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Adrenal cancer
Pathology

Histologic Findings: A specific histologic diagnosis may be difficult in a case that is lacking clinical evidence of metastasis. Some of the macroscopic features that suggest malignancy include a weight of more than 500 g, the presence of areas of calcification or necrosis, and a grossly lobulated appearance. Most adrenal cortical carcinomas are large, but size alone either has no effect on survival time or has minimal effect.

Adrenal adenomas are usually well encapsulated and homogeneous on cross-section and do not metastasize; in contrast, adrenal carcinomas are large, multilobulated tumors with areas of necrosis and evidence of capsular and vascular invasion.

Various systems of histologic diagnosis have been proposed for adrenal cortical carcinomas,
but the most commonly used system is the one described by Medeiros andWeiss. Nine histologic findings have been described:

1. High nuclear grade
2. Mitotic grade greater than 5 mitoses/50 high-power fields (HPF)
3. Atypical mitotic figures
4. Eosinophilic tumor cell cytoplasm
5. Diffuse architecture
6. Necrosis
7. Venous invasion
8. Sinusoidal invasion
9. Capsular invasion

Malignant tumors meet four or more of these histologic criteria. The three most commonly found are a mitotic rate greater than 5 mitoses/50 HPF, atypical mitotic figures, and venous invasion.
The mitotic rate is an important criterion not only for distinguishing malignant from benign tumors, but also for predicting the clinical virulence of adrenal cortical carcinomas.

Patients with carcinomas having a high mitotic rate (more than 20 mitoses/10 HPF) have a shorter disease free survival period than patients whose carcinomas have a low mitotic rate (less than 20 mitoses/10 HPF).

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Depending on the degree of cell differentiation, adrenal cortical carcinomas have been classified as well-differentiated or anaplastic. Although well-differentiated carcinomas may have a less aggressive course than the anaplastic tumors, cell differentiation may not predict survival independently of the mitotic rate.

Microscopically, adrenocortical carcinoma is a malignant neoplasm of the adrenal cortical cells demonstrating partial or complete histological and functional differentiation.

• Differentiated: Functioning tumors are usually differentiated. Approximately 60% of adrenocortical carcinomas produce hormones.
• Anaplastic: Production of hormones by anaplastic tumors is rare.
• Hormonal.

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