541001
research-article2014
IJSXXX10.1177/1066896914541001International Journal of Surgical Pathology XX(X)Casadei et al
Case Report
Ectopic Thyroid Tissue in the Adrenal Gland: Report of a Case
International Journal of Surgical Pathology 2015, Vol. 23(2) 170–175 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1066896914541001 ijs.sagepub.com
Gian Piero Casadei, MD1, Claudia Bertarelli, MD1, Eleonora Giorgini, MD1, Nadia Cremonini, MD1, Dario de Biase, BSc, PhD2, and Giovanni Tallini, MD, PhD2
Abstract Foci of ectopic thyroid tissue are uncommon. Most sites of thyroid ectopia are confined to the neck region. The presence of ectopic thyroid tissue outside the migration pathway of the primitive thyroid in other locations is exceptional. Given that any disease of the thyroid gland may also affect ectopic thyroid tissue, pathologists has to recognize benign or malignant conditions that may develop in the ectopic focus. We present the case of a 32-year-old woman with ectopic thyroid parenchyma in the adrenal gland. Clinically, postoperative thyroid ultrasound echography and computed tomography scans did not reveal any thyroid tumor. The ectopic tissue was a cyst bordered by mature follicular thyroid structures and was histologically benign, without the molecular alterations associated with malignant tumors of follicular cell derivation (BRAFV600E, N-RAS, H-RAS, K-RAS). Review of the literature reveals that adrenal ectopic thyroid tissue is nearly always cystic and has distinctive pathologic features. Keywords thyroid, ectopic thyroid tissue, adrenal gland
Introduction
Material and Methods
Ectopic thyroid tissue (ETT) is a term that refers to the localization of thyroid parenchyma outside the orthotopic position of the thyroid gland. Although uncommon, ETT may be present anywhere along the line of caudal migration traveled by the developing thyroid (thyroglossal duct), in its descent from the floor of the primitive foregut—the foramen cecum—to its final position the neck, in close proximity and anterior to the first part of the trachea. Ectopic thyroid tissue is frequently observed around the course of the thyroglossal duct or laterally in the neck, from the tongue to the anterior midline and lateral cervical structures, in the so-called Wölfler’s area. This anatomical region is triangular, with its base at the edges of the mandible and its apex at the aortic arch, and is named after the Austrian surgeon Wölfler who first postulated the existence of “accessory” thyroid glands.1 However, ETT is not limited to this area and has been reported in a remarkable variety of places outside the neck, including intrathoracic sites and below the diaphragm.2 Among these uncommon sites the adrenal gland is a peculiar location. To date, intraadrenal ectopic thyroid tissue has been reported in nine cases. We present a further case, in a patient with normal endocrine status and review the pertinent literature.
A 32-year-old woman was admitted to the Ospedale Maggiore in Bologna, Italy, after a 5-month history of severe pain in right lumbar side. Ultrasound (US) studies showed a 4 cm mass in the right adrenal gland. A computed tomography (CT) scan confirmed the US finding and showed the lesion to be cystic with borders pushing into the periadrenal soft tissues. Routine laboratory tests were completely negative for hormonal abnormalities. The patient was referred to surgery, underwent laparoscopic exploration of the abdominal cavity, and a simple adrenal-sparing resection was performed to remove the mass. The postoperative course was unremarkable. After histological examination revealed that the lesion consisted of differentiated thyroid tissue, diagnostic workup was performed to exclude a primary thyroid cancer. Careful evaluation of the thyroid and of the neck lymph nodes with CT and US scans were entirely negative. Thyroid-specific 1
AUSL Bologna Maggiore Hospital, Bologna, Italy Bellaria Hospital, University of Bologna, Bologna, Italy
2
Corresponding Author: Gian Piero Casadei, Unit of Anatomic Pathology, AUSL Bologna Maggiore Hospital, Largo Nigrisoli 2, 40133 Bologna, Italy. Email: [email protected]
171
Casadei et al
Figure 2. The cyst wall is bordered by fibrous tissue with a single layer of epithelial cell and includes many follicles occupied by colloid, intermingled with adrenal tissue (hematoxylin and eosin, 250×).
Figure 1. The surgical specimen shows a cyst in the adrenal gland and in the peri-adrenal tissue (arrows).
laboratory tests—serum thyroid-stimulating hormone, free T3, and free T4 levels—were normal. Postoperative imaging studies did not show any residual or recurrent lesions in the adrenal gland; nor were any lesions subsequently found in the thyroid or in the neck. The patient is currently asymptomatic and free of disease, 3 years after the surgical procedure. On gross examination, the resected specimen consisted of a portion of the adrenal gland that on cut sections showed a single paracentral cyst, measuring 4 cm in maximal diameter, with a 0.5 cm thick wall (Figure 1). Formalin-fixed samples of the specimen were routinely processed. Microscopic examination demonstrated a cyst that extended from the border of the adrenal cortex with the medulla to the periadrenal soft tissues. The cyst contained a dense, homogeneous, eosinophilic, colloid-like substance that was surrounded by a monolayer of cubic epithelial cells. The cyst wall, in addition to the layer of cubic epithelial cells, consisted of fibrous tissue within which were embedded numerous thyroid follicles of various size, filled with colloid and lined by cuboidal cells showing regular, round nuclei with inconspicuous nucleoli. There were no nuclear atypia, grooves or cytoplasmic pseudo-inclusions (Figure 2). Some follicles were intermingled with adrenal cortical cells, and there was a patchy infiltrate of reactive lymphoid cells. Immunohistochemical analysis included staining for thyroglobulin, thyroid transcription factor–1 (TTF-1), calcitonin, CK 19, and galectin 3. Follicular cells, as well as the monolayer of cubic epithelial cells immediately surrounding the cyst were diffusely positive for thyroglobulin
Figure 3. Positive thyroid transcription factor–1 (TTF-1) immunostain (brown chromogen) confirms the presence of ectopic thyroid tissue (120×).
and TTF-1 (Figure 3). No significant immunoreactivity was observed for CK19 and galectin 3. Calcitonin was negative, indicating that no parafollicular cells were intermixed with the follicular cells. To exclude metastatic thyroid carcinoma DNA extracted from formalin-fixed paraffin-embedded material from the wall of the cyst was analyzed for mutations in the BRAF (exon 15), N-RAS (exon 3), H-RAS (exon 3), and K-RAS (exon 2 and exon 3) genes using 454 next generation sequencing (Roche, Manheim, Germany).3 No mutations were identified in any of the genes.
Discussion Ectopic thyroid tissue is a developmental defect of the thyroid gland defined by the presence of thyroid tissue at sites
172 other than its normal orthotopic anterior cervical location. ETT often coexists as a separate structure in individuals with a normally located thyroid gland. It may also represent the only functioning parenchyma—thyroid gland ectopia—a condition that represents the most extreme form of ETT in which a significant part of, or the entire thyroid gland, is not located in the usual site. Ectopic thyroid tissue has been reported with a prevalence of 1:100 000 to 1:300 000 but the prevalence seems higher—1:4000 to 1:8000—in patients with thyroid disease.2 It is often discovered incidentally in asymptomatic individuals particularly during adolescence or pregnancy because of the increased demand for thyroid hormones,4 it occurs more commonly in females and is more frequent in Asian people.5 Ectopic thyroid tissue is a sporadic condition. Around 2% of cases of ectopic thyroid have been shown to be familial,6 but the genetic basis is at present undefined. Morphogenesis and migration of the embryonic thyroid depend on the complex interaction of several transcription factors: HHEX (hematopoietically expressed homeobox) protein, PAX8, TTF-1 (Titf-1/Nkx2.1), FOXE1 (TTF-2). The HHEX protein has a role in sustaining the expression of PAX8, TTF-1 and FOXE1; PAX8, TTF1 are primarily implicated with proliferation survival and differentiation of follicular cells, while FOXE1 is the factor mainly responsible for cell migration.7,8 Transgenic knock-out mice lacking FOXE1 have a thyroid gland that is sublingual or altogether absent.7 In humans loss-of-function FOXE1 mutations have been reported in patients with Bamforth syndrome, a rare hereditary disorder characterized by congenital hypothyroidism due to thyroid dysgenesis (usually athyreosis), cleft palate, and spiky hair. However, no specific gene alterations have been associated with ETT.7,9 Of all ETT locations, the base of the tongue around the area of the foramen cecum is the most common, and the so-called “lingual thyroid” represents up to 90% of ETT cases.10 A lingual thyroid is often the manifestation of complete migration failure of the primitive gland during embryogenesis and it is therefore the most common form of thyroid ectopia. In 70% to 75% of individuals with macroscopically evident lingual thyroid no thyroid parenchyma is found in its normal anatomical neck location.11 Interestingly, the true prevalence of defective thyroid gland migration during development may be much higher, since microscopic foci of thyroid tissue have been found by Sauk12 at the base of the tongue in 20 of 200 (10%) consecutive necropsies. Ectopic thyroid tissue at other sites in or around Wölfler’s area (anterior tongue, submandibular, trachea, larynx, anterior mediastinum) is less common, and other localizations are rare, with a frequency that decreases with increasing distance from Wölfler’s area. Nevertheless,
International Journal of Surgical Pathology 23(2) ETT has been described at intrathoracic sites—including the heart13 and the lung,14 in the head and neck region— including the iris of the eye15 and the sella turcica,16 and in a series of subdiaphragmatic locations such as the gallbladder and porta hepatis, duodenum, pancreas, mesentery, and uterus.2 Thyroid parenchyma in the ovary—“struma ovarii”—is not considered a bona fide type of ectopia, but a neoplasm resulting from the dominant growth of thyroid tissue in a teratoma.1 An orthotopic thyroid in the anterior neck is typically present in patients with ETT, with the exception of those with a macroscopically evident lingual thyroid. This is an important consideration because removal of the ectopic thyroid gland renders the patient hypothyroid if no additional thyroid parenchyma is present. Among all the possible sites for ETT the adrenal gland is one of the most peculiar. The adrenal gland is very distant from the site of origin of the thyroid and, unlike the thyroid, which is of endodermal derivation, it is in part derived from the mesoderm—the adrenal cortex, in part from the ectoderm—the adrenal medulla, and its anatomical location is totally unrelated with the migration pathway of the primitive thyroid. Several cases have been reported (Table 1). The first 6 were described in Japanese patients,17-21 the case of Bohinc et al22 was from an African American patient, those of Romero-Rojas et al23 were 1 each from Colombia and Spain.23 We report herein the 10th case, the second one in an individual of European descent. The mean age of the patients with adrenal ETT was 52.2 years (range, 32-67 years). In our case, and in at least another case (case 1, Shiraishi et al18), the patient complained of bland back pain that could be related to the adrenal mass. However, most adrenal ETT have been discovered incidentally, as unsuspected and asymptomatic lesions after CT or US evaluation for unrelated pathology (Table 1). The majority of patients have no endocrine abnormalities, but in 2 there was hyperaldosteronism due to a concurrent benign cortical adenoma in the same adrenal gland with the ETT.22,23 The pathologic features of adrenal ETT are very similar, to the point that they almost represent a distinct entity. In all cases, but one, the lesions were macrosopic cysts of a fair size, ≥3 cm in 8 of the 10 cases (Table 1), containing colloid-like material. All but one were mostly associated with the adrenal cortex, although one was mainly located in the medulla.20 Most cysts were unilocular, but 3 were multilocular (case 1, Shiraishi et al,18 Shuno et al,19 and Takao et al20). Histologic examination reveals the cyst wall be made by an inner stratum of thyroglobulin and TTF-1 positive cells overlaying a fibrous layer of variable thickness and collagenization, that contains well-developed colloid-filled follicles of thyroid parenchyma. The thyroid follicles blend and are variably intermixed with the adrenal cells. No significant cytologic atypia is present in the
173
Casadei et al Table 1. Review of Cases of ETT in Adrenal Gland From the Literature and the Present Case. Age/Sex/Ethnicity 61/F/Asian 50/F/Asian 50/M/Asian 50/F/Asian 54/F/Asian 67/F/Asian
Clinical Data/Endocrine State Incidental occurrence on CT/normal Right hypochondrial pain/ normal Incidental occurrence on US/normal Incidental occurrence on CT/normal Incidental occurrence on CT/hypertension, elevated aldosterone Incidental occurrence on CT/normal Incidental occurrence on CT/hypertension, elevated aldosterone
Lesion/Location/Size (cm) Cystic, unilocular/right AG/3.5 Cystic, multilocular/right AG/3.0 Cystic, unilocular/right AG/NA Cystic, multilocular/left AG/5.5 Cystic, unilocular/left AG/1.6
38/F/Hispanic (Colombia)
Back pain/elevated aldosterone
Cystic, multilocular/left AG/3.0 Solid nodule/adjacent to and within the capsule of a left AG cortical adenoma/
research-article2014
IJSXXX10.1177/1066896914541001International Journal of Surgical Pathology XX(X)Casadei et al
Case Report
Ectopic Thyroid Tissue in the Adrenal Gland: Report of a Case
International Journal of Surgical Pathology 2015, Vol. 23(2) 170–175 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1066896914541001 ijs.sagepub.com
Gian Piero Casadei, MD1, Claudia Bertarelli, MD1, Eleonora Giorgini, MD1, Nadia Cremonini, MD1, Dario de Biase, BSc, PhD2, and Giovanni Tallini, MD, PhD2
Abstract Foci of ectopic thyroid tissue are uncommon. Most sites of thyroid ectopia are confined to the neck region. The presence of ectopic thyroid tissue outside the migration pathway of the primitive thyroid in other locations is exceptional. Given that any disease of the thyroid gland may also affect ectopic thyroid tissue, pathologists has to recognize benign or malignant conditions that may develop in the ectopic focus. We present the case of a 32-year-old woman with ectopic thyroid parenchyma in the adrenal gland. Clinically, postoperative thyroid ultrasound echography and computed tomography scans did not reveal any thyroid tumor. The ectopic tissue was a cyst bordered by mature follicular thyroid structures and was histologically benign, without the molecular alterations associated with malignant tumors of follicular cell derivation (BRAFV600E, N-RAS, H-RAS, K-RAS). Review of the literature reveals that adrenal ectopic thyroid tissue is nearly always cystic and has distinctive pathologic features. Keywords thyroid, ectopic thyroid tissue, adrenal gland
Introduction
Material and Methods
Ectopic thyroid tissue (ETT) is a term that refers to the localization of thyroid parenchyma outside the orthotopic position of the thyroid gland. Although uncommon, ETT may be present anywhere along the line of caudal migration traveled by the developing thyroid (thyroglossal duct), in its descent from the floor of the primitive foregut—the foramen cecum—to its final position the neck, in close proximity and anterior to the first part of the trachea. Ectopic thyroid tissue is frequently observed around the course of the thyroglossal duct or laterally in the neck, from the tongue to the anterior midline and lateral cervical structures, in the so-called Wölfler’s area. This anatomical region is triangular, with its base at the edges of the mandible and its apex at the aortic arch, and is named after the Austrian surgeon Wölfler who first postulated the existence of “accessory” thyroid glands.1 However, ETT is not limited to this area and has been reported in a remarkable variety of places outside the neck, including intrathoracic sites and below the diaphragm.2 Among these uncommon sites the adrenal gland is a peculiar location. To date, intraadrenal ectopic thyroid tissue has been reported in nine cases. We present a further case, in a patient with normal endocrine status and review the pertinent literature.
A 32-year-old woman was admitted to the Ospedale Maggiore in Bologna, Italy, after a 5-month history of severe pain in right lumbar side. Ultrasound (US) studies showed a 4 cm mass in the right adrenal gland. A computed tomography (CT) scan confirmed the US finding and showed the lesion to be cystic with borders pushing into the periadrenal soft tissues. Routine laboratory tests were completely negative for hormonal abnormalities. The patient was referred to surgery, underwent laparoscopic exploration of the abdominal cavity, and a simple adrenal-sparing resection was performed to remove the mass. The postoperative course was unremarkable. After histological examination revealed that the lesion consisted of differentiated thyroid tissue, diagnostic workup was performed to exclude a primary thyroid cancer. Careful evaluation of the thyroid and of the neck lymph nodes with CT and US scans were entirely negative. Thyroid-specific 1
AUSL Bologna Maggiore Hospital, Bologna, Italy Bellaria Hospital, University of Bologna, Bologna, Italy
2
Corresponding Author: Gian Piero Casadei, Unit of Anatomic Pathology, AUSL Bologna Maggiore Hospital, Largo Nigrisoli 2, 40133 Bologna, Italy. Email: [email protected]
171
Casadei et al
Figure 2. The cyst wall is bordered by fibrous tissue with a single layer of epithelial cell and includes many follicles occupied by colloid, intermingled with adrenal tissue (hematoxylin and eosin, 250×).
Figure 1. The surgical specimen shows a cyst in the adrenal gland and in the peri-adrenal tissue (arrows).
laboratory tests—serum thyroid-stimulating hormone, free T3, and free T4 levels—were normal. Postoperative imaging studies did not show any residual or recurrent lesions in the adrenal gland; nor were any lesions subsequently found in the thyroid or in the neck. The patient is currently asymptomatic and free of disease, 3 years after the surgical procedure. On gross examination, the resected specimen consisted of a portion of the adrenal gland that on cut sections showed a single paracentral cyst, measuring 4 cm in maximal diameter, with a 0.5 cm thick wall (Figure 1). Formalin-fixed samples of the specimen were routinely processed. Microscopic examination demonstrated a cyst that extended from the border of the adrenal cortex with the medulla to the periadrenal soft tissues. The cyst contained a dense, homogeneous, eosinophilic, colloid-like substance that was surrounded by a monolayer of cubic epithelial cells. The cyst wall, in addition to the layer of cubic epithelial cells, consisted of fibrous tissue within which were embedded numerous thyroid follicles of various size, filled with colloid and lined by cuboidal cells showing regular, round nuclei with inconspicuous nucleoli. There were no nuclear atypia, grooves or cytoplasmic pseudo-inclusions (Figure 2). Some follicles were intermingled with adrenal cortical cells, and there was a patchy infiltrate of reactive lymphoid cells. Immunohistochemical analysis included staining for thyroglobulin, thyroid transcription factor–1 (TTF-1), calcitonin, CK 19, and galectin 3. Follicular cells, as well as the monolayer of cubic epithelial cells immediately surrounding the cyst were diffusely positive for thyroglobulin
Figure 3. Positive thyroid transcription factor–1 (TTF-1) immunostain (brown chromogen) confirms the presence of ectopic thyroid tissue (120×).
and TTF-1 (Figure 3). No significant immunoreactivity was observed for CK19 and galectin 3. Calcitonin was negative, indicating that no parafollicular cells were intermixed with the follicular cells. To exclude metastatic thyroid carcinoma DNA extracted from formalin-fixed paraffin-embedded material from the wall of the cyst was analyzed for mutations in the BRAF (exon 15), N-RAS (exon 3), H-RAS (exon 3), and K-RAS (exon 2 and exon 3) genes using 454 next generation sequencing (Roche, Manheim, Germany).3 No mutations were identified in any of the genes.
Discussion Ectopic thyroid tissue is a developmental defect of the thyroid gland defined by the presence of thyroid tissue at sites
172 other than its normal orthotopic anterior cervical location. ETT often coexists as a separate structure in individuals with a normally located thyroid gland. It may also represent the only functioning parenchyma—thyroid gland ectopia—a condition that represents the most extreme form of ETT in which a significant part of, or the entire thyroid gland, is not located in the usual site. Ectopic thyroid tissue has been reported with a prevalence of 1:100 000 to 1:300 000 but the prevalence seems higher—1:4000 to 1:8000—in patients with thyroid disease.2 It is often discovered incidentally in asymptomatic individuals particularly during adolescence or pregnancy because of the increased demand for thyroid hormones,4 it occurs more commonly in females and is more frequent in Asian people.5 Ectopic thyroid tissue is a sporadic condition. Around 2% of cases of ectopic thyroid have been shown to be familial,6 but the genetic basis is at present undefined. Morphogenesis and migration of the embryonic thyroid depend on the complex interaction of several transcription factors: HHEX (hematopoietically expressed homeobox) protein, PAX8, TTF-1 (Titf-1/Nkx2.1), FOXE1 (TTF-2). The HHEX protein has a role in sustaining the expression of PAX8, TTF-1 and FOXE1; PAX8, TTF1 are primarily implicated with proliferation survival and differentiation of follicular cells, while FOXE1 is the factor mainly responsible for cell migration.7,8 Transgenic knock-out mice lacking FOXE1 have a thyroid gland that is sublingual or altogether absent.7 In humans loss-of-function FOXE1 mutations have been reported in patients with Bamforth syndrome, a rare hereditary disorder characterized by congenital hypothyroidism due to thyroid dysgenesis (usually athyreosis), cleft palate, and spiky hair. However, no specific gene alterations have been associated with ETT.7,9 Of all ETT locations, the base of the tongue around the area of the foramen cecum is the most common, and the so-called “lingual thyroid” represents up to 90% of ETT cases.10 A lingual thyroid is often the manifestation of complete migration failure of the primitive gland during embryogenesis and it is therefore the most common form of thyroid ectopia. In 70% to 75% of individuals with macroscopically evident lingual thyroid no thyroid parenchyma is found in its normal anatomical neck location.11 Interestingly, the true prevalence of defective thyroid gland migration during development may be much higher, since microscopic foci of thyroid tissue have been found by Sauk12 at the base of the tongue in 20 of 200 (10%) consecutive necropsies. Ectopic thyroid tissue at other sites in or around Wölfler’s area (anterior tongue, submandibular, trachea, larynx, anterior mediastinum) is less common, and other localizations are rare, with a frequency that decreases with increasing distance from Wölfler’s area. Nevertheless,
International Journal of Surgical Pathology 23(2) ETT has been described at intrathoracic sites—including the heart13 and the lung,14 in the head and neck region— including the iris of the eye15 and the sella turcica,16 and in a series of subdiaphragmatic locations such as the gallbladder and porta hepatis, duodenum, pancreas, mesentery, and uterus.2 Thyroid parenchyma in the ovary—“struma ovarii”—is not considered a bona fide type of ectopia, but a neoplasm resulting from the dominant growth of thyroid tissue in a teratoma.1 An orthotopic thyroid in the anterior neck is typically present in patients with ETT, with the exception of those with a macroscopically evident lingual thyroid. This is an important consideration because removal of the ectopic thyroid gland renders the patient hypothyroid if no additional thyroid parenchyma is present. Among all the possible sites for ETT the adrenal gland is one of the most peculiar. The adrenal gland is very distant from the site of origin of the thyroid and, unlike the thyroid, which is of endodermal derivation, it is in part derived from the mesoderm—the adrenal cortex, in part from the ectoderm—the adrenal medulla, and its anatomical location is totally unrelated with the migration pathway of the primitive thyroid. Several cases have been reported (Table 1). The first 6 were described in Japanese patients,17-21 the case of Bohinc et al22 was from an African American patient, those of Romero-Rojas et al23 were 1 each from Colombia and Spain.23 We report herein the 10th case, the second one in an individual of European descent. The mean age of the patients with adrenal ETT was 52.2 years (range, 32-67 years). In our case, and in at least another case (case 1, Shiraishi et al18), the patient complained of bland back pain that could be related to the adrenal mass. However, most adrenal ETT have been discovered incidentally, as unsuspected and asymptomatic lesions after CT or US evaluation for unrelated pathology (Table 1). The majority of patients have no endocrine abnormalities, but in 2 there was hyperaldosteronism due to a concurrent benign cortical adenoma in the same adrenal gland with the ETT.22,23 The pathologic features of adrenal ETT are very similar, to the point that they almost represent a distinct entity. In all cases, but one, the lesions were macrosopic cysts of a fair size, ≥3 cm in 8 of the 10 cases (Table 1), containing colloid-like material. All but one were mostly associated with the adrenal cortex, although one was mainly located in the medulla.20 Most cysts were unilocular, but 3 were multilocular (case 1, Shiraishi et al,18 Shuno et al,19 and Takao et al20). Histologic examination reveals the cyst wall be made by an inner stratum of thyroglobulin and TTF-1 positive cells overlaying a fibrous layer of variable thickness and collagenization, that contains well-developed colloid-filled follicles of thyroid parenchyma. The thyroid follicles blend and are variably intermixed with the adrenal cells. No significant cytologic atypia is present in the
173
Casadei et al Table 1. Review of Cases of ETT in Adrenal Gland From the Literature and the Present Case. Age/Sex/Ethnicity 61/F/Asian 50/F/Asian 50/M/Asian 50/F/Asian 54/F/Asian 67/F/Asian
Clinical Data/Endocrine State Incidental occurrence on CT/normal Right hypochondrial pain/ normal Incidental occurrence on US/normal Incidental occurrence on CT/normal Incidental occurrence on CT/hypertension, elevated aldosterone Incidental occurrence on CT/normal Incidental occurrence on CT/hypertension, elevated aldosterone
Lesion/Location/Size (cm) Cystic, unilocular/right AG/3.5 Cystic, multilocular/right AG/3.0 Cystic, unilocular/right AG/NA Cystic, multilocular/left AG/5.5 Cystic, unilocular/left AG/1.6
38/F/Hispanic (Colombia)
Back pain/elevated aldosterone
Cystic, multilocular/left AG/3.0 Solid nodule/adjacent to and within the capsule of a left AG cortical adenoma/
