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The plasma cortisol level (6.13?��g/dL) showed no suppression at the end of test. We interpreted these results as subclinical Cushing GDC-0449 syndrome because he had no symptoms or signs of Cushing's syndrome. 123I-Metaiodobenzylguanidine (123I-MIBG) scintigraphy was performed to check for the presence of pheochromocytoma. For this purpose, 3 mCi of 123I-MIBG was injected and whole body images were obtained after 6?h and after 24?h. From the 24?h images, eccentric uptake by a large left adrenal gland mass was confirmed (Figures 2(a) and 2(b)). On the image of 123I-MIBG SPECT/CT, left adrenal gland tumor showed 123I-MIBG uptake in the peripheral portion (Figure 2(c)). Figure 2 Early 123I-MIBG scintigraphy showed no 123I-MIBG uptake in suprarenal area (a). 24-hour delayed 123I-MIBG scintigraphy, however, showed increased 123I-MIBG uptake in left suprarenal area (b). On the image of 123I-MIBG SPECT/CT, left adrenal gland tumor ... During preparation of surgery for suspected subclinical Cushing's syndrome and pheochromocytoma, chest X-ray and chest CT (Figure 3) confirmed metastatic lymphadenopathy of the mediastinum. PET-CT (Figure 4) and endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) were also performed. From the lymph node biopsy obtained Quinapyramine by EBUS-TBNA, metastatic carcinoma of unknown origin was suspected, and surgery was prepared in suspicion of malignant pheochromocytoma or adrenocortical carcinoma, accompanied by metastatic lymphadenopathy. Figure 3 Chest computed tomography scan shows the multiple metastatic lymph nodes enlargement at subcarinal area (white arrow). Figure 4 Transaxial image of 18F FDG PET/CT showed heterogeneously FDG-avid left adrenal gland tumor (a) and MIP of 18F FDG PET/CT (b) also revealed multiple FDG-avid lymphadenopathies in mediastinum and right supraclavicular area. Starting from 2 weeks prior to the surgery, phenoxybenzamine and propranolol were administered. Laparoscopic left adrenalectomy was performed. MS-275 clinical trial The resected tumor measured 8.5 �� 7.5 �� 5.1?cm; central necrosis and hemorrhaging were present, with involvement of the resection margins (Figure 5). Microscopically, the tumor revealed a solid sheet arrangement composed of pleomorphic cells. Tumor cells had enlarged pleomorphic nuclei with prominent nucleoli and abundant cytoplasm, while some cells show rhabdoid features with abundant eosinophilic cytoplasm and eccentric nuclei (Figure 6). Pathologically, pheochromocytoma could be excluded since neuroendocrine markers (chromogranin, CD56, and NSE) were negative. The tumor was located within adrenal parenchyma with outside protruding feature in grossly. And inhibin and vimentin immunohistochemical stains were positive in tumor cells. Both antibodies are usually positive in adrenal cortical tumor.
