PMC3025966_01
Abdominal ultrasound depicting a large mixed cystic/solid right adrenal mass
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F1
Renal ultrasound examination, to rule out underlying renal pathology, revealed an incidental 8cm right adrenal mass of both solid and cystic components (Figure 1).
CT abdomen further illustrating a solid heterogeneous right adrenal mass with focal cystic degeneration, slightly displacing the right kidney.
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F2
No regional adenopathy, vascular invasion or metastatic disease was evident (Figure 2).
Catecholamine and metabolite concentrations before and after adrenalectomy, taken from 24-hour urine sample. Normal ranges: noradrenaline (0-900nmol/24h); adrenaline (0-230nmol/24h); dopamine (0-3300 nmol/24h); normetanephrine (50-2800nmol/24h); metanephrine (25-1800nmol/24h).
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F3
A 24-hour urinary collection provided biochemical confirmation with grossly elevated levels of catecholamines and metabolites (Figure 3).
Graph displaying the dramatic reduction in insulin requirements and HbA1C following adrenalectomy for pheochromocytoma.
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F4
Her recovery after this period was uncomplicated with an observed reduction in insulin requirements and anti-hypertensive therapy (Figure 4).
Gross adrenal pheochromocytoma specimen following surgical excision.
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F5
Histopathological examination of the excised tissue confirmed a 9.5x9.6cm solid heterogeneous tumor arising from her right adrenal medulla (Figure 5).
(a) Low power (10X) image depicting nests of tumour cells with prominent intervening capillary network giving characteristic Zellballen appearance; (b) High power (20X) image highlighting the presence of abundant finely granular amphophilic cytoplasm, round nuclei, marked focal nuclear pleomorphism and tumor giant cells. These findings do not correlate with malignant behavior.
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F6
There was no invasion of adjacent tissues or blood vessels and the MIB-1 proliferation index was 3%, favoring benign behavior (Figure 6).
MIBG scintigraphy two weeks post-adrenalectomy displaying no evidence of residual chromaffin cell uptake or metastatic disease.
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F7
Iodine-131-metaiodobenzylguanidine (MIBG) scintigraphy performed two weeks post-operatively confirmed complete excision with no evidence of metastatic disease (Figure 7).