Pathologic Features

Aldosterone-producing adenomas are usually solitary tumors involving only one adrenal gland (Fig. 68-1). Most adenomas are smaller than 2 cm in diameter. The mean diameter in 210 patients with surgically proven aldosterone-producing adenomas in our series was 1.8 cm, which is consistent with previous reports.12 The cut surface usually has a characteristic golden yellow appearance. Microscopically, the typical tumor is mostly composed of large lipid-laden clear cells. In contrast, idiopathic hyperaldosteronism usually affects both adrenal glands and appears as micro-nodular or macronodular hyperplasia.

Despite these typical pathologic features of adenoma and hyperplasia, there is a pathologic continuity between predominant unilateral adenoma and macronodular and micronodu-lar hyperplasia. For instance, the extratumoral cortex of a solitary adenoma is not always normal: it may be hyperplastic or occasionally atrophic. Macroscopic or microscopic nodules often accompany aldosterone-producing adenoma (Fig. 68-2). Of our patients, 19% had multiple macronodules in association with distinct adenoma and an additional 43% had adenoma-associated micronodules.13 Other authors have reported similar frequencies (55% and 42%) of macronodular or micronodular lesions associated with adenoma.1415 Macronodular hyperplasia and nonfunctioning cortical nodules associated with adenoma are not always distinguishable histologically. Patients with macronodules associated with adenoma are likely to have severe, prolonged hypertension.

In addition, rare cases of bilateral solitary adrenal adenomas16"18 and unilateral adrenal hyperplasia4,5 have been reported. These variable presentations thus reflect the fact that clinical primary aldosteronism is not a single pathologic entity, and they have important clinical implications with regard to therapy.

FIGURE 68-1. Cut surface of an adrenal gland showing a typical aldosterone-producing adenoma.
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