PMC8850263_01
Imaging analysis. (A) Non-enhanced computed tomography (CT) at the first admission. (B, C) Non-enhanced (B) and enhanced (C) CT 3 years after the first admission. (D) T2-weighted magnetic resonance imaging (MRI) at the second admission.
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A 67-year-old woman was incidentally diagnosed with a nodular lesion in her right adrenal gland (25 x 29 mm) by non-enhanced abdominal computed tomography (CT) ( Figure 1A ). Three years after her admission, abdominal non-enhanced and enhanced CT demonstrated that the right adrenal tumor had enlarged (35 x 40 mm) and became heterogeneous ( Figures 1B, C ). Abdominal magnetic resonance imaging (MRI) was performed for the patient and showed a high-intensity region inside the tumor, suspected to be adrenal hemorrhage, despite having no abdominal pain ( Figure 1D ).
(A) Surgical specimen showing hemorrhage in the adrenal tumor. (B) Hematoxylin and eosin-stained tumor section showing hemorrhage in the tumor. (C) Hematoxylin and eosin-stained section on high magnification showing hemorrhage without vasculitis and ominous findings of infection (40x). (D) CD31 immunostaining (40x).
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Macroscopically, a well-circumscribed yellow nodule of the adrenal gland was detected in the resected specimen ( Figure 2A ). These findings above were all consistent with the possibility of intratumoral hemorrhage and thrombosis mainly caused by antiphospholipid syndrome ( Figures 2B-D  and  3A, B ).
(A) Hematoxylin and eosin immunostaning. (B) Hematoxylin and eosin-stained tumor section on high magnification showing cortical adenoma (40x). (C) c17 immunostaining. (D) c17-stained tumor section on high magnification (40x). (E) HSD3B2 immunostaining. (F) HSDB2-stained tumor section on high magnification (40x). (G) CYP11B1 immunostaining. (H) CYP11B1-stained tumor section on high magnification (40x). (I) HSDB1 immunostaining. (J) HSDB1-stained tumor section on high magnification (40x). (K) DHEA-ST immunostaining. (L) DHEA-ST-stained tumor section on high magnification (40x). (M) Hematoxylin and eosin-stained concomitant adrenal tissue on high magnification (40x). (N) High magnification of DHEA-ST-stained concomitant adrenal tissue on high magnification (40x). (O) CYP11B2 immunostaining. (P) CYP11B2-stained tumor section on high magnification (40x).
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These findings above were all consistent with the possibility of intratumoral hemorrhage and thrombosis mainly caused by antiphospholipid syndrome ( Figures 2B-D  and  3A, B ). The tumor cells were immunohistochemically positive for steroidogenic enzymes illustrated in the figures, including DHEA-ST and 3BHSD1 ( Figures 3C - L ). On the other hand, adrenocortical atrophy was not detected, but DHEA-ST immunoreactivity was diminished in the concomitant adrenocortical cells, consistent with the clinical findings that this tumor had slightly elevated autonomous secretion of cortisol ( Figures 3M, N ). In addition, paradoxical hyperplasia of the zona glomerulosa was not detected ( Figures 3O, P ).