Second Example of the “Duffy” Antibody

Discussion These cases present interesting features both clinically and pathologically. Laparotomy was essential in order to make a diagnosis, and easily removable tumours were found, but in both cases blood pressure fell sharply afterwards, suggestive of suprarenal shock, and it seems probable that this feature was in part, if not entirely, the cause of death. It is therefore important to consider the possibility of a cortical suprarenal neoplasm when a very large encapsulated retroperitoneal tumour is found which is causing no symptoms referable to the organ of origin; for it seems likely that if the diagnosis were made early enough hormonal replacement therapy might prevent post-operative collapse. It is therefore particularly valuable to note that the naked-eye appearances in my two cases and in the case described by Anderson et al. (1943) were exactly similar. Walters and Kepler (1938) pointed out that probably the most important single feature in the surgical treatment of cortical adrenal tumours was the control of post-operative shock. Cecil (1933) stated that 39% of patients operated on died of shock. It may be added in this connexion that Cahill et al. considered that post-operative shock occurred only in those cases in which, as a result of the tumour, a syndrome of Cushing's type was present and hormonal excess was affecting metabolic functions such as salt-and-water balance and capillary permeability. They further state that, in their series, cases without clinical hormonal upsets were never associated with post-operative collapse. This view cannot be confirmed from the present cases. From the pathological point of view the gross and the microscopical structure of these tumours provokes discussion whether they are benign or malignant. Features in favour of their benignity are the presence of the wellformed capsule and the absence of evidence of metastases, although it must be admitted that it was not possible to perform necropsies. The absence of demonstrable mitoses and the close resemblance of the tumour cells to those of the normal adrenal seem to point to a non-malignant origin, although it may be repeated that numbers of metastasizing tumours with complete differentiation of cell type have been described. It is somehow difficult to reconcile such very large masses showing so much necrosis and haemorrhage with benign growths. Another feature suggestive of malignancy is the association of tumour cells with the vessel walls, and in many cases the presence of strands of cells lying free in blood spaces. The marked tendency towards thrombosis in the vessels is more commonly seen in malignant than in benign tumours. Examples in the literature of large cortical adrenal tumours are rare. Among the largest is the case recorded by Holmes (1925) in which a tumour weighing 1,025 g. (2 lb. 4 oz.) and measuring 17 by 14 by 9.5 cm. was found to be of benign type, and that of Anderson et al. (1943), who described a malignant cortical tumour weighing 1,780 g. (3 lb. 14 oz.) in which a solitary metastasis was found in the liver. The latter case is of interest, as the appearance of the tumour was identical with those described above, although a relatively anaplastic histological nattern was recorded. It may again be stressed that histologically benign tumours merge imperceptibly into the malignant varieties, and in the absence of demonstrable metastases opinions might well differ about their correct interpretation. It might be argued that haemorrhage into a simple adenoma is the more correct view in the above cases, but it is my opinion, based on the reasons already given, that these are examples of slowly advancing malignant tumours.