The adrenal gland is an important endocrine organ in the body, and because of its location in close relationship with the kidneys, surgical management has traditionally been the responsibility of urology. Adrenal tumors are divided into two main categories: functional and non-functional, with the former referring to tumors with endocrine function. Tumors can occur in both the adrenal cortex and medulla. Those that cause endocrine function variation are called functional tumors, while those that do not cause endocrine function variation are called non-functional tumors. There are mainly the following major categories:
1, cortisolism mainly has chronic glucocorticoid increase leading to a group of clinical manifestations: full moon face, buffalo back, centripetal obesity, hirsutism, diabetic tendency, abnormal sexual function, menstrual disorder, sperm reduction, etc. It should be noted that about half of children have cancer caused by more than half of them, female masculinization or male feminization performance is obvious, also suggest the possibility of cancer.
2, primary aldosteronism blood pressure gradually increases, the effect of antihypertensive is poor, and there is hypokalemia and alkalosis manifestations (muscle weakness, muscle paralysis, cardiac arrhythmia, hand and foot twitching, painful muscle spasm, etc.).
3.Adrenal pheochromocytoma releases adrenaline and norepinephrine in large quantities, which can cause vasoconstriction and increased heart rate, thus causing paroxysmal hypertension with severe headache, pale skin, especially pale face, rapid heartbeat, tremor of limbs and head, sweating, weakness, sometimes chest tightness and shortness of breath, nausea and vomiting.
4. Non-functional tumors include metastases, hematomas, cysts, etc.
OverviewTumors occurring in the adrenal gland are adrenal tumors, which are divided into adrenocortical adenoma, adrenocortical carcinoma and adrenal medullary tumors.
The adrenal glands are glands above the kidneys, and like the kidneys, there are 2 of them, one on each side, located above the retroperitoneal kidneys. The left adrenal gland is semilunar in shape and its superior neighbor is the spleen; the right adrenal gland is triangular in shape and its superior neighbor is the liver. The adrenal gland is a very important and indispensable endocrine organ for the human body. It can secrete 4 major categories and dozens of hormones, which are transported to various tissues and organs of the body through blood circulation to exert their specific physiological effects.
The pathology of the adrenal cortex is located in the lateral part of the adrenal gland and encloses the medulla. The volume of the cortex accounts for about 90% of the entire adrenal gland. The outermost layer is the globular zone, which accounts for about 15% of the total cortex; the middle layer is the fascicular zone, which is the thickest and accounts for about 78% of the total cortex; and the inner layer is the reticular zone, which accounts for only 7% of the cortex and is the thinnest.
The adrenal medulla is in the middle part of the adrenal gland, accounting for only about 10% of the adrenal gland. The morphology of the medullary cells varies; they are called chromophobic because the granules in these cells are found to be colorable when the medullary cells are treated with a chromium-containing liquid.
There are four types of endocrine cells in the three bands of adrenal cortex and medulla, each secreting different hormones and carrying out different missions in this small area.
1, adrenocortical adenoma adrenocortical adenoma and focal nodular hyperplasia are similar lesions, and both can be complicated. Adenomas are usually unilateral and solitary with a thin envelope and compression of surrounding tissues, which is the main point of differentiation. The size is 1-5 cm in diameter, the cut surface is yellow and sometimes reddish-brown, and microscopically they are mostly foamy, clear cells resembling fasciculated bands, rich in lipid-like material, sometimes composed of eosinophils with little lipid-like content, or a mixture of both. The tumor cells are arranged in clusters, separated by a small amount of interstitium containing capillaries. Some adenomas are functional and can cause aldosteronism or Cushing’s syndrome, which are morphologically indistinguishable from non-functional adenomas.
Adrenocortical carcinoma is rarely seen and is usually functional. When found, it is usually larger than adenoma, often weighing more than 100g, and grows infiltratively. Smaller adenocarcinomas may have an envelope. The cut surface is brownish-yellow in color, and hemorrhage, necrosis and cystic changes are common. Microscopically, poorly differentiated adenocarcinoma is highly heterogeneous, and the tumor cells are of different sizes, with odd-shaped nuclei and multinuclei. Metastasis to abdominal aortic lymph nodes or hematogenous metastasis to lung and liver is common. If the differentiation is high, it looks like adenoma under microscope. If the cancer body is small and has envelope, it is difficult to distinguish it from adenoma, some people think that if the diameter exceeds 3cm, it should be considered as highly differentiated adenocarcinoma.
Adrenal medullary tumors come from the neural crest, and the original cells are sympathetic neuroblasts, which later differentiate into ganglion cells and chromophobe cells.
Pheochromocytomas occur in 80% to 90% of the adrenal medulla, most of them are unilateral, occasionally they are bilateral, 90% are benign, and they occur between 30 and 50 years old. The tumor cells can secrete norepinephrine and epinephrine, mainly norepinephrine, and occasionally dopamine and other hormones, so the clinical symptoms are mainly catecholamine hypertension, manifested as increased blood pressure, mostly intermittent episodes, accompanied by headache, sweating, peripheral vasoconstriction, accelerated pulse, increased blood sugar, increased basal metabolism and other symptoms. To the naked eye, the size varies, averaging about 100g or even up to 2000g, with envelope, gray-red and gray-brown cut surface, and common hemorrhage, necrosis, cystic degeneration and necrotic foci.
Microscopically, chromophobe cells are large polygonal cells, forming cell cords or nests, which may have different degrees of pleomorphism, sometimes appearing as giant cells, and there are a large number of chromophobic microgranules in the cytoplasm of tumor cells. The interstitium is mainly blood sinusoid. There is no clear-cut boundary between benign and malignant tumors in terms of cell morphology, and invasion of the envelope is not definite evidence of malignancy, but if there is infiltration of surrounding tissues and metastasis, then there is no doubt that it is malignant.
Extra-adrenal pheochromocytomas are multiple and located in the distribution of paraganglioma cells on both sides of the aorta, which is often called paraganglioma. This tumor occurs between 10 and 20 years of age, and most are part of multiple endocrine tumors, 40% of which are malignant.
Tumors can occur in both the adrenal cortex and medulla. Those that cause endocrine function variation are called functional tumors, while those that do not cause endocrine function changes are called nonfunctional tumors.
Aldosteronism is mainly caused by cortical adenoma. The most predominant symptom is hypertension, which is usually moderately elevated. The second type of symptoms are muscle weakness or paralysis and abnormal sensation. The third type of symptoms are polyuria, nocturia, and irritable thirst.
Cortisolism is mostly caused by adrenal cortical hyperplasia or tumors and manifests as full moon face, buffalo back, central obesity with thin extremities, polycythemia and purple lines. Fatigue, exhaustion, low back pain; hypertension; hirsutism, hair loss, acne; sexual dysfunction, amenorrhea or decreased menstruation.
Gonadal anomalies are caused by cortical tumors and are classified as precocious genital enlargement, female pseudohermaphroditism, and female masculinization.
The main symptoms of pheochromocytoma are hypertension and altered metabolism. Episodic hypertension is increased with palpitations, shortness of breath, headache, sweating, nervousness, and chills and tremors in the extremities.
Non-functional adrenal tumors occur mainly from mesenchymal cells in the cortex or medulla, mainly non-functional cortical adenomas and adenocarcinomas, neuroblastomas, and ganglion cell neuralgia.
IV. Common treatments Surgery is the only treatment for adrenocortical carcinoma at present. In addition, there are some breakthroughs in treating adrenal tumors with rocket freezing technique, retroperitoneoscopic surgery and argon helium knife.
The recurrence rate of postoperative adrenocortical carcinoma with spread and metastasis is high. It has been reported that the mean survival time of reoperative treatment of recurrent tumors is significantly longer (15.8±14.9 months) than that of the non-operated group (3.2±2.9 months). It is generally believed that the cancer cells are difficult to be exposed at the time of reoperation, and there is a possibility that they have metastasized, and the chance of complete resection is small, so the significance of reoperation is still difficult to be sure.
The prognosis of adrenocortical carcinoma is high malignancy and poor prognosis, and the natural course of the disease rarely exceeds 1 year.
Classification
1.Adrenal tumors include adrenocortical adenoma and adrenocortical carcinoma. It mainly causes cortisolism and primary aldosteronism (mostly caused by adenoma). Among the main manifestations of cortisolism are: centripetal obesity, full-moon face, lower abdomen, buttocks and femur may have purple skin lines, increased body hair, often acne, mostly hypertension, palpitations, chest tightness and other symptoms, increased blood sugar, osteoporosis, back bone pain, and hypogonadism. The manifestations of aldosteronism are: hypertension, hypokalemia, periodic muscle weakness, paralysis or convulsions.
2.Adrenal tumor is mainly pheochromocytoma. It mainly causes paroxysmal or persistent hypertension, and metabolic disorder syndrome. The main manifestations are: sudden increase of blood pressure, accompanied by headache, tachycardia, sweating method, pallor, etc., often triggered by emotional excitement, strenuous exercise, position change, and compression of abdominal tumor. In addition, there are also manifestations of increased basal metabolic rate such as hypothermia, excessive sweating, high blood sugar, weakness, weight loss, etc.