Molecular Endocrine Pathology
Moderators: Dr. Ricardo Lloyd and Dr. George Kontogeorgos
Section 5 -
Adrenal Cortical Tumors
Thomas J. Giordano
Background and Introduction
Adrenal cortical tumors (ACT) are relatively rare. However, these tumors are worthy of
attention for several main reasons. First, the incidence of the adrenal "incidentaloma" has risen over
the last decade due to improved imaging studies. Second, these tumors are clinically and pathologically
fascinating due to their associated hormonal and genetic syndromes. Finally, the therapeutic choices
currently available for adrenal cortical carcinoma (ACC) are quite limited. Thus, there is a
considerable clinical need for new, more effective and less toxic therapies. Many of these aspects were
discussed at a recent international meeting held in Ann Arbor in September 2003 .
The majority of ACTs can be adequately evaluated by histopathology. The accurate
separation of ACTs into adrenal cortical adenoma (ACA) and carcinoma (ACC) is usually straightforward in
most cases using established criteria . Furthermore, valuable prognostic information can also be
obtained using objective criteria . Using this prognostic grading system, mitotic activity is
assessed by light microscopy and tumors are divided into low- and high-grade groups based on whether
tumors have less than or greater than 20 mitoses per 50 high power fields. In my unpublished experience
at the University of Michigan, this mitotic activity based grading system is easy to perform and
Immunohistochemistry (IHC) of ACTs is performed for two reasons. The first reason is to
provide support for adrenal cortical differentiation in either a metastatic tumor or a poorly
differentiated tumor of the retroperitoneum. In this instance, IHC for α-inhibin, melan-A, and
calretinin may be of some utility
The second and more challenging reason to perform IHC on ACTs is to accurately separate ACAs and
ACCs. Not surprisingly, most of the work to date has focused on proliferation-related markers such as
MIB-1/Ki-67 labelling index or topoisomerase II α
The common theme throughout all of
these studies is that ACCs have much higher levels of proliferation that can be exploited diagnostically
and prognostically. However, there are still rare ACTs that are difficult to classify with these
adjunctive tools and hence occasional tumors still merit a diagnosis of "ACT of uncertain malignant
As with other types of human tumors, ACTs acquire mutations in their DNA that manifest in
the typical forms that range from gross chromosomal abnormalities (e.g. rearrangements) to single base
substitutions. These mutations have been studied in an effort to better understand the pathogenesis of
ACC, but it is also hoped that they can be exploited to develop a robust way to differentiate ACA from
Comparative Genomic Hybridization
The experimental methods used to examine mutations in ACTs include Comparative Genomic Hybridization
(CGH), which is designed to identify large regions of the chromosomes that have either undergone deletion
or amplification. By examining a large cohort of ACTs with CGH, it is possible to identify regions that
have consistently been altered and thus identify regions that contain either oncogenes or tumor
suppressor genes. There have at least been four CHG studies performed on adult ACTs
is clear that CGH is a powerful chromosomal discovery tools and the resulting CGH data in ACTs support a
model in which ACA can progress to ACC in a stepwise fashion, CGH has not yet yielded a genotype that can
be clinically exploited to assist in the diagnosis of these tumors.
Single Marker Genotyping
One of the most successful ways to identify cancer related genes has been to isolate the
genes responsible for familial cancer syndromes. There are 2 such syndromes in which ACC is a common
manifestation; Beckwith-Wiedemann syndrome (BWS) (Online Mendialian Inheritance in Man (OMIM) entry
130650) and Li-Fraumeni syndrome (OMIM entry 151623). BWS is an overgrowth disorder associated several
tumors types. The mutations causing BWS have been tightly linked to the chromosomal region 11p15.5,
which is a complex and imprinted region that contains several genes including H19, KIP2, and IGF2.
Based on numerous studies, the role of IGF2 in sporadic and familial ACC has been well established
IGF2 can undergo a variety of rearrangements, the most common
being paternal isodisomy (loss of maternal allele and duplication of paternal allele), that increase the
expression of IGF2 and that these are essentially restricted to ACCs.
The Li-Fraumeni syndrome has been linked to mutations of the TP53 gene . Many studies
have examined TP53 mutations in ACTs with quite variable results
Generally mutations were found
in 20 to 67% of ACCs and were rare in ACAs. While the highest mutation frequency reported in ACCs was
67%, this is not high enough to be used clinically to accurately separate benign and malignant tumors.
LOH studies hold the greatest diagnostic potential.
Other mutations have been associated with ACTs (reviewed in )such as mutations of the
but they have not been demonstrated to have any utility in separating
ACAs from ACCs.
Molecular Profiling Studies
One of the difficulties or limitations of using genotyping in a clinical setting is that
several different types of mutations can inactivate (or activate) the same gene. Point mutations can be
distributed across large genes (i.e. point mutations of MEN1) making their
identification technically difficult, and it is also possible to mutate a single gene via distinct
mutational mechanisms. For example, the most common type of BRAF mutation
in papillary thyroid carcinoma is a point mutation, but less common translocations and amplifications
have also been reported
Thus, a method based on DNA sequencing for point mutations will
completely fail to identify the other mutations. For this reason, as well as others, there is much
excitement over high-throughput methods to examine gene expression in tissues
of commercially-available DNA microarrays has permitted their use in a variety of clinicopathologic
studies and the first such studies of adrenal cortical tumors have been published.
In a study from our laboratory , we used oligonucleotide arrays and small cohort of
normal adrenal cortex, ACAs and ACCs identify a gene expression profile that robustly separated benign
and malignant tumors, including one low-grade tumor. Using a large group of variably expressed genes
selected without reference to pathologic diagnosis, separation of ACA from the other cortical tissues was
observed. The one low grade ACC (designated C13) was intermediate in its classification. When a reduced
gene list of differentially expressed genes was used, C13 clearly segregated with the other ACCs. This
was observed when both Principal component analysis (PCA) and hierarchical clustering was performed.
Consistent with the IGF2 molecular work described above, IGF2 expression was greatly increased in the ACCs compared to the other tissues
along with many other genes related to increased proliferation. While limited to a small cohort of
tumors, this study clearly illustrates the power of molecular profiling approaches for tumor
classification and gene discovery.
A second microarray paper used a larger set of tumors but a smaller set of 230 genes
. The power of this study comes not from the depth of its array but from their ability to correlate
gene expression and patient outcome. Combining these variables, a 22-gene set was developed and shown to
possess predictive power.
Collectively, these 2 studies demonstrated clear differences in gene expression between
benign and malignant adrenal cortical tumors and illustrate the potential power of molecular profiling
approaches based on gene expression for tumor classification. A new study with larger number of tumors
is in its early phases at the University of Michigan.
It is difficult to predict the exact path this field with take in the years to come,
especially given the rapid evolution of high-throughput technologies to comprehensively investigate
various aspects of tumor cell biology. However, it is clear the fields of oncology and pathology are on
the edge of a near-radical transformation in which more targeted therapies become available and more
intelligent therapeutic choices are made, largely driven by molecular profiling-based assessments of
patient's tumors. It will be exhilarating to witness and participate in this transformation as it is
applied to the diagnosis, prognosis and treatment of adrenal cortical carcinoma.
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