RE: GIANT LIPOMA OF THE ADRENAL GLAND

293

LETTERS TO THE EDITOR 1. Watson, G.: The use of a sheathless basket via miniature ureteroscopes. Diagn Ther Endosc, 2: 177, 1995 DOI: 10.1097/01.ju.0000039607.58722.6e

lipoma: a rare tumour of the adrenal gland. Histopathology, 15: 195, 1989 5. Lam, K. Y., Chan, A. C. and Ng, I. O.: Giant adrenal lipoma: a report of two cases and review of literature. Scand J Urol Nephrol, 31: 89, 1997 6. Buttner, A.: Lipoma of the adrenal gland. Pathol Int, 49: 1007, 1999

RE: GIANT LIPOMA OF THE ADRENAL GLAND K. N. Milathianakis, C. D. Farfarelos, I. M. Mpogdanos and D. K. Karamanolakis J Urol, 167: 1777, 2002 To the Editor. The authors report a case of giant lipoma of the right adrenal gland, which was found incidentally during ultrasonographic examination following a car accident. Lipoma is composed of mature adipose tissue, and occasionally has fibrous connective tissue as septations.1 Therefore, lipoma appears on computerized tomography as a well defined homogeneous tumor with low attenuation value. However, in figure 1 in the article the right adrenal tumor demonstrates a large amount of nonfatty soft tissue attenuation material. This finding suggests adrenal myelolipoma rather than pure lipoma since the nonfatty soft tissue in the reported tumor may represent hematopoietic cells. Adrenal myelolipoma is more common than lipoma, and is composed of hematopoietic cells and fat similar to bone marrow. Myelolipoma typically manifests as a well defined suprarenal mass with an area of clearly recognizable fat attenuation. Some higher attenuation areas are usually seen, often with attenuation readings less than that of true soft tissue, as well as indistinct margins because of the irregular intermixture of fat and myeloid elements seen microscopically.2, 3 On magnetic resonance imaging predominantly fatty areas usually have increased signal intensity on T1-weighted images and moderate hyperintensity complicated by the presence of marrow-like elements in the corresponding regions on T2-weighted images.3 Calcification is rare in pure lipoma but has been observed in 24% of reported cases of myelolipoma.2, 3 To make a diagnosis of pure lipoma, there should not be any evidence of hematopoiesis or adrenal medulla cells on serial sections. If a pathologist examines only the fatty component of myelolipoma, the tumor can be misdiagnosed as lipoma. In previously reported cases of adrenal lipoma there was no pathological evidence of hematopoietic elements despite the fact that serial sections or multiple blocks were taken from the lesions.4 – 6 Another possibility is that the nonfatty material in the tumor may represent intratumoral bleeding due to trauma. However, this possibility is less likely in this case because there is no evidence of rib fracture or abdominal wall injury in figure 1. Myelolipomas with hemorrhage have been reported in larger lesions, and the appearance of the myelolipoma is altered on imaging.2, 3 Angiomyolipoma, liposarcoma and teratoma may also be included in the differential diagnosis based on computerized tomography findings but these tumors are extremely rare at the adrenal gland.1 We recommend that the authors conduct a careful pathological examination of serial sections, and hope that they will report the composition of the nonfatty material in the tumor. Respectfully, Yoshito Tsushima Department of Radiology Motojima General Hospital 3-8 Nishi-Honcho, Ohta, Gunma 373-0033 Japan and Keigo Endo Department of Diagnostic Radiology and Nuclear Medicine Gunma University Hospital 3-39-15 Showa-machi, Maebashi, Gunma 371-8851 Japan 1. Lam, K. Y. and Lo, C. Y.: Adrenal lipomatous tumours: a 30 year clinicopathological experience at a single institution. J Clin Pathol, 54: 707, 2001 2. Kenney, P. J., Wagner, B. J., Rao, P. and Heffess, C. S.: Myelolipoma: CT and pathologic features. Radiology, 208: 87, 1998 3. Rao, P., Kenney, P. J., Wagner, B. J. and Davidson, A. J.: Imaging and pathologic features of myelolipoma. Radiographics, 17: 1373, 1997 4. Avinoach, I., Robinson, C. R., Avinoah, E. and Peiser, J.: Adrenal

Reply by Authors. The tumor has been reevaluated since the initial anatomicopathological examination in its total volume in serial sections. It was quite laborious to reexamine all of these sections but for deontological reasons reexamination was conducted by the initial examiner consultant anatomicopathologist, then by another consultant and then by the director of the department. None of these sections demonstrated evidence of migrated hematopoietic cells from the bone marrow. As for the presence of calcifications in the specimen, it is obvious that in large tumors the homogeneity of the tissue is not the same as in small tumors. In an adrenal tumor of greater than 30 cm. the presence of connective tissue with calcifications is to be expected. These findings confirm the integrity of the first pathological diagnosis. We would also like to mention that there was no evidence of previous or intraoperative hemorrhage within any of the tissue studied. Thus, we once again have confirmed that the examined tumor is the largest pure adrenal lipoma reported in the literature. DOI: 10.1097/01.ju.0000039826.81532.8f

RE: PREDICTION OF PATHOLOGICAL STAGE IN PATIENTS WITH CLINICAL STAGE T1C PROSTATE CANCER: THE NEW CHALLENGE R. W. Veltri, M. C. Miller, L. A. Mangold, G. J. O’Dowd, J. I. Epstein and A. W. Partin J Urol, 168: 100 –104, 2002 To the Editor: The authors convincingly argue that nuclear characteristics can provide important prognostic information in the described setting (patients with clinical T1c disease). However, I would like to raise several issues. First, the authors only address clinical stage T1c disease. Surely if the proposed “biological markers” are accurate, then they should be equally applicable to other important clinical situations such as T2 and the less common T1a,b disease. In addition, no data were provided regarding the excluded 131 patients (31% of all T1c patients). How many patients were excluded because of the mentioned exclusion criteria, namely the possible confounding effect of hormonal treatment, and how many were excluded due to other causes, and to what extent did they differ from those who were included? Also, how was prostate specific antigen (PSA) density calculated? Was it calculated by using preoperative ultrasound volume measurement of the prostate, or by the weight of the radical prostatectomy specimen? The data suggest the latter in that the average weights of radial prostatectomy specimens were provided. If this is the case, then the data invalidate the results of this variable to a great extent as such accurate information would not be available preoperatively. If ultrasound volume was used, then how accurate was this measurement in relation to the postoperatively available weight of the prostate? Furthermore, how reproducible are the results of nuclear grading? It is obvious that the difference between organ confined and nonorgan confined disease is better demonstrated using nuclear grading (0.14 ⫾ 0.4 versus 0.39 ⫾ 0.26) compared to Gleason score (6.1 ⫾ 0.4 versus 6.4 ⫾ 0.7). Adding Gleason score and complexed PSA density to nuclear grading improves the area under receiver operating characteristics by a small and perhaps imperceptible margin (from 80.6% to 82.4%). In that case is nuclear grading capable of replacing the perhaps more subjective Gleason score? The example given in the discussion to illustrate the value of nuclear grading seems to be extreme. In that example the same Gleason score (7) was used. However, the difference in quantitative nuclear grading was extreme (0.005 versus 0.9155). How realistic is this example? In other words, what is the correlation coefficient between the 2 variables, namely nuclear grading and Gleason score? In general, it is unlikely that using relatively blunt instruments such as nuclear morphology/ploidy, Gleason score, PSA or its deriv-