs. secondary adrenal insufficiency: Biochemical differences (3).
Primary: Low ACTH, low aldosterone, high renin.
Secondary: High ACTH, normal aldosterone, normal renin.
Primary vs. secondary adrenal insufficiency: Gross-pathology difference.
Primary: Small, pale adrenal gland.
Secondary: Enlarged gland.
Adrenal insufficiency: How much adrenal tissue is essential to normal function?
About 10%.
Autoimmune polyglandular syndromes.
APS-1: Includes candidiasis and alopecia; mutation in AIRE-1.
APS-2: Schmidt’s syndrome.
Primary adrenal cortical hyperplasia: Types (3).
ACTH-independent macronodular hyperplasia.
Primary pigmented nodular adrenal cortical disease.
Other.
ACTH-independent macronodular hyperplasia: Syndrome that can cause it, and its gene.
McCune-Albright syndrome, GNAS1.
Primary pigmented nodular adrenal cortical disease: Syndromes (2).
Carney’s complex.
Isolated primary pigmented nodular adrenal cortical disease.
Primary pigmented nodular adrenal cortical disease: Genes (2).
PRKAR1A.
PDE11A.
Other syndromes (2) that can cause bilateral adrenal hyperplasia.
MEN-1.
FAP.
Secondary adrenal cortical hyperplasia: Causes (2).
Pituitary adenoma or hyperplasia.
Ectopic ACTH.
Adrenal cortical hyperplasia: Presentation.
Primary: Various endocrine abnormalities.
Secondary due to pituitary: Severe, typical Cushing’s syndrome.
Secondary due to ectopic ACTH: Severe, atypical Cushing’s syndrome.
Adrenal cortical hyperplasia: Pharmacological therapy.
Ketoconazole and similar drugs.
Adrenal cortical hyperplasia: Degree of enlargement (3).
Severe: Ectopic ACTH, AIMAH.
Mild or moderate: Pituitary disease, PPNAD.
Grossly inapparent: Conn’s syndrome due to hyperplasia of zona glomerulosa.
Enlargement may be nodular or diffuse.
Hyperplasia of zona glomerulosa: Histopathology (3).
Involvement limited to the periphery of the gland.
Abnormal continuity of the zona.
More than 5 nests thick.
ACTH-independent macronodular adrenal cortical hyperplasia: Histopathology (2).
Mixture of large clear cells and small compact cells.
Nodules of cells containing dark brown pigment.
Primary pigmented nodular adrenal cortical disease: Histopathology.
Cortical tissue between nodules is atrophic and disorganized.
Adrenal cortical hyperplasia: Immunohistochemistry.
AIMAH: 3β-hydroxysteroid dehydrogenase.
PPNAD: Synaptophysin, 17α-hydroxylase.
Clinical findings that favor adrenal adenoma over adrenal hyperplasia (2).
Solitary, unilateral nodule.
Evidence of autonomous growth.
Adrenal cortical adenoma: Familial syndromes (3).
MEN-1.
Familial hyperaldosteronism.
Congenital adrenal hyperplasia.
Spoardic adrenal cortical adenoma associated wth Conn’s syndrome: Genes (3).
KCNJ5: Potassium channel.
ATP1A1, ATP2B3: Na/K-ATPases.
Adrenal cortical adenoma: Most common hormonal excess.
None: Most adenomas are nonfunctioning.
Adrenal cortical adenomas: Presentations of the functioning types (4).
Cushing’s syndrome.
Conn’s syndrome.
Virilization (rare).
Feminization (strongly suggests adenocarcinoma).
Adrenal cortical adenomas: Possible colors (3).
Golden yellow: Conn’s syndrome.
Mahogany: Oncocytic.
Black: Pigmented (lipofuscin).
Adrenal cortical adenoma associated with Conn’s syndrome: Histopathology (2).
Clear, lipid-rich cytoplasm.
Spironolactone bodies (if spironolactone has been given).
Adrenal cortical adenoma: Histopathology of non-adenomatous tissue (2).
Cushing’s syndrome: Atrophy of zona reticularis.
Conn’s syndrome: Paradoxical hyperplasia of zona glomerulosa.
Electron microscopy of adrenal cortical adenomas: General (3).
Much lipid.
Much smooth endoplasmic reticulum.
Many mitochondria.
Electron microscopy of adrenal cortical adenomas: Mitochondria (2).
Aldosterone-producing cells: Lamellar cristae.
Steroid-producing cells: Tubulovesicular cristae.
Epithelioid angiomyolipoma: Biological behavior.
Can be malignant.
Epithelioid angiomyolipoma: Histopathology (2).
Polygonal epithelioid cells with much cytoplasm and sometimes with a large nucleolus, forming nests or sheets.
Some cells may be multinucleate or bizarre.
Epithelioid angiomyolipoma:
A. Immunohistochemistry.
B. Electron microscopy.
A. Cells express melanocytic and myoid markers.
B. Melanosomes and pre-melanosomes.
Adrenal cortical carcinoma: Hereditary syndromes (5).
Li-Fraumeni.
Beckwith-Wiedemann.
MEN-1.
Carney’s complex.
Hereditary isolated glucocorticoid deficiency.
Adrenal cortical carcinoma: Genes mutated in sporadic tumors (6).
TP53.
β-Catenin.
Menin.
PRKAR1A.
IGF-II.
MC2-R.
Adrenal cortical carcinoma:
A. How many are functional?
B. What is the most common function?
A. About 79%.
B. Virilization due to secretion of 17-ketosteroids and DHEA.
Adrenal cortical carcinoma: Treatment (2).
Complete resection if possible; otherwise, mitotane.
Adrenal cortical carcinoma: Typical size and weight.
14-15 cm; 100-1000 g.
Adrenal cortical carcinoma: Features diagnostic for malignancy (3).
Weight greater than 100 g.
Vascular invasion.
Metastasis.
ACTH-independent macronodular hyperplasia: Other associated genes.
ACTH receptor.
GIP, β-adrenergic receptor, LH receptor.
Adrenal cortical carcinoma: Diagnostic immunohistochemistry (4,2,2).
Positive: Inhibin-α, steroidogenic factor-1, Melan-A, D11.
Negative: β-Catenin (aberrant loss), chromogranin,
Variable: Cytokeratins, synaptophysin.
Adrenal cortical carcinoma: Prognostic immunohistochemistry (2).
Ki-67.
Cyclin E: Positive staining implies advanced stage.
Vascular invasion by adrenal cortical carcinoma:
A. Definition.
B. Sites of metastasis.
A. Thrombus must accompany tumor cells.
B. Liver, lung, lymph nodes.
Adrenal medullary hyperplasia: Associations (4).
MEN 2a, MEN 2b.
Beckwith-Wiedemann syndrome.
Cystic fibrosis.
Not: VHL syndrome, neurofibromatosis.