Contributed by Firas G. Petros, M.D.
CT of left adrenal mass
MRI of left adrenal mass
Contributed by Debra L. Zynger, M.D.
Ill defined spongy lesion
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White solid and cystic surface
Cystic surface
Cystic spongy surface
Solid gray surface
Contributed by Debra L. Zynger, M.D.
Cystic lesion
Anastomosing channels
Microcysts
Delicate septae
Tubules and signet rings
Entrapped cortex
Lymphoid aggregates
Calcification
Infiltrative
CK7
WT1
MelanA
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Homogeneous left adrenal mass with distinct borders
Left adrenal mass
(A) Plain CT and (B) contrast CT show left suprarenal mass
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Moon facies and central obesity
Contributed by @Andrew_Fltv and @SueEPig on Twitter
Adenoma
Adenoma
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External surface, during surgery
Intact capsule
Well circumscribed
1.3 cm left adrenal adenoma
3 x 3 cm exophytic adrenal mass
Contributed by Xiaoyin "Sara" Jiang, M.D., Debra Zynger, M.D., @Andrew_Fltv on Twitter and @SueEPig on Twitter
Spironolactone bodies with aldosteronoma
Adenoma with spironolactone bodies
Adrenal cortical aldosterone producing adenoma
Adenoma
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Multiple ACAs comprised of clear cells
Resembles normal adrenal fasciculata
Clear cells
Low power
S100- basement cells
Contributed by Edward Calomeni, B.S.
Spironolactone bodies
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Diagnostic algorithm for ACC stratification
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Heterogeneous enhancing mass with lymphadenopathy
CT imaging of advanced ACC
Contributed by Debra Zynger, M.D.
Organ confined, ≤ 5 cm (pT1)
Organ confined, > 5 cm (pT2)
Extra-adrenal invasion (pT3)
Liver invasion (pT4)
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250 g, 10 cm tumor
Large tumor compressing kidney
Large tumor dwarfing kidney
Contributed by Maria Tretiakova, M.D., Ph.D.
High nuclear grade
Pleomorphic ACC
Necrosis
Capsule / fat invasion
Positive margin
Reticulin loss
Diffuse growth
Ki67
MelanA
Inhibin
Contributed by Debra Zynger, M.D.
High mitotic rate
Lymphovascular invasion
Extra-adrenal adipose invasion
Liver involvement
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Discohesive, round to polygonal tumor cells
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Hallmark molecular features
Contributed by Debra L. Zynger, M.D.
Partial nephrectomy
Contributed by Yuto Yamazaki, M.D., Ph.D., Hironobu Sasano, M.D., Ph.D., Debra L. Zynger, M.D. and Sean R. Williamson, M.D.
Spermatic cord adrenal rest and SF1
Spermatic cord adrenal rests
Paratesticular adrenal cortical rest
Intrarenal adrenals
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Human adrenal gland
Adrenal gland zones and products
Paraganglia, anatomic location
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Longitudinal ultrasound, infant
CT, normal, teen
CT of normal adrenal glands
MRI of normal adrenal glands
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Normal adult glands, whole
Normal adult gland, sectioned
Right adrenal gland in situ
Contributed by Nicole Stringham, Ph.D. (source: University of Michigan virtual slide box) and Debra L. Zynger, M.D.
Adrenal gland full thickness
Zona glomerulosa and fasciculata
Zona glomerulosa
Zona fasciculata
Zona reticularis
Cortex medulla junction
Zona glomerulosa and fasciculata
Zona fasciculata
Zona fasciculata and reticularis
Zona reticularis
Zona reticularis with lipofuscin
Adrenal medulla
Contributed by Xiaoyin "Sara" Jiang, M.D.
Normal adrenal gland
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Zona glomerulosa
Adrenal chromaffin cells
Adrenal gland histology
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CT scan of abdomen showing a cystic adrenal lesion on the right
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Anterior linear crease
Posterior helical ear pits
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Large lobulated adrenal glands
Enlarged placenta with multiple vesicles
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Adrenocortical cytomegaly
Visceral anomalies in the fetus
Placental histological anomalies
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Giant endothelial cyst
Giant pseudocyst
Hydatid cyst
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Pseudocyst
Hydatid cyst
Contributed by Debra L. Zynger, M.D.
Endothelial cyst with clot
Endothelial cyst with minimal blood
Pseudocyst reclassified as endothelial cyst
Pseudocyst
Contributed by Debra L. Zynger, M.D. and Lan L. Gellert, M.D., Ph.D.
Endothelial cyst
Pseudocyst
Mesothelial cyst
Hydatid cyst
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Hydatid cyst
Contributed by Debra Zynger, M.D. and Maria Tretiakova, M.D., Ph.D.
Extra-adrenal adipose invasion (pT3)
High mitotic rate
Lymphovascular invasion
Myxoid variant
Oncocytic variant
Liver involvement (pT4)
Transition to myxoid area
Myxoid variant
Extra-adrenal adipose invasion (pT3)
Positive margin
Regional node involvement (pN1)
Contributed by Debra L. Zynger, M.D.
pT1
pheochromocytoma
pT2
pheochromocytoma
pT3 pheochromocytoma
pT2 sympathetic
paraganglioma
Contributed by Debra L. Zynger, M.D.
Capsular invasion
Vascular, capsular and adipose invasion
Cellular spindling
Nuclear pleomorphism
Mitosis
pT2 sympathetic
paraganglioma
pT3 pheochromocytoma
with extra-adrenal
adipose invasion
pT3 pheochromocytoma
with invasion
of the kidney
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Various images
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Spiral CT: hyperechoic mass
Contributed by Carmen Perrino, M.D. and Debra L. Zynger, M.D.
Stroma rich, intermixed type
Focal undifferentiated component
Stroma rich, nodular type
With treatment related changes
Contributed by Carmen Perrino, M.D. and Debra L. Zynger, M.D.
Intermixed type
Composite types
Intermixed type
Ganglion cells
Fibrillary background
Aggregate of ganglion cells
Lymphocyte aggregate
Area with Schwannian stroma
Maturing ganglion cells
Stroma rich, intermixed type
Nodular type
Stroma rich, nodular type
Neuroblast cell component
Homer Wright pseudorosettes
Vaguely formed Homer Wright pseudorosettes
Hemorrhagic component
Contributed by Carmen Perrino, M.D. and Debra L. Zynger, M.D.
Numerous ganglion cells
Contributed by Leica Biosystems
MYCN (2p24) / AFF3 (2q11)
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Various images
Contributed by @SueEPig on Twitter
Adrenal ganglioneuroma
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Adrenal ganglioneuroma
Adrenal ganglioneuroma, cut surface
Contributed by Carmen Perrino, M.D., Debra Zynger, M.D. and @SueEPig on Twitter
Prominent myxoid background
Scattered mature ganglion cells
Cluster of mature ganglion cells
Intervening stroma
Ganglioneuroma (top) and residual normal adrenal cortical cells (bottom)
Mature ganglion cells admixed with stroma
Mature ganglion cells
Adrenal ganglioneuroma
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Schwann cells and admixed ganglion cells (insets), neck
Schwann cells (a, c) and ganglion cells (b, d), neck
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Left adrenal gland
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Diffuse and nodular adrenal medullary hyperplasia
Contributed by Lan L. Gellert, M.D., Ph.D.
Adrenal medullary hyperplasia
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Unilateral adrenal metastasis from breast cancer
Right renal mass and the left adrenal metastatic mass on CT
Adrenal metastasis from
colon adenocarcinoma
before and after
chemotherapy
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Adrenal metastasis from ovarian carcinoma
Contributed by Lan L. Gellert, M.D., Ph.D.
Adrenal metastasis from lung adenocarcinoma
Adrenal metastasis from lung small cell carcinoma
Adrenal metastasis from clear cell renal cell carcinoma
Adrenal metastasis from melanoma
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Adrenal metastasis
from moderately
differentiated sigmoid
colon adenocarcinoma
Adrenal metastasis from ovarian clear cell carcinoma
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Abdominal US
CT abdomen findings
MRI findings
Giant bilateral myelolipomas of abdomen
CT axial section showing mass in right renal gland
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Large suprarenal mass
Contributed by Debra L. Zynger, M.D. and Anil Parwani, M.D., Ph.D.
Fat predominant
Extensive hemorrhage
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Intact adrenal specimen
Bright yellow and focally red, fatty tumor with extensive hemorrhage
Grey / brown / yellowish with hemorrhage
Well circumscribed
tumor with hemorrhage
Contributed by Debra L. Zynger, M.D., Anil Parwani, M.D., Ph.D., O. Hans Iwenofu, M.D., Ph.D. and @ThatGlassTho on Twitter
Hematopoietic cells
Increased megakaryocytes
Hematopoietic cells and mature fat
Hematopoietic cells and adrenal cortex
Myelolipoma in adrenal gland
Hematopoietic cells on core biopsy
Myelolipoma
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Survival analysis comparing myxoid ACC to other variants
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Myxoid ACC on CT, MRI and PET / CT imaging
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Robot assisted laparoscopic adrenalectomy
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Gelatinous and solid whitish appearance
Obvious areas of hemorrhage and necrosis
Contributed by Maria Tretiakova, M.D., Ph.D.
ACC with predominant myxoid component
Delicate arborizing cords
Mucin pools with floating cells
Pseudoglandular architecture
Complex architecture
Adjacent benign adrenal
Focal myxoid pattern
Transition to myxoid area
Microcystic architecture
Positive margin
pT3 myxoid ACC
Mitoses
Normal reticulin network
Loss of reticulin framework
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Right adrenal mass
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Congenital neuroblastoma
Caudally located neuroblastoma
Contributed by Carmen Perrino, M.D.
With anaplasia
Anaplasia and a mitotic figure
Homer-Wright pseudorosettes
High power pseudorosettes
Poorly differentiated
Dystrophic calcification
Posttreatment
Metastatic to bone marrow
Significant crush artifact
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Small round blue cell
Neuroblasts
Mats of neuropil and focal resetting
Differentiating bladder neuroblastoma
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Occasional rossetting
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C: neurosecretory dense core granules in the cytoplasm
Poorly differentiated neuroblasts
Widespread neuritic processes
Contributed by Leica Biosystems
MYCN (2p24) / AFF3 (2q11)
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CT imaging of oncocytic ACC
F18 FDG PET of oncocytic ACC
Contributed by Maria Tretiakova, M.D., Ph.D.
Large lobulated yellow mass
Contributed by Maria Tretiakova, M.D., Ph.D.
Oncocytic ACC with confluent necrosis
Diffuse discohesive growth
Trabecular pattern
Capsule invasion
Pleomorphic morphology
Nuclear pleomorphism
Abundant mitoses
Fat invasion & positive margin
Regional node involvement
Disrupted reticulin network
Contributed by Debra L. Zynger, M.D.
Subcapsular spindle cells
Spindle cells with entrapped adrenal cortical cells
Bland spindle cells
Thick hyalinized fibers
WT1
Desmin
MelanA
Contributed by Luvy Delfin, M.D., Sylvia L. Asa, M.D., Ph.D. and Debra Zynger, M.D.
Adrenal pheochromocytoma
Para-aortic paraganglioma
Carotid body paraganglioma
Parapharyngeal paraganglioma
Contributed by Luvy Delfin, M.D. and Sylvia L. Asa, M.D., Ph.D.
Adrenal pheochromocytoma
Duodenum
Pheochromocytoma
Organ of Zuckerkandl
Pheochromocytoma in VHL
Pheochromocytoma with metastatic behavior
Metastatic pheochromocytoma in lymph node
Metastatic paraganglioma in bone
Composite pheochromo-
cytoma with ganglioneuroma
Middle ear: jugulotympanic paraganglioma
Cardiac paraganglioma
Para-aortic paraganglioma
Carotid body paraganglioma
S100
Chromogranin
GATA3
Tyrosine hydroxylase
S100 protein
SOX10
Ki67
SDHB intact
SDHB deficient
CAIX
Inhibin
S100 staining in metastatic pheochromocytoma
Ki67 in metastatic pheochromocytoma
Contributed by Luvy Delfin, M.D. and Sylvia L. Asa, M.D., Ph.D.
Paraganglioma
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CT and scintigraphy
MRI
PET / CT and scintigraphy
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Café au lait spots and axillary freckling in NF1
Intraoperative
images of giant
pheochromocytoma
Contributed by Debra L. Zynger, M.D. (Case #319)
Well circumscribed tan mass
Well circumscribed tan mass
Renal invasion
Composite
pheochromocytoma
Contributed by Debra L. Zynger, M.D. (Case #319), Brian Werstein, M.D. and Nicole K. Andeen, M.D. (Case #489)
Nested architecture
Sheets of cells
Abundant cytoplasm
Capsular invasion
Adipose invasion
Vascular invasion
Cellular spindling
Nuclear pleomorphism
Mitotic activity
Necrosis
Large nests
Lymph node metastasis
Synaptophysin
Chromogranin
GATA3
S100
S100
Composite pheochromocytoma with ganglioneuroma
Contributed by Debra L. Zynger, M.D.
Diff-Quik
Touch preparation
Contributed by Debra L. Zynger, M.D. and Edward Calomeni, B.S.
Numerous epinephrine granules
Norepinephrine granules
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Neurosecretory granules
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NF1 mutation
TMEM127 mutation
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Survival analysis:
sarcomatoid ACC
versus other
variants
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CT scan: necrotic areas replacing adrenal gland
Coronal abdominal CT with large adrenal mass
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Whitish fleshy, variegated hemorrhagic and necrotic surface
Tumor adherent
to pancreas (A)
and compressing
kidney (B)
Contributed by Maria Tretiakova, M.D., Ph.D.
Sarcomatoid ACC biphasic
Epithelioid and spindle cells
Heterologous differentiation
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Epithelioid and spindle cell components
Contributed by Debra Zynger, M.D.
Organ confined, ≤ 5 cm (pT1)
Organ confined, > 5 cm (pT2)
Extra-adrenal invasion (pT3)
Liver invasion (pT4)
Contributed by Debra Zynger, M.D. and Maria Tretiakova, M.D., Ph.D.
Extra-adrenal adipose invasion (pT3)
Liver involvement (pT4)
Regional node involvement (pN1)
Images hosted on other servers:
Children's Oncology
Group (COG)
neuroblastoma risk
grouping system
INRG stage definitions
INRG consensus pretreatment classification
Contributed by Debra L. Zynger, M.D.
pT1
pheochromocytoma
pT2
pheochromocytoma
pT3 pheochromocytoma
pT2 sympathetic
paraganglioma
Contributed by Debra L. Zynger, M.D., Brian Werstein, M.D. and Nicole K. Andeen, M.D. (Case #489)
pT2 sympathetic
paraganglioma
pT3
pheochromocytoma
with extra-adrenal
adipose invasion
pT3
pheochromocytoma
with invasion
of the kidney
pN1
pheochromocytoma
Contributed by Eric L. Vey, M.D
Fatal meningococcemia in 10 month old boy
Adrenal glands in situ
Normal (top) and hemorrhagic (bottom) adrenal glands
Gill: 2022
IARC: 2017
Lack: 2007
Lloyd: 2002
Mete: 2016
Nosé: 2022
Tickoo: 2015
VandenBussche: 2022
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