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    Adrenal

    Background

    Adrenal glands are frequently removed during a radical nephrectomy, either partially or totally and may reveal direct spread or metastatic deposits of renal carcinomas. Adrenalectomies are also undertaken when an adrenal mass is detected on imaging, most commonly these are cortical adenomas or phaeochromocytomas but infective lesions and congenital conditions also occur.

    Rarely malignant tumours such as adrenal cortical carcinoma and infiltration by retroperitoneal tumours are detected.

    Bilateral adrenalectomy may be necessary as a treatment for Cushing’s disease or ectopic adrenocorticotrophic hormone (ACTH) syndrome.1,2 Other rare conditions have been described such as bilateral primary pigmented nodular adrenocortical disease3 and adrenal medullary hyperplasia in familial medullary thyroid carcinoma.4

    The adrenals are flat, ovoid glands with irregular surfaces located on the superior poles of kidneys, within Gerota’s fascia. The right adrenal gland is triangular in shape whereas the left is broader and crescent-shaped due to its compression between the kidney and the liver. When present with the kidney in a nephrectomy, the adrenal gland’s position and shape assist in identifying the laterality and orientating the kidney. The left adrenal lies within the perirenal fat but the right has one surface exposed along the upper border. Though small (approx. 75 x 7mm), they are yellow in colour in contrast to adjacent red-brown kidney tissue.5 The left adrenal gland is often heavier than the right. Weight is an important criterion to predict malignancy in both adrenocortical neoplasms and phaeochromocytoma. Therefore it is important to remove the adipose tissue for an accurate weighing of the gland. However consideration should be given to ensuring any invasion of the tumour into the adrenal capsule or adjacent tissue is not missed.

    Ectopic or accessory adrenal tissue can be present in other organs (particularly the retroperitoneum at the coeliac plexus); described as adrenal rests.5

    Record the patient identifying information and any clinical information supplied together with the specimen description as designated on the container. See overview page for more detail on identification principles.

    • No
      • Non-routine fixation (not formalin), describe.
    • Yes
      • Special studies required, describe.
      • Ensure samples are taken prior to fixation.
    • Not performed
    • Performed, describe type and result
      • Frozen section
      • Imprints
      • Other, describe

    See general information for more detail on specimen handling procedures.

    Inspect the specimen and dictate a macroscopic description.


    External Inspection

    Orientate and identify the anatomical features of the specimen.1

    Record additional orientation or designation provided by operating clinician:

    • Absent
    • Present
      • Method of designation (e.g. suture, incision)
      • Featured denoted

    Photograph the intact specimen if required.

    Describe the following features of the specimen:

    Procedure

    Describe as stated by the clinician.

    • Total adrenalectomy
    • Partial adrenalectomy
    • Other, describe

    Specimen laterality

    • Left
    • Right

    Anatomical components (more than one may apply) and specimen dimensions (mm)

    • Total specimen, in three dimensions,6 length x width (transverse) x height (superior-inferior)
    • Adrenal
    • Kidney. See kidney protocols for more detail.
    • Other, describe

    Specimen weight

    • Weight of adrenal gland (g)

    If tumour invasion into soft tissue is suspected:

    • Weight of total specimen (g)6

    Weight is considered an important diagnostic feature in malignancy for both adrenocortical neoplasms and phaeochromocytomas. Therefore the adrenal should be weighed after removal of adipose tissue unless this is likely to prevent assessment of tumour invasion through the adrenal capsule.6


    Dissection

    Where tumour is present and after sufficient fixation, paint the relevant surgical margins (the external surface is considered a resection margin) 6 with ink and record the colours applied.

    Serially section the gland from head to tail (perpendicularly to the gland’s long axis).6


    Internal Inspection

    Describe the internal or cut surface appearance including the following items:

    Tumour

    • Absent
    • Present
    • Number; if more than one tumour, designate and describe each tumour separately

    Tumour size (mm)

    • Maximum dimension

    Tumour capsule integrity6

    • Intact
    • Not intact

    Location/relationship with normal tissue6

    • Indeterminate
    • Cortex
    • Medulla
    • Other, specify

    Borders6

    • Encapsulated
    • Infiltrative

    Non-lesional tissue appearance

    Describe the following:

    Cortex6

    • Unremarkable
    • Atrophic (thin)
    • Hypertrophic (thickened)
    • Not identified

    Cortical nodules6

    • Absent
    • Present
      • Maximum dimension of largest nodule (mm) or <10mm

    Cortical nodules should be <10mm in size.6

    Medulla6

    • Unremarkable
    • Atrophic (thin)
    • Hypertrophic (thickened)
    • Not identified

    Medullary hyperplasia/nodule6

    • Absent
    • Present
      • Maximum dimension (mm)
    • Not assessable

    There is little or no medullary tissue in the adrenal tail so its presence indicates medullary hyperplasia. A medullary nodule by definition is a lesion <10mm. Larger lesions are considered to be phaeochromocytomas.6,7

    Retrieved from resection specimen

    • Describe site(s)
    • Number retrieved

    Separately submitted

    • For each specimen container, record specimen number and designation
    • Collective size of tissue in three dimensions (mm)
    • Number of lymph nodes submitted
    • Maximum diameter of each (mm)

    Photograph the dissected specimen if required.

    Note photographs taken, diagrams recorded and markings used for identification.


    Processing

    Dissect the specimen further and submit sections for processing according to the illustrations provided.

    • Submit one representative section
    • Submit all tissue for processing if gland is <30mm in maximum dimension6
    • Submit representative sections, one per 10mm from larger glands6

    Adrenal with large tumour (>20mm) present

    Submit representative sections of:

    • Surgical margins (soft tissue) perpendicular sections
    • Tumour, at least one block per 10mm of the largest tumour
    • Demonstrating relationship to capsule6
    • Demonstrating adjacent or invasion into soft tissue6
    • Demonstrating relationship with adjacent normal adrenal tissue6
    • Preferentially sampling areas of suspected necrosis and capsular irregularity/penetration (to facilitate microscopic assessment; more sections may be requested after initial examination).6

    Submit representative sections of other structures, if applicable.

    Submit all lymph nodes.

    Record details of each cassette.

    An illustrated block key similar to those provided below may be useful.

    Block allocation keys

    Cassette id
    Site
    No. of pieces
    A
    One representative section
     
    Cassette id
    Site
    No. of pieces
    A-C
    All tissue or representative sections (see above)
     
    D+
    Lymph nodes, if applicable
     
    Cassette id
    Site
    No. of pieces
    A
    Surgical margins, perpendicular sections
     
    B-D
    Tumour, full face representative sections including capsule and adjacent normal tissue
     
    E-F
    Suspicious areas of haemorrhage and/or necrosis
     
    G-H
    Areas of capsular irregularity or invasion, if applicable
     
    I-J
    Lymph nodes, if applicable
     

    nbsp;

    Acknowledgements

    Prof Alfred Lam for his contribution in reviewing and editing this protocol.


    References

    1. Moonim MT, Johnson SJ and McNicol AM. Cancer dataset for the histological reporting of adrenal cortical carcinoma and phaeochromocytoma/paraganglioma, The Royal College of Pathologists, London, 2012.
    2. Milne D, Johnson SJ, Stephenson T and Poller D. Tissue pathways for endocrine pathology, The Royal College of Pathologists, London, 2012.
    3. Shenoy BV, Carpenter PC and Carney JA. Bilateral primary pigmented nodular adrenocortical disease. Rare cause of the Cushing syndrome. Am J Surg Pathol 1984;8(5):335-344.
    4. DeLellis RA, Wolfe HJ, Gagel RF, Feldman ZT, Miller HH, Gang DL and Reichlin S. Adrenal medullary hyperplasia. A morphometric analysis in patients with familial medullary thyroid carcinoma. Am J Pathol 1976;83(1):177-196.
    5. Lester SC. Manual of Surgical Pathology, Saunders Elsevier, Philadelphia, 2010.
    6. Lam A, Chong G, Dahlstrom J, McNicol AM, Gill A and Sullivan L. Adrenal gland tumours structured reporting protocol, Royal College of Pathologists Australasia, Surry Hills, NSW, 2013.
    7. Carney JA, Sizemore GW and Sheps SG. Adrenal medullary disease in multiple endocrine neoplasia, type 2: pheochromocytoma and its precursors. Am J Clin Pathol. 1976;66(2):279-290.

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      Adrenal 1

      Adrenal with tumour

      Adrenal 2

      Adrenal with tumour, dissected

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      25-Mar-2019
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