Heterotopic adrenal gland in undescendent testis - Case report.

Heterotopic adrenal cortex is usually found in the kidney, retroperitoneum and spermatic cord. The adrenal gland has a dual embryonic origin: the cortex arises from the mesoderm and the medulla from ectoderm of the neural crest. Adrenal cortex and gonads both arise from genital ridge, because of that adrenal tissue with descending gonads may migrate in early embryonic period. We report a case of adrenal rest in upper pole of testes.

Introduction

Heterotopic adrenal tissue along the spermatic cord is a rare diagnosis in childhood. It can be found near organs that were in the neighborhood of suprarenal glands during embryonic origin and have moved away in the process of development. Usually is found in the kidney, retroperitoneal fat, rarely in the ovary, testis, spermatic cord, liver, colon transversum, and gastric wall. Overall incidence in different studies varies from 1% to 9.3% of the patients who underwent groin surgical explorations. Morgagni first described them in 1740 along the spermatic cord. Heterotopic adrenal tissue can undergo hyperplasia and protentional malignant neoplasm leading to different complications if they left untreated.

Case report

We present 6 years old boy, with clinical diagnosis of undescended right testis. From the ultrasonography the testis was found in the inguinal canal, and after consultation send for operation. During the exploration of the testis we found capsulated yellowish small nodule 5 × 5 mm between the testis and head of the epididymis. We enucleated this nodule and send for pathology and make orchidopexy of the testis. The pathology result was heterotopic adrenal cortex(zona fasciculata). The patient was discharge next day without complications.

Discussion

Most cases of ectopic adrenal tissue in spermatic cord have been found incidentally during surgical procedures (like herniotomy, orchiopexy, etc) in the inguinoscrotal region. Ectopic or accessory adrenal tissue known as adrenal rest tissue occur when fragments of tissue break off during development. The adrenal gland has a dual embryonic origin: the cortex arises from the mesoderm and the medulla from ectoderm of the neural crest. Adrenal cortex and gonads both arise from genital ridge, in early embryogenesis adrenal cortical tissue can migrate with the developing gonad. If adrenal tissue migrates more distally it will developed gonad contains cortex only. As seen in our case it's found poorly formed zona fasciculata, no evidence of medullary cells found in these rests[Fig. 1]. The immunohistochemical analysis showed that the described cells were positive for Melan A and Synaptophysin[Fig. 2, Fig. 3].These heterotopic rests are common in children but not so in adults. Ectopic adrenal tissue usually atrophies so that it occurs in 1% of adults only. Normally these rests are asymptomatic as in our case, but they can grow in size and come to clinical manifestation, liberating hormones and producing symptoms and cause morbidity and mortality in patients. Another clinical aspect is the possibility of malignant transformation in heterotopic adrenal tissue. Testicular adrenal rests in testis may cause azoospermia due to obstruction of seminiferous tubules.

Fig. 1

Histological examination of the surgical specimen revealed lesion, composed of small trabecular structures and clusters of round cells with clear margins, vacuolated pale cytoplasm, oval shaped monomorphous nuclei, inconspicuous nucleoli – morphology of adrenal cortex (zona fasciculata). Heterotopic adrenal_gland_40x_H&E.

Fig. 2

The immunohistochemical analysis showed that the described cells were positive for Melan A.

Fig. 3

The immunohistochemical analysis showed that the described cells were positive for Synaptophysin.

Conclusion

Clinical implications of these adrenal rests are essentials, in surgical approach to a patient. There is a high risk of developing malignant disease in these ectopic tissues. Based on these facts, we think that whenever ectopic nodule found in testis or any other site during surgical operations in inguinal region should be removed. Hence even though incidentally found surgical removal should be contemplated.