procedure likely to give the patient approach- ing a 100% survival is amputation.
References
1. Geshickter, C. F., and Copeland, M. M .: Parosteal Osteoma of Bone: A New Entity, Ann Surg 133:790. 1951.
2. Dwinnel !. L. A., Dahlin. D. C., and Ghormuley, R. K .: Parosteal Juxtacortical Osteogenic Sarcoma. J Bone Joint Surg 36A:732. 1954.
3. Scaglietti. O., and Calendriello, B .: Ossifying Parosteal Sarcoma: Parosteal Osteoma or Juxtacortical Osteogenic Sarcoma, J Bone Joint Surg 44A:635, 1962.
4. Jaffc, H. L .: Tumors and Tumerous Condition of the Bones and Joints. Philadelphia, Lea & Febiger, 1958.
5. Penrhyn Lowc. E. A. (Enschede, Holland), and van Ron- nen. J. (Leiden): Parosteal Sarcoma, in Proceedings of British Orthopaedic Travelling Club, J Bone Joint Surg 44B:957. 1962.
6. Speed. J. S., and Gilmer, W. S., Jr .: Progressive Fascial Ossification and Pleomorphic Sarcoma of Fascia: Juxta- cortical (Parosteal) “Osteogenic” Sarcoma. in Proceedings of American Academy of Orthopaedic Surgeons, 1960. J Bone Joint Surg 42A:881, 1950.
7. Lichenstein. L .: Tumors of l’eriesteal Origin, Cancer 8: 1060. 1955.
Bilateral Adrenocortical Carcinoma
HUSHANG PAYAN, M.D., and JOSEPH LANCASTER, M.D.,t Clarksburg, W. Va.
BILATERAL PRIMARY nonfunctioning malignant tumor of the adrenal cortex is rare.1-6 Destruction of the adrenal glands due to primary or metastatic carcinoma is sel- dom extensive enough to produce clinical evidence of hypoadrenalism. Guttman,2 compiling 566 cases of Addison’s disease, found only 2 primary neoplasms of the adrenal glands as the cause of this disease.
Case Report. A 49 year old white man was admitted to the hospital with a 6 months history of pain in the right flank and weight loss of 14 lbs. in 3 weeks, with anorexia and extreme weakness. B.P. was 80/62, P. 80, R. 14 and T. 101ºF. Physical examination revealed a few rales over the lower portion of the right lung.
Serum sodium was 118, potassium 6.8, chlorides 118, and CO: combining power 22 mEq./L. The BUN. was 24 and blood sugar 72 mg./100 ml. The W.B.C. count was 14,400 with a normal differential count. A retro- pleural mass was noted in routine x-ray and inter- preted as a metastatic neoplasm (Fig. 1). Needle biopsy of the chest tumor revealed mainly necrotic and hemorrhagic material with a few anaplastic malignant cells.
A
HI
The lateral (A) and anteroposterior (B) views of the retro- pleural mass interpreted as pleural or extrapulmonary, meta- static tumor.
+From the Departments of Pathology and Surgery, Clarksburg Veterans Administration Hospital and West Virginia University.
A
C
B
D
The adrenal gland tumor (A) was well encapsulated. with large areas of hemorrhage and necrosis. The metastases to the brain (B), pleura (C) and lymph nodes (D) showed the same hemorrhagic and necrotic appearance. (Formalin fixed.)
The patient died suddenly on July 18, 1965, 4 days after admission.
Autopsy findings: Both adrenal glands were mark- edly enlarged, oval in shape, each measuring 8 x 10 cm., and completely replaced by a well encapsulated yellow-grey structure alternating with reddish-brown hemorrhagic and necrotic areas (Fig. 2,A). The same
Continued on page 350
lergy. Both outdoor air concentrations of rag- weed pollen and the severity of allergic re- sponse noted in patients were roughly propor- tional to the extent of disappearance of Barr bodies. Neither common medications taken for allergic symptoms nor the sex hormone fluctuations related to menstrual cycles dimin- ished Barr body counts in these allergic pa- tients. The disappearance of Barr bodies is considered to reflect a change in the physical state of this DNA material. The mechanisms involved in this change are not known.
We thank our two technicians Mrs. Lorraine Miner and Miss Beatriz Vargas for their painstaking work.
836 Bonifant Street Silver Spring, Maryland
References
1. William, D. I … and Runyon. J .: Sex Chromatin and Chromosome Analysis in the Diagnosis of Sex Abnormali- ties. Ann Intern Med 64:422. 1966.
2. Barr. M. L., and Bertram. E. G .: Morphological Distinc- tion Between Neurones of Male and Female, and Behav- four of Nucleolar Satellite During Accelerated Nucleo- Protein Synthesis, Nature (London) 163:616, 1949.
3. Durham. O. C .: Volumetric Incidence of Atmospheric Allergens. IV. Proposed Standard Method of Gravity Sampling. Counting and Volumetric Interpolation of Re- sults. J Allerg 17:59. 1946.
4. Platt, L. I., and Kailin, E. W .: Sex Chromatin Frequency, JAMA 18 ;: 182. 1964.
5. Taylor. A. I .: Nuclear Sex and Cortisone, Human Chrom- osome Newsletter 4:27. 1961. (Quoted in Ref. #1 above.)
6. Weissman. G., and Dingle, J .: Release of Lysosomal Pro- tease by Ultraviolet Irradiation and Inhibition by Hydro- cortisone, Exp Cell Res 25:207, 1961.
7. de del Campo. B., and Ramirez. O. E. G .: Fluctuations of the Sex Chromatin During the Menstrual Cycle, Acta Cytol (Balı) 9:251. 1965.
8. Waksman. B. H., and Bocking. D .: Study with Fluorescent Antibody of Fate of Intradermally Injected Proteins in Rabbits, Proc Soc Exp Biol Med 82:738. 1953.
9. Coons, A. H., Leduc. E. H., and Connolly, J. M .: Studies on Antibody Production. I. A Method for the Histochem- ical Demonstration of Specific Antibody and its Applica- tion to a Study of the Hyperimmune Rabbit. J Exp Med 102:49. 1955.
10. (a) Analytical Cytology. Ed. by Mellors. R., 2nd Ed. New York. McGraw-Hill Book Company, 1959, p. 27. (b) Coons. A. H .: Histochemistry with Labelled Antibody. Int Rev Ctyol. Ed. by Bourne. G. H., and Danielli, J. F. Vol. 5. New York. Academic Press, 1956. p. I.
11. Rustad. R. C .; Recent Progress in Surface Science. Vol. 2. Ed. by Danielli. J. F., Pankurst, K. G. A., and Riddi- ford. A. C., New York, Academic Press. 1964.
12. Schumaker. V. N .: Uptake of Protein from Solution by Amoeba Proteus, Exp Cell Res 15:314, 1958.
13. Rose, G. G .: Microkinetospheres and VP Satellites of Pino- cytic Cells Observed in Tissue Cultures of Gey’s Strain Hela with Phase Contrast Cinematographic Techniques, J Biophys Biochem Cytol 3:697. 1957.
14. Lycette. R. R., and Pearmain. G. E .: Further Observations on Antigen-induced Mitosis. Lancet 2:386. 1963.
15. Rose. N. R., Girard, J. P .. Kunz. M. L .. Kobayashi. S .. Dolovich. J .. and Arbesman. C. E .: Report to Annual Meeting American Academy of Allergy. Feb. 1966. Quoted also in Dome Newsletter Vol. 3, No. 1, Page 6. 1966.
16. (a) Allison, A. C., and Mallucci. L .: Lysosomes in Dividing Cells with Special Reference to Lymphocytes. Lancet 2: 1371. 1964. (b) Ling. N. R., and Husband. E. M .: Specific and Non- specific Stimulation of Peripheral Lymphocytes, Lancet 1: 363. 1964.
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tumor structure was found in the posterior part of the left parietal lobe of the brain measuring 1.5 x 2 cm. in diameter (Fig. 2.B), in the posterior aspect of the right lung within the two layers of the pleura, and adherent firmly to the lung and chest wall, measuring 10 x 12 cm. (Fig. 2.C), and in a few periaortic lymph nodes, up to 4 cm. in diameter (Fig. 2,D). Microscopic examina- tion of the tumor and metastases revealed an anaplastic neoplasm mostly formed by groups of spindle-shaped cells with moderate to severe morphologie variation (Fig. 3). Occasional small groups of polyhedral cells
Sections of various parts of the adrenal gland tumor with marked morphologic variation (A), bizarre nuclei (B), and spindling of cells (C)- (H & E x 860)
with clear eosinophilic cytoplasm. frequent mitotic figures, massive necrosis and hemorrhage were seen in all sections. The remainder of the autopsy findings were not significant.
Discussion. Carcinoma of the adrenal cortex is often bilateral.4 However, when unilateral. it is found pre- dominantly on the left side.” Such tumors are either nonfunctional or are associated with increased adreno- cortical activity.6 Flank pain and mass, plus radiologic findings, are the main clinical features.” The common sites of metastases are periaortic lymph nodes and lungs.+ The present case is unusual in that the patient presented himself with an Addisonian picture and had brain metastasis.
Summary. Bilateral carcinoma of the adrenal cortex is a rare tumor. An Addisonian picture as a conse- quence of bilateral adrenal carcinoma is extremely rare. This is the report of such a case with another unusual feature, namely brain metastasis.
References
1. Constantinou. E .: Non-functioning Malignant Tumor of the Adrenal Cortex, Arch Path (Chicago) 77:140, 1964.
2. Guttman, P. H .: Addison’s Disease, a Statistical Analysis of 566 Cases and a Study of the Pathology, Arch Path (Chicago) 10:742, 1930.
3. Hagtvet, J .: Adrenocortical Insufficiency due to Metastatic Infiltration of the Adrenal Glands, Acta Med Seand 174:1. 1963.
4. Karsner. H. T .: Tumors of the Adrenal. Atlas of Tumor Pathology, Sect. VIII-Fasc. 29. Armed Forces Institute of Pathology, Washington, D. C., 1950.
5. Knight, D. C., Trichel, B. E., and Mathews, W. R .: Non- functioning Carcinoma of the Adrenal Cortex, Ann Surg 151:349, 1960.
6. Leddy, J. E., Brand, L. M., and Postma, K. J .: Adrenal Carcinoma, Canad J Surg 3:295, 1960.