case_images: PMC6801880_01
case_images: Macro- and microscopic findings of the excised adrenal. All microscopic
  images are magnified x100 unless otherwise stated. (a) The resected adrenal
  specimen with postoperative incisions into the twin ACAs
  aldosterone-producing to the left, cortisol-producing to the right). Note
  the canary-yellow cut surface of the left nodule and the yellow-orange color
  tone of the right lesion. (b) Routine hematoxylin and eosin (H&E)
  staining of the aldosterone-producing ACA displaying predominance of
  lipid-rich cells reminiscent of the zona fasciculata arranged in nests.
  (c)-(d) Same case stained negative for CYP11B1 and intensely positive for
  CYP11B2, respectively. (e) Routine H&E staining of the
  cortisol-producing ACA. Note the increased proportion of eosinophilic cells
  as well as the myolipomatous changes. (f)-(g) Same case stained positive for
  CYP11B1 and negative for CYP11B2, respectively. (h) Adjacent area of the
  adrenal tail with prominent adrenal medulla magnified x40, indicating
  adrenal medullary hyperplasia (AMH). The adrenal medulla clearly exceeds one
  third of the gland's thickness. (i) ACTH immunostaining of the AMH component
  visualizes ACTH production in subsets of the chromaffin cells.
case_images: 10.1177_2050313X19883770-fig1.jpg
case_images: PMC6801880_01_10.1177_2050313X19883770-fig1.jpg
case_images: fig1-2050313X19883770
case_images: The removed adrenal weighted 52 g, and the pathology grossing identified two adrenocortical lesions; one larger measuring 27 mm x 20 mm x 14 mm displaying a yellow and solid cut surface, as well as a second nodule measuring 22 mm x 17 mm x 17 mm with a yellow-orange appearance (Figure 1(a)). Microscopically, the larger lesion was demarcated and encapsulated by a thin capsule and composed of cells reminiscent of zona fasciculata with abundant, finely vacuolated cytoplasm and small nuclei arranged in nests and cords (Figure 1(b)). Surprisingly, no CYP11B1 immunoreactivity was noted, while a strong and diffuse CYP11B2 staining was seen in most tumor cells:verifying the lesion as aldosterone-producing (Figure 1(c) and (d)). The separate 22-mm large lesion was similar in appearance, but with a larger proportion of eosinophilic cells (20%) (Figure 1(e)). A, Inhibin alpha, calretinin and CYP11B1 stained positive, while CYP11B2 immunoreactivity was absent (Figure 1(f) and (g)). AMH was confirmed microscopically and investigated for ACTH production given the twin adrenocortical nodules and the coupling between AMH and intra-adrenal ACTH production. Subsets of adrenomedullary cells were positive for ACTH (Figure 1(h)).