PMC4900127_01
20-year-old female with Cushing's syndrome. Photographs demonstrate the physical exam findings associated with Cushing's Syndrome. A. Profile illustrates acne and hirsutism. B. Posterior-neck and upper-back view illustrates a typical "buffalo hump" and hirsutism. C. Lateral view of the abdomen illustrates abdominal striae.
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Physical examination demonstrated moon facies, "buffalo hump," and diffuse striae (abdomen, hip, buttock, breast, and lower extremity), as well as acne, bruising, and significant hirsutism (Figs. 1A-C).
20-year-old female with Cushing's syndrome. Abdominal CT images were obtained in the axial (A), sagittal (B), and coronal (C) planes, 75 seconds after the administration of IV contrast. A heterogeneously enhancing mass measuring 8x4.5x7cm arose from the left adrenal gland. Portions of the mass had ill-defined borders, and there was suggestion of invasion into the retroperitoneal fat at the posterior margin of the lesion (arrow). There was no evidence for invasion of the adjacent pancreas or kidney.
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Portions of the mass showed poorly defined margins, raising suspicion for local invasion into the retroperitoneal fat (Figs. 2A-C).
20-year-old female with Cushing's syndrome. Gross specimen.
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An elongated, lobulated, left adrenal mass weighing 136g was removed (Fig. 3).
20-year-old female with Cushing's syndrome. On light microscopy, the vast majority of the tumor showed a lobular-to-solid growth pattern with deeply eosinophilic cytoplasm (A). A few vacuolated foci were present (B). The adrenocortical carcinoma (ACC) showed extensive infiltration into fat (C), and large nodular foci were present in separately submitted periadrenal soft tissue.
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On light microscopy, the vast majority of the tumor showed a lobular-to-solid growth pattern with deeply eosinophilic cytoplasm (Fig. 4a). A few vacuolated foci were present (Fig. 4b). The adrenocortical carcinoma (ACC) showed extensive infiltration into the adjacent fat (Fig. 4c).
20-year-old female with Cushing's syndrome. The tumor showed strong positivity for Melan A (A) and sparse positivity for synaptophysin but was negative for chromogranin. Multiple blocks were stained for ACTH, all with negative findings (B). A Ki-67 showed 4.5 % positivity (C).
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Curiously, despite the aggressive pattern of invasion, mitotic figures were less than 5/50 hpf, and no atypical mitoses were noted. Furthermore, the tumor did not stain for ACTH (Fig. 5).