Overview of the 2022 WHO Classification of Adrenal Cortical Tumors

Advances in multimodal imaging for adrenal gland disorders: integrating CT, MRI, and nuclear medicine

Adrenal diseases pose significant diagnostic challenges due to the wide range of neoplastic and non-neoplastic pathologies. Radiologists have a crucial role in diagnosing and managing these conditions by, leveraging advanced imaging techniques. This review discusses the vital role of computed tomography (CT), magnetic resonance imaging (MRI), and nuclear medicine in adrenal imaging, and focuses on morphological and functional evaluations. First, the anatomy and physiology of the adrenal glands are described, followed by a discussion on ectopic adrenocortical adenomas and how they develop. The concepts and imaging findings of congenital diseases, such as congenital adrenal hyperplasia (CAH), adrenal rest tumors, and adrenocortical nodular disease, considering recent updates to the WHO Classification of Tumours (5th ed.) terminology are highlighted. The diagnostic value of dynamic contrast-enhanced CT and chemical-shift MRI for identifying adrenocortical adenomas are emphasized, alongside the use of adrenocortical scintigraphy such as 131I-adosterol scintigraphy for diagnosing Cushing's disease, Cushing's syndrome (CS), subclinical CS, and ectopic adrenocorticotropic hormone-producing tumors. Systemic complications associated with CS, and the diagnosis and treatment of pheochromocytomas, paragangliomas (PPGLs), and neuroblastomas, will also be discussed focusing on 123I-metaiodobenzylguanidine (MIBG) imaging and 131I-MIBG therapy. Pitfalls in 123I-MIBG imaging and the increasing importance of diagnosing hereditary PPGLs due to increased genetic testing are also be discussed. Additionally, the broad differential diagnosis for adrenal masses-including malignancies like adrenal carcinoma, metastases, and malignant lymphoma, as well as benign conditions like myelolipoma and ganglioneuroma, and complications, such as adrenal hemorrhage, infarction, and infections-will be outlined. The goal of this review was to provide an overview of adrenal diseases that includes the most recent information for radiologists to stay updated on the latest imaging techniques and advancements that can ensure accurate diagnosis and effective management.

Adrenal cortical carcinoma - a case series and literature review of aggressive adrenal incidentalomas

OBJECTIVE

Adrenal cortical carcinoma (ACC) is a rare and aggressive endocrine malignancy. Clinical symptoms are mainly related to excess hormone secretion. Hypercortisolism and virilisation are among the most common presentations.

METHODS

We report a case series of five patients with ACC, three of which presented as adrenal incidentalomas. Additionally, a literature review on current diagnosis and management of ACC was performed.

RESULTS

ACCs are often incidentally detected because of the liberal use of medical imaging. Management of ACC remains challenging, and the poor prognosis makes early diagnosis of crucial importance to increase chances of a better outcome. Biochemical evaluation should be performed to diagnose hormonally active tumours.

CONCLUSION

Surgery is the main and only potentially curative treatment option. Adjuvant treatment with mitotane may improve survival and is indicated for patients with a perceived high risk of recurrence. Aggressive cytotoxic therapy should be given to patients with an unfavourable prognosis.

ABCC3 Is a Differential Marker of CYP11B2-Negative Zona Glomerulosa Cells in Human Adrenal Cortex

ATP Binding Cassette Subfamily C Member 3 (ABCC3) is a membrane transporter that exports diverse compounds, influencing drug resistance in cancers and impacting metabolic and malignant diseases. We previously reported ABCC3 upregulation in human adrenal cells under lipid peroxidation-induced oxidative stress. We investigated ABCC3 expression and function in the human adrenal cortex in the context of primary aldosteronism, focusing on its relationship to CYP11B2 (aldosterone synthase) in zona glomerulosa (ZG) cells and aldosterone-producing lesions. ABCC3 expression in aldosterone-producing adenomas (APAs) was markedly reduced compared to the adjacent adrenal cortex, cortisol-producing adenomas, and non-functioning adenomas. The reduction in APAs showed genotypic variability: in APAs harboring KCNJ5 mutations-known drivers of autonomous aldosterone production via altered potassium channel function-ABCC3 mRNA/protein levels were significantly higher than in wild-type KCNJ5 APAs. Spatial transcriptomics and immunofluorescence colocalization revealed an inverse expression pattern between ABCC3 and CYP11B2 (aldosterone synthase) in APAs and aldosterone-producing micronodules (APMs). Notably, high ABCC3 expression was exclusively observed in adrenal ZG cells that lacked CYP11B2 expression. This expression pattern distinguishes ABCC3 from common ZG markers such as KCNJ5 and DAB2, which are expressed across adrenal ZG cells, APMs, and APA tumor cells. In cultured human adrenocortical cells, both angiotensin II stimulation and induced expression of the KCNJ5-L168R mutation resulted in upregulation of CYP11B2 transcription while concomitantly suppressing ABCC3 expression. In conclusion, ABCC3 serves as a novel marker of CYP11B2-negative ZG cells, providing a histopathological tool to differentiate normal adrenal zonation from aldosterone-producing lesions in primary aldosteronism, as well as from cortisol-producing and nonfunctional adenomas.

A deep learning algorithm for automated adrenal gland segmentation on non-contrast CT images

BACKGROUND

The adrenal glands are small retroperitoneal organs, few reference standards exist for adrenal CT measurements in clinical practice. This study aims to develop a deep learning (DL) model for automated adrenal gland segmentation on non-contrast CT images, and to conduct a preliminary large-scale study on age-related volume changes in normal adrenal glands using the model output values.

METHODS

The model was trained and evaluated on a development dataset of annotated non-contrast CT scans of bilateral adrenal glands, utilizing nnU-Net for segmentation task. The ground truth was manually established by two experienced radiologists, and the model performance was assessed using the Dice similarity coefficient (DSC). Additionally, five radiologists provided annotations on a subset of 20 randomly selected cases to measure inter-observer variability. Following validation, the model was applied to a large-scale normal adrenal glands dataset to segment adrenal glands.

RESULTS

The DL model development dataset contained 1301 CT examinations. In the test set, the median DSC scores for the segmentation model of left and right adrenal glands were 0.899 and 0.904 respectively, and in the independent test set were 0.900 and 0.896. Inter-observer DSC for radiologist manual segmentation did not differ from automated machine segmentation (P = 0.541). The large-scale normal adrenal glands dataset contained 2000 CT examinations, the graph shows that adrenal gland volume increases first and then decreases with age.

CONCLUSION

The developed DL model demonstrates accurate adrenal gland segmentation, and enables a comprehensive study of age-related adrenal gland volume variations.

Spanish consensus on the diagnosis and management of adrenocortical carcinoma

Adrenocortical carcinoma (ACC) is a rare endocrine malignancy with an estimated incidence of 0.7-2 cases per million/year. The rarity of this disease, coupled with limited preclinical models and clinical trials, has hindered progress, resulting in poor outcomes, with a 5-year survival rate of approximately 35%. Currently, the only available curative treatment is complete surgical resection of the adrenal tumor. For unresectable or metastatic ACC, the current standard therapeutic modalities are mitotane, chemotherapy, radiotherapy and locoregional treatments; however, these are noncurative. Mitotane has an adrenolytic and anti-steroidogenic effect, and it is used in the adjuvant setting for high-risk patients, as systemic therapy for metastatic disease, and/or to control hormonal secretion. While key pathways in ACC pathogenesis have been identified as potential therapeutic targets, results with targeted therapies remain modest, showing that there is a clinical unmet need for novel treatments or new combinations of exiting drugs. Effective management requires a multidisciplinary team of experts to optimize outcomes for patients. This article presents a multidisciplinary consensus on the diagnosis, management, prognosis and follow-up of patients with ACC, and the approach to two special contexts, ACC in pregnant women and hormone-producing ACC. The consensus was coordinated by the Spanish Society of Endocrinology and Nutrition (SEEN) and the Spanish Group of Neuroendocrine and Endocrine Tumors (GETNE), with contribution from experts from related societies including the Spanish Association of Surgeons (AEC), Spanish Society of Urology (AEU), Anatomic-Pathology (SEAP), Nuclear Medicine (SEMNIM), Medical Oncology (SEOM) and Radiotherapeutic Oncology (SEOR).

Efficacy of Propranolol Combined with Different Modalities of Unilateral Adrenalectomy in a Case Series of 4 ARMC5-mutated Patients

Limited research has explored the efficacy of β-blockers in combination with unilateral total, subtotal, or partial adrenalectomy in ARMC5-mutated patients with primary bilateral macronodular adrenocortical hyperplasia (PBMAH). Additionally, there is no consensus on determining the optimal side for adrenal gland resection. To assess the clinical utility of three unilateral adrenalectomy (ULA) modalities-total, subtotal, and partial-combined with β-blocker treatment in patients with PBMAH and Cushing's syndrome (CS). This study was conducted at a single tertiary referral center involving a series of four patients with suspected CS. Diagnosis of PBMAH was confirmed through dexamethasone suppression testing, evaluation of ectopic receptor expression, and whole-exome sequencing. Three patients underwent unilateral total, subtotal, or partial adrenalectomy, respectively, while one patient declined surgery. All patients received β-blocker treatment. The median treatment duration among the four ARMC5-mutuated PBMAH patients was 30.5 months (range: 6-45 months). Two patients who underwent total or subtotal adrenalectomy on the side with more pronounced nodularity showed postoperative improvement in clinical CS signs, glycemic control, and hypertension. These two patients, along with another patient with bilateral diffuse (non-nodular) adrenal hyperplasia who declined surgery, showed further improvement in hypercortisolism and cortisol/adrenocorticotropic hormone (ACTH) ratio (CAR: plasma cortisol (nmol/L)/plasma ACTH (pg/ml), newly reported as a reliable parameter of cortisol secretory capacity in patients with adrenal CS) after propranolol treatment. The patient who underwent partial adrenalectomy on the side with less pronounced nodularity showed no significant improvement in hypercortisolism or CAR, and the response to propranolol was also unsatisfactory. All four cases harbored pathogenic variants in the ARMC gene, including two novel germline mutations.In ARMC5-mutuated patients with PBMAH, unilateral total adrenalectomy on the side with more pronounced nodularity appears to be an effective treatment option. Propranolol may be considered as an alternative or adjunctive therapy to ULA for managing hypercortisolism in those with ARMC5 mutations.

Clinical value of CXCR4-targeted PET-CT in primary aldosteronism: a systematic review and meta-analysis

PURPOSE

Primary aldosteronism (PA), a common cause of secondary hypertension, requires precise localization and subtype differentiation for appropriate management. C-X-C chemokine receptor 4 (CXCR4) targeted PET-CT emerges as a promising non-invasive modality for evaluating PA. This study aims to assess its performance in three key areas: lateralizing aldosterone secretion, differentiating PA subtypes, and predicting surgical outcomes.

METHODS

A systematic review and meta-analysis were performed, including studies that evaluated CXCR4-targeted PET-CT for PA diagnosis. Relevant literature was retrieved from PubMed, Embase, Scopus, Web of Science, WanFang, and CNKI (through January 10, 2025). Studies were included if they provided data on lateralization, subtype differentiation, or postoperative outcomes. Risk of bias was assessed using the QUADAS-2 tool. Pooled diagnostic metrics were calculated using random-effects models, with summary receiver operating characteristic curves analysis.

RESULTS

Fourteen studies involving 1043 patients were included. CXCR4-targeted PET-CT demonstrated a pooled sensitivity of 74%[95%CI: 69-79%] and specificity of 85%[95%CI: 64-95%] for lateralizing aldosterone secretion. For subtype differentiation, sensitivity was 91%[95%CI: 82-96%] and specificity 92%[95%CI: 85-96%] in distinguishing aldosterone-producing adenoma from non- aldosterone-producing adenoma. In predicting postoperative outcomes, the sensitivity was 91%[95%CI: 84-95%], with accuracy of 77%[95%CI: 64-90%].

CONCLUSION

CXCR4-targeted PET-CT demonstrated clinical applications in: (1) accurately determining PA lateralization with high specificity; (2) reliably distinguishing PA subtypes; and (3) effectively predicting postoperative benefit. These findings support its potential use as an adjunctive tool in the clinical management of PA.

SYSTEMATIC REVIEW REGISTRATION NO

CRD42025636887 (PROSPERO).

Localization and Classification of Adrenal Masses in Multiphase Computed Tomography: Retrospective Study

BACKGROUND

The incidence of adrenal incidentalomas is increasing annually, and most types of adrenal masses require surgical intervention. Accurate classification of common adrenal masses based on tumor computed tomography (CT) images by radiologists or clinicians requires extensive experience and is often challenging, which increases the workload of radiologists and leads to unnecessary adrenal surgeries. There is an urgent need for a fully automated, noninvasive, and precise approach for the identification and accurate classification of common adrenal masses.

OBJECTIVE

This study aims to enhance diagnostic efficiency and transform the current clinical practice of preoperative diagnosis of adrenal masses.

METHODS

This study is a retrospective analysis that includes patients with adrenal masses who underwent adrenalectomy from January 1, 2021, to May 31, 2023, at Center 1 (internal dataset), and from January 1, 2016, to May 31, 2023, at Center 2 (external dataset). The images include unenhanced, arterial, and venous phases, with 21,649 images used for the training set, 2406 images used for the validation set, and 12,857 images used for the external test set. We invited 3 experienced radiologists to precisely annotate the images, and these annotations served as references. We developed a deep learning-based adrenal mass detection model, Multi-Attention YOLO (MA-YOLO), which can automatically localize and classify 6 common types of adrenal masses. In order to scientifically evaluate the model performance, we used a variety of evaluation metrics, in addition, we compared the improvement in diagnostic efficacy of 6 doctors after incorporating model assistance.

RESULTS

A total of 516 patients were included. In the external test set, the MA-YOLO model achieved an intersection over union of 0.838, 0.885, and 0.890 for the localization of 6 types of adrenal masses in unenhanced, arterial, and venous phase CT images, respectively. The corresponding mean average precision for classification was 0.885, 0.913, and 0.915, respectively. Additionally, with the assistance of this model, the classification diagnostic performance of 6 radiologists and clinicians for adrenal masses improved. Except for adrenal cysts, at least 1 physician significantly improved diagnostic performance for the other 5 types of tumors. Notably, in the categories of adrenal adenoma (for senior clinician: P=.04, junior radiologist: P=.01, and senior radiologist: P=.01) and adrenal cortical carcinoma (junior clinician: P=.02, junior radiologist: P=.01, and intermediate radiologist: P=.001), half of the physicians showed significant improvements after using the model for assistance.

CONCLUSIONS

The MA-YOLO model demonstrates the ability to achieve efficient, accurate, and noninvasive preoperative localization and classification of common adrenal masses in CT examinations, showing promising potential for future applications.

Cytological Assessment of Adrenal Tumours: Insights From 22-Years Single Centre Experience

OBJECTIVE

The incidence of adrenal tumours has increased in the last decades, mainly due to increased use of imaging. The diagnostic evaluation of adrenal masses can be complex and, in some cases, necessitates cytological evaluation. However, concerns remain regarding the potential complications associated with adrenal gland biopsy.

DESIGN

We conducted a retrospective cohort study to evaluate the safety and diagnostic effectiveness of cytology in patients who underwent fine-needle aspiration (FNA) of adrenal glands at Karolinska University Hospital in Stockholm, Sweden, between 2000 and 2022. The aim was to evaluate the accuracy of the sample and the complication rate.

PATIENTS AND MEASUREMENTS

A total of 241 patients and 251 FNAs were included, with 10 patients undergoing two FNAs each. Data on clinical, radiological and laboratory presentation was collected and corelated with cytological findings and outcomes.

RESULTS

Diagnostic FNA was obtained in 90% of patients (n = 217) with endoscopic ultrasound technique being most successful (95.8%), followed by CT (88.7%) and transabdominal ultrasound technique (86.7%). The sensitivity and the specificity were 93.8% respectively 96.7%. More than half of the FNA samples (52.7%) indicated a diagnosis consistent with metastases to the adrenal gland. The complication rate was 7.9% (n = 20). Based on the FNA results, adrenalectomy was performed on 13.6%, while 52.8% of the patients with benign findings were managed conservatively. Chemotherapy was started for 78.7% of patients with malignant findings.

CONCLUSION

FNA of the adrenal glands is a safe, minimally invasive diagnostic procedure that can be useful in the assessment of adrenal lesions.

Immunohistochemical characterization of normal feline adrenal tissue and adrenal tumors secreting aldosterone

It is suggested that primary hyperaldosteronism (PHA) is an under-diagnosed cause of systemic hypertension in cats. No immunohistochemical markers of aldosterone synthesizing tissues have been identified, meaning that endocrine function cannot be inferred from examining feline tissues. In humans, expression of CYP11B2 (aldosterone synthase) is used for this purpose, but cats have a single CYP11B enzyme responsible for the terminal steps in synthesis of both aldosterone and cortisol, precluding its use as an indicator of steroidogenic function. This study aimed to identify immunohistochemical markers of aldosterone producing tissues. In addition, since there are no existing guidelines for classification of feline adrenal tumors as benign or malignant, this study aimed to investigate potential markers of adrenal tumor malignancy in PHA. Normal adrenals (n = 9) and adrenal tumors secreting aldosterone (n = 31) or cortisol (n = 4) were immunolabeled for steroidogenic enzymes (CYP11B, CYP17A1, and CYB5A), the zona glomerulosa (including KCNJ5 visinin-like 1 (VSNL1), and neuron-specific enolase (NSE)), and proliferation markers (Ki67). Histochemical staining for reticulin was also performed. Transcriptomes of normal (n = 4) and aldosterone secreting tumors (n = 5) were compared. Weak or absent CYP17A1 in conjunction with strong KCNJ5 or VSNL1 immunolabeling was present in aldosterone producing tissues from normal and tumorous cat adrenals. CYP17A1 RNA expression was lower in aldosterone producing tumors compared with normal adrenals (P < .0001). VSNL1 and NSE were not specific markers of aldosterone producing tissue. CYB5A and CYP17A1 were not expressed within the zona reticularis, suggesting minimal adrenal production of androgens. Ki67 proliferative index and reticulin network disruption were not predictive of malignancy.

The prognostic value of CXCR4 PET/CT imaging in unilateral primary aldosteronism patients after adrenalectomy

BACKGROUND

CXCR4 PET/CT imaging has emerged as a tool for diagnosis and subtyping of primary aldosteronism (PA). But its prognostic value for postoperative blood pressure recovery has not been fully discussed.

RESULTS

The lesional SUVmax to the contralateral adrenal tissue SUVmean ratio (LCR) was identified as an independent predictor of clinical success at both the 3-month and 6-month assessments. The AUC for LCR was 0.894 at the 3-month and 0.832 at the 6-month. Patients were divided into high and low LCR groups according to the optimal cut-off of 3.240. The high LCR group exhibited elevated CXCR4 and CYP11B2 expression, higher PAC level, a greater probability of achieving complete clinical success compared to the low LCR group. Moreover, LCR was correlated with lateralization index and contralateral suppression index.

CONCLUSIONS

LCR is a reliable independent predictor of postoperative blood pressure recovery in PA. Patients with LCR over 3.240 may benefit more from adrenalectomy. We recommend increased utilization of CXCR4 PET/CT for patients with PA.

REGISTRATION

ChiCTR2200062844. Registered 20 August 2022.

A new predictive factor VGF based on IHC experiments, gene pathways and molecular functional groups for tumor immune microenvironment and prognosis of adrenocortical carcinoma

Background

Adrenocortical carcinoma (ACC) is a rare and aggressive malignancy with a poor prognosis, and its clinical management remains a significant challenge due to the high recurrence rates and limited treatment options. Despite advances in understanding the molecular mechanisms underlying ACC, no reliable biomarkers have been validated for routine clinical use.

Methods

We analyzed RNA sequencing data from The Cancer Genome Atlas (TCGA) database (n=79) and Genotype Tissue Expression (GTEx) database (n=128) to investigate the expression of VGF in ACC and normal adrenal tissues. Gene expression levels of VGF were quantified and correlated with clinicopathological features and survival outcomes. Statistical methods included Cox proportional hazards models and Kaplan-Meier analysis, while Gene Set Enrichment Analysis (GSEA) was utilized to identify relevant biological pathways associated with VGF expression. Clinical data from 7 ACC patients from YANTAI YUHUANGDING Hospital were also analyzed. The expression of VGF in ACC and normal adrenal gland tissue was further validated through IHC experiments.

Results

Our results demonstrate that VGF expression is elevated in ACC tissues compared to normal adrenal tissues and is significantly associated with advanced disease stages, lymph node involvement, metastasis and poor overall survival. VGF levels also correlate with immune cell infiltration, including Th2 cells, T helper cells, and Neutrophils. Importantly, our study establishes VGF as a potential prognostic biomarker for ACC and highlights its role in tumor progression and immune modulation. Additionally, GSEA analysis suggests that VGF is involved in cytokine receptor interaction and the P13K-Akt signaling pathway, possibly relating to tumor immunity.

Conclusions

VGF could serve as a valuable marker for patient stratification, monitoring disease progression, and predicting responses to immunotherapies. Future studies should focus on investigating circulating VGF levels as a non-invasive biomarker for ACC to improve clinical management and treatment outcomes.

Adrenal Gland Pathology Reporting Among Genitourinary Pathologists: An Orphan Field Handled by Foster Pathologists?

Due to their association with the kidney, adrenal glands are frequently resected by urologists and evaluated by genitourinary (GU) pathologists. However, given the growing complexity of adrenal pathology and advent of a dedicated "endocrine pathology" subspecialty, herein we sought to assess the sentiment regarding adrenal pathology among GU pathologists. One hundred twenty-eight pathologists who handle GU specimens participated in a survey including both junior (40% < 10 years in practice) and experienced pathologists (60% > 11 years in practice), who work in academic (75%) or private practice settings (25%). Participants reported "on the job" adrenal pathology training (61%) and/or formal training during GU fellowship (36%). While participants felt mainly "comfortable" (36%) or "neutral" (29%) reporting adrenal specimens, some felt "uncomfortable" (15%) or "very uncomfortable" (5%). Most reported that adrenal specimens are handled by GU pathology (56%) versus general surgical pathology (26%) or endocrine pathology (22%; although only 30% reported having formal endocrine pathologists). However, when the participants were asked who they felt should be handling adrenal specimens, participants most strongly endorsed either endocrine pathology (74%) or GU pathology (58%). For workplaces that didn't have a dedicated endocrine pathologist, the main limitations were insufficient number of endocrine pathology specimens for the position (53%; 81% reporting an average of ≤10 per month) or insufficient number of qualified endocrine pathologists (46%). Although adrenal specimens are typically received from urology colleagues, many GU pathologists feel it may be prudent to consider them under the rubric of endocrine pathology services as they become more readily available.

Multicentric Retrospective Analysis of Oncocytic Adrenocortical Carcinoma: Insights into Clinical and Management Strategies

Oncocytic adrenocortical carcinoma (OAC) is a rare variant of conventional adrenocortical carcinoma (ACC), characterized by oncocytic tumor cells comprising more than 90% of the tumor. Due to its rarity, there is a lack of reliable data on the clinicopathological features and outcomes of OAC. The aim of this study was to assess the clinical presentation, treatment modalities, and outcomes of patients with OAC, comparing these results with a cohort of patients with conventional ACC. Data from 9 referral centers in Italy on 44 patients with OAC were retrospectively analyzed and compared with data from 145 patients with conventional ACC. Patients with OAC had a smaller median tumor size, more favorable resection margin status, and lower incidences of venous invasion and persistent/recurrent disease during follow-up. Additionally, patients with OAC exhibited longer times to progression (TTP) and overall survival (OS) compared to patients with conventional ACC. Multivariable analyses identified Ki67 and tumor size as features independently associated with disease progression during post-surgical follow-up, while Ki67 and distant metastases at diagnosis were independently associated with OS in OAC patients. After complete tumor removal, the risk of recurrent disease was higher in patients with either Ki67 ≥ 20% or ENSAT stage III/IV. OAC appears to have a more indolent clinical course and better prognosis than conventional ACC. Similar to conventional ACC, Ki67 remains a significant prognostic marker for OAC and, along with ENSAT stage, serves as a reliable biomarker for identifying patients who may benefit from adjuvant mitotane therapy.

Oncocytic Adrenal Tumors: A Tri-Focal Review with Integrated Cytopathological, Pathological, and Molecular Perspectives

BACKGROUND

Oncocytic lesions of the adrenal gland pose several diagnostic challenges as they can be associated with both functional and non-functional adrenal disorders and may be either benign or malignant.

SUMMARY

Oncocytic tumors are predominantly (>90%) composed of oncocytic cells, characterized by bulky, eosinophilic cytoplasm due to an abundance of mitochondria. Notably, the conventional histopathological criteria for diagnosing adrenal cortical carcinoma (ACC), such as the Weiss criteria, are not recommended for oncocytic tumors, and separate classification algorithms have been proposed for this entity. In addition to their unique cytopathology and histopathology, oncocytic adrenal cortical neoplasms share many driver gene alterations with conventional adrenal tumors, albeit at lower frequencies. However, these tumors also exhibit some distinct genetic changes, particularly deletions of mitochondrial DNA, which are consistent with patterns seen in oncocytic lesions of other endocrine organs. Interestingly, the presence of oncocytic features may correlate with prognosis in ACCs, making this morphological distinction clinically significant. Some studies suggest that oncocytic features could be linked to either a more favorable or unfavorable outcome, depending on other molecular markers. This highlights the importance of accurate diagnostic work-up for these lesions and underscores the critical role of endocrine pathologists in their management. While cytology is not part of the routine work-up for primary adrenal tumors, fine-needle aspiration cytology may still be useful in distinguishing primary adrenal tumors from metastases.

KEY MESSAGES

This review examines the histological and molecular characteristics of oncocytic adrenal cortical lesions, highlighting their clinically relevant differences from conventional adrenal tumors. It clarifies the limited role of cytology in diagnosing primary adrenal tumors while recognizing its usefulness in distinguishing adrenal metastases. Finally, it underscores the need for a tailored diagnostic approach to effectively manage this complex entity.

Total or partial adrenalectomy for aldosterone-producing adenoma: can 68Ga-Pentixafor PET/CT predict surgical outcomes?

OBJECTIVE

This study aimed to compare the accuracy of adrenal vein sampling (AVS) and 68Ga-Pentixafor positron emission tomography (PET)/computed tomography (CT) in predicting the functional outcome from adrenalectomy in patients with primary aldosteronism (PA), and to investigate the utility of 68Ga-Pentixafor PET/CT in laparoscopic partial adrenalectomy.

METHODS

We prospectively enrolled patients diagnosed with PA. All patients underwent 68Ga-Pentixafor PET/CT and AVS. Patient management was discussed by a multidisciplinary team. Ninety surgically eligible patients were randomized to partial (n = 45) or total adrenalectomy (n = 45), while 97 received medical therapy. Postoperative Aldosterone Surgical Outcome (PASO) criteria served as the gold standard.

RESULTS

In total, 187 patients with PA were examined using 68Ga-pentixafor PET/CT and AVS, and 90 patients who underwent surgery were included in the analysis. The accuracy of 68Ga-Pentixafor PET/CT in correctly predicting biomedical partial or complete success, biomedical complete success, clinical partial or complete success, and clinical complete success was 78.89%, 77.78%, 77.67%, and 67.78%, respectively. For AVS, the accuracies were 74.44%, 73.33%, 70.00%, and 54.44%, respectively. 68Ga-pentixafor PET/CT was not significantly superior, but the differences lay within the pre-specified - 10% margin for non-inferiority. Functional outcomes did not significantly differ between the partial and total adrenalectomy groups. Multivariable logistic analysis demonstrated that the lower highest systolic blood pressure and higher SUVmax were independent factors of complete clinical success. The AUC for SUVmax in determining clinical complete success was 0.896, with an optimal cutoff value of 9.8. Subgroup analysis showed no functional outcome difference between laparoscopic partial and total adrenalectomy for patients with an SUVmax over 9.8. However, for those with an SUVmax below 9.8, laparoscopic total adrenalectomy yielded better results than laparoscopic partial adrenalectomy.

CONCLUSION

The accuracy of 68Ga-Pentixafor PET/CT is comparable to the conventional, invasive method of AVS in forecasting the functional outcomes of adrenalectomy. SUVmax is an independent factor in determining complete clinical success and can potentially predict the functional outcome of laparoscopic adrenalectomy. It is suggested that laparoscopic partial adrenalectomy be performed on individuals who present an SUVmax value exceeding 9.8. The ability of 68Ga-Pentixafor PET/CT to localize aldosterone-producing adenoma ultimately paves the way for the use of more focal treatment options.

TRIAL REGISTRATION

ChiCTR2300070830. Registered 23 April 2023.

Management of adrenocortical adenoma in systemic sclerosis: A case report

Systemic sclerosis is a rare autoimmune disorder that affects multiple organ systems, including the lungs, kidneys, and liver, and often leads to fatal complications. Adrenocortical adenoma, a benign tumor, can secrete hormones such as cortisol, resulting in symptoms including hypertension, diabetes, and obesity, although it can also be asymptomatic. This article presents a case of a patient with systemic sclerosis and adrenocortical adenoma, detailing the diagnostic and therapeutic journey before and after laparoscopic adrenal tumor resection. It offers insights into the clinical management of such cases and analyzes how surgical removal of the adenoma affects the treatment and prognosis of systemic sclerosis. This study aimed to provide valuable knowledge to healthcare professionals managing patients with this dual diagnosis, further contributing to the medical understanding of treatment outcomes in such cases.

The differential diagnosis of adrenocortical tumors: systematic review of Ki-67 and IGF2 and meta-analysis of Ki-67

Distinguishing benign from malignant adrenocortical tumors (ACT) is not always easy, particularly for tumors with unclear malignant potential based on the histopathological features comprised of the Weiss score. Previous studies reported the potential utility of immunohistochemistry (IHC) markers to recognize malignancy, in particular the Insulin-like growth factor 2 (IGF2) and the proliferation marker, Ki-67. However, this information was not compiled before. Therefore, this review aimed to collect the evidence on the potential diagnosis utility of IGF2 and Ki-67 IHC staining. Additionally, a meta-analysis was performed to assess the Ki-67 accuracy to identify adrenocortical carcinoma. The systematic review and meta-analysis were conducted according to the PRISMA guidelines. From the 26 articles included in the systematic review, 21 articles provided individual data for IGF2 (n = 2) or for Ki-67 (n = 19), while 5 studies assessed both markers. IGF2 staining was positive in most carcinomas, in contrast to adenomas. However, the different immunostaining evaluation methods adopted among the studies impeded to perform a meta-analysis to assess IGF2 diagnostic accuracy. In contrast, for the most commonly used cut-off value of 5% stained cells, Ki-67 showed pooled specificity, sensitivity and log diagnostic odds ratio of 0.98 (95% CI 0.95 to 0.99), 0.82 (95% CI 0.65 to 0.92) and 4.26 (95% CI 3.40 to 5.12), respectively. At the 5% cut-off, Ki-67 demonstrated an excellent specificity to recognize malignant ACT. However. the moderate sensitivity observed indicates the need for further studies exploring alternative threshold values. Additionally, more studies using similar approaches are needed to assess the diagnostic accuracy of IGF2.Registration code in PROSPERO: CRD42022370389.

Diagnostic challenges of retroperitoneal leiomyosarcoma: A case of confusion with adrenal tumour

Leiomyosarcoma (LMS) represents an aggressive neoplasm that often involves a diagnostic challenge when encountered in atypical anatomical sites. The case here exposed involves a 70-year-old female with a retroperitoneal mass measuring 65mm×65mm, likely of adrenal origin, warranting consideration for adrenalectomy. Histopathological examination reveals spindle cells arranged in intersecting fascicles, displaying pleomorphism and necrosis, and is immunohistochemically positive for actin and desmin markers. The definitive diagnosis is LMS, demonstrating venous origin without infiltration of the adrenal gland. Regrettably, the patient succumbed to post-operative complications. The inconspicuous nature of LMS in this anatomical niche complicates preclinical detection, underscoring the pivotal role of histopathological analysis in its identification. Furthermore, achieving complete excision proves challenging, resulting in a poorer prognosis compared to conventional LMS, despite the availability of alternative treatment modalities. Given the absence of standardized management protocols, a multidisciplinary approach remains essential.

Adrenal oncocytoma: a rare presentation of a benign 18 F-fluorodeoxyglucose PET avid virilising adrenal tumour

A woman in her 70s presented with features of hyperandrogenism including clitoral enlargement and deepening of her voice. Biochemical investigations revealed raised plasma androgens and urinary androgen metabolites and imaging findings showed a highly F-18 fluorodeoxyglucose (FDG)-PET avid left adrenal tumour initially suspected to be a malignant adrenocortical carcinoma (ACC). She subsequently underwent an uncomplicated laparoscopic adrenalectomy where complete resection of her tumour was achieved. Histopathological analysis demonstrated a benign adrenal oncocytoma with no evidence of malignancy. This case illustrates a rare presentation of a functioning virilising adrenal oncocytoma as a benign mimic of ACC.

GBDKVA score: a scoring system for preoperative risk assessment of adrenal tumors ≤6cm

Objectives

To propose a comprehensive scoring system for adrenal tumors ≤ 6cm and evaluate its rationality and validity.

Materials and methods

This study retrospectively analyzed 268 patients with primary adrenal tumors who underwent laparoscopic surgery from January 2018 to December 2022 and all of them met the inclusion criteria. Evaluation scores were calculated for gender (G), body mass index (BMI) (B), tumor diameter (D), the relative position of the tumor to the kidney (K), the relative position of the tumor and the blood vessels (V) and the tumor location in the adrenal gland (A). Then, the total scores were correlated with the operation results, so as to verify the feasibility of GBDKVA in evaluating the surgical risk.

Results

The GBDKVA score showed a consistent and statistically significant correlation with operation time (OT) and blood loss (BL), as well as a correlation with postoperative complications in patients (p < 0.01), but no significant correlation was found with recovery time of gastrointestinal function, bed rest days, indwelling drainage tube days and postoperative hospitalization time were opposite.

Conclusions

GBDKVA score is reliable for preoperative risk assessment of patients with adrenal tumors ≤6cm.

Primary Aldosteronism and Hypokalemia-induced Rhabdomyolysis in a Patient with Aldosterone-producing Adenoma: A Case Report and Literature Review

Many cases of primary aldosteronism (PA) in patients who developed hypokalemia-induced rhabdomyolysis and underwent adrenalectomy for aldosterone-producing adenoma (APA) have been reported; however, the immunohistopathological and molecular features remain unknown. We herein report the case of a 28-year-old woman with PA who presented with hypokalemia-induced rhabdomyolysis and underwent adrenalectomy for unilateral APA. An immunohistochemical analysis revealed that most adenoma cells were positive for steroidogenic enzymes, including CYP11B2. A genetic analysis revealed a somatic mutation in the KCNJ5. These findings suggest a strong aldosterone production capacity in our patient's adenoma, which was presumably related to her severe hyperaldosteronism and the resultant hypokalemia-induced rhabdomyolysis.

Discordance between adrenal vein sampling and imaging: the role of unilateral cortisol excess

OBJECTIVE

Adrenal vein sampling (AVS) is considered the gold-standard for identifying unilateral primary aldosteronism (PA), but is sensitive to any asymmetry in cortisol production. Subclinical autonomous cortisol production likely contributes to discordance between cross-sectional imaging and AVS.

DESIGN AND METHODS

Retrospective chart review was performed of patients in Calgary, Alberta who (1) had a diagnosis of PA with clear adrenal mass, (2) had discordant AVS and cross-sectional imaging, and (3) underwent dexamethasone-suppressed NP59-iodocholesterol adrenal scintigraphy (n = 25). Postoperative biochemical and clinical outcomes were evaluated. Surgical pathology was analyzed with immunohistochemical staining for CYP11B1 and CYP11B2.

RESULTS

NP59 scanning demonstrated autonomous steroidogenesis from the same side as the computed tomography (CT)-identified lesion, despite discordant AVS results, in 19/25 cases. Out of the 16 patients who underwent adrenalectomy (guided by NP59), 11 cases had a final diagnosis of cortisol-producing adenoma with bilateral PA, while the final diagnosis in the remaining 5 cases was cortisol-producing adenoma with unilateral PA (defined by a complete biochemical response). All cases preoperatively had low/suppressed adrenocorticotropin hormone that rose postadrenalectomy, in keeping with the resolution of cortisol autonomy. Adrenal vein sampling incorrectly diagnosed the subtype of PA or falsely localized the side of aldosterone excess in 10/16 cases.

CONCLUSIONS

Discordant CT and AVS results in patients with PA and obvious adrenal mass are often explained by subclinical asymmetric cortisol excess. Clinicians should be aware of the limitations of AVS in the presence of subtle autonomous cortisol secretion and must be able to counsel patients regarding the possible outcomes from surgery when discordant lateralization is present.

Atypical clinical presentation of oncocytic adrenocortical carcinoma with decompensated metabolic syndrome and psychotic outbreak

Adrenal incidentalomas, mostly adrenal adenomas, affect 3%-10% of the global population. Adrenocortical carcinoma (ACC) is rare, with an incidence of 0.7-2 cases per million. Adrenocortical oncocytic neoplasms (ACONs) account for about 10% of ACC cases, often discovered incidentally, with 17-34% being functionally active.We report a case of a woman in her 60s with treatment-resistant hypertension, diabetes and psychotic delirium. Imaging revealed a 6 cm left adrenal mass with marginally elevated metanephrines. Laparoscopic adrenalectomy was performed. Histology confirmed ACON. Positive margins necessitated adjuvant chemotherapy and radiotherapy. Postoperatively, psychiatric symptoms and hypertension resolved, indicating the tumour's secretory nature.This case highlights the diverse ACONs hormonal secretions, leading to complex clinical presentations, including metabolic and psychiatric symptoms. ACONs secretory nature may not be reflected in standard hormonal panels.ACONs challenging diagnosis and management emphasise the need for a multidisciplinary approach and further research.

Prevalence and main characteristics of primary aldosteronism in bilateral macronodular adrenal disease: a systematic review of the literature

CONTEXT

Bilateral macronodular adrenal disease (BMAD) typically presents with bilateral benign adrenocortical macronodules and variable cortisol excess. Anecdotal evidence suggests oversecretion of other adrenal steroids, including mineralocorticoids.

HYPOTHESIS

We hypothesized that primary aldosteronism (PA) can occur in BMAD, resulting in a distinct, more severe phenotype compared to BMAD with isolated cortisol hypersecretion or unilateral PA (uPA).

OBJECTIVE

To assess the prevalence and characteristics of PA in BMAD.

METHODS

We systematically reviewed case reports and series of BMAD patients with PA, following PRISMA guidelines. BMAD was defined by bilateral adrenal nodules ≥10 mm. PA diagnosis followed US or Japanese Endocrine Society guidelines. We compared these findings with 2 cohorts from LMU Hospital Munich: BMAD with isolated cortisol hypersecretion and uPA.

RESULTS

From 1018 articles, 18 representing 68 cases were included. Of these, 66 had BMAD with PA and 2 had BMAD with aldosterone precursor excess. The PA proportion in published BMAD series ranged from 2% to 43%. BMAD patients with PA were predominantly male (75%) and younger (median 51.5 years) than those with isolated cortisol hypersecretion (median 60.5 years, P < .01). Their median blood pressure was higher (170/100 mm Hg) compared to those with isolated cortisol hypersecretion (138/80 mm Hg) or uPA (153/94 mm Hg, P < .01). Treatment was only described in 28 cases, with 93% undergoing adrenalectomy. Clinical outcome was similar across groups post-treatment.

CONCLUSION

This review highlights the need for increased screening for PA in younger, hypertensive BMAD patients. Larger multicenter studies are needed to determine the association between these conditions, cardiovascular risk, and optimal treatment.

Updates on WHO 5th edition classification, molecular characteristics and tumor microenvironment of adrenocortical carcinomas

Discerning malignancy in adrenocortical tumors is clinically pivotal in the management of patients but has also been one of the most difficult areas in both clinical and pathology settings. The recently published WHO 5th edition "Endocrine and Neuroendocrine Tumours" recommends a diagnostic algorithm employing not only one but several proposed histopathological criteria-including the Weiss criteria and its revision and the Helsinki criteria-in addition to the Reticulin algorithm, the Ki-67 proliferative index, and others depending upon their histopathological features. On the other hand, the risk classification proposed by ENSAT (European Network of Study for Adrenal Tumors) in 2018 was primarily based on the Ki-67 proliferative index of carcinoma cells, especially focusing on whether or not postoperative or adjuvant chemotherapy could be administered. The recently reported results of the ADIUVO study, although preliminary, discuss the necessity of postoperative therapy with mitotane in patients with low-grade adrenocortical carcinomas (ACCs) after complete resection. In addition, recently reported comprehensive genetic analyses attempted to classify ACCs into four major molecular subtypes: (i) the Wnt/-catenin pathway, (ii) the p53/Rb1 pathway, (iii) the chromosomal maintenance/chromatin remodeling pathway, and (iv) the MMR (Mismatch repair) pathway. Among those, groups (i) and (ii) are more commonly detected in high-grade ACCs but it is also true that specific therapeutic targets based on the molecular characteristics of tumors have remained limited. In addition, possible effects of glucocorticoid excess in functional ACCs on the tumor microenvironment have also been examined, and the utility of immune checkpoint inhibitors is being explored at this juncture.

Oncocytic Adrenal Neoplasms: Clinical Profiles and Long-Term Outcomes

Background: Oncocytic adrenal neoplasms, defined by ≥90 % of oncocytic cells, are rare. The significance of oncocytic changes within an adrenal neoplasm remains unclear.Methods: A retrospective study of adults who underwent adrenalectomy at a large center identified pure oncocytic neoplasms on final pathology (1997-2022). Neoplasms were categorized based on Lin-Weiss-Bisceglia system as malignant, benign, or of uncertain malignant potential. Analysis was performed using Fisher exact, Kruskal-Wallis tests, and Kaplan-Meier analysis.Results: Among a total of 33 patients, 24% had benign, 36% malignant, and 39% neoplasm of uncertain malignant potential. None of the benign neoplasms recurred, while 50% of the malignant neoplasms recurred (median of 40 months). Two of 13 neoplasms initially thought to be of uncertain malignant potential recurred as distant metastatic adrenocortical carcinoma at 11 and 25 months, over a median follow-up duration of 31 months. Ki67% was available for 20 patients: median (IQR) Ki67% was 5 (1, 5) for benign, 10 (6, 15) for malignant, and 6.5 (5, 10) for neoplasms of uncertain behavior, P = 0.05. Recurred neoplasms had higher Ki67% at initial resection compared to cases that did not recur.Conclusion: While oncocytic adrenal neoplasms are rare, a significant proportion are malignant or have malignant potential. Judicious follow-up is required for oncocytic adrenal neoplasms of uncertain malignant potential, as they can recur as metastatic adrenocortical carcinoma. Ki67% should always be obtained in cases of malignancy or uncertain malignant potential as it can predict recurrence. Larger studies are needed to evaluate the appropriate follow-up protocols for these neoplasms.

Adrenocortical carcinoma with dual androgen and cortisol secretion

Adrenocortical carcinoma (ACC) is a rare endocrine cancer that originates in the adrenal cortex, known for its capacity to produce hormones such as cortisol, aldosterone, estrogens, or androgens. These hormonal imbalances lead to a diverse array of clinical manifestations. This case report describes a middle-aged male patient presenting with a dual-hormone secreting ACC, characterized by the secretion of both androgens and cortisol. This hormonal profile resulted in Cushing syndrome along with symptoms of androgen excess, including bilateral lower limb edema, prolonged fatigue, and altered mental status. An extensive diagnostic evaluation, including clinical assessments, laboratory tests and imaging revealed the presence of an adrenal mass and lung metastases. Imaging-guided biopsy confirmed diagnosis of ACC with simultaneous androgen and cortisol secretion. This report enriches the sparse literature on dual-secreting ACC, highlighting the complexities in its diagnosis and management.

Does adjuvant mitotane impact cure rates in adrenocortical carcinoma? Insights from the ICARO-GETTHI/SEEN registry

BACKGROUND

Adrenocortical carcinoma (ACC) is a rare, aggressive malignancy with a high risk of postoperative recurrence. Although adjuvant mitotane is commonly used, its potential for achieving cure rather than simply postponing inevitable recurrence remains uncertain. This study investigates whether mitotane impacts ACC recurrence patterns by preventing or delaying recurrence.

METHODS

This retrospective analysis used data from the ICARO-GETTHI/SEEN registry, which includes 36 Spanish hospitals. Recurrence in non-metastatic ACC patients after resection was analyzed using Cox models, flexible longitudinal models, and mixture cure models to evaluate the impact of mitotane.

RESULTS

Among 244 patients, 133 (52%) received adjuvant mitotane, with therapeutic levels monitored in 84%. Findings suggest a possible "cure fraction" with a 32.5% estimated 30-year cure rate (95% CI, 23.4%-45.0%). Cox regression indicated a 39% reduced recurrence risk (HR 0.61; 95% CI, 0.39-0.95) for mitotane-treated patients, with effects diminishing over 24 months. Mixture cure models suggest mitotane primarily delays rather than prevents recurrence. Effect modification analysis showed significant benefit in males (HR 0.33; 95% CI, 0.16-0.69), younger patients, tumors with higher Ki-67% (modeled as a continuous variable), and those with venous invasion (HR 0.47; 95% CI, 0.27-0.82), with potential synergy when combined with radiotherapy.

CONCLUSION

This study underscores the intriguing possibility that adjuvant mitotane delays recurrence, yet questions remain as to its curative capacity. The early benefit suggests a cytostatic effect, but certain subgroups-especially males, younger individuals, and those with high-risk tumors-may experience a more durable outcome. Further research is needed to explore mitotane's curative potential in ACC management.

Blood pressure improvement after resection of non-functioning adrenal adenomas: influencing factors and serum metabolic features

Introduction

Non-functioning adrenal adenomas (NFAs) are typically regarded as benign tumors that lack hormonal secretion. However, emerging evidence has shown that some patients with NFAs and hypertension experience improvements in blood pressure after adrenalectomy, indicating a potential correlation between NFAs and hypertension. Nevertheless, the precise mechanisms that underpin this phenomenon remain elusive.

Methods

We collected data from all patients with adrenal adenomas who underwent unilateral laparoscopic partial or total adrenalectomy at the First Affiliated Hospital of Xi'an Jiaotong University in 2023. A statistical analysis was conducted on factors such as tumor diameter, duration of hypertension, BMI, and age. Additionally, we gathered serum samples from six patients who experienced postoperative blood pressure improvement and six patients who did not. These samples were subjected to targeted and untargeted metabolomic analyses to identify significant serum metabolites.

Results

Our findings revealed that 50.9% of patients with NFAs and hypertension experienced blood pressure improvement after surgery. Additionally, patients in the improvement group (IG) exhibited larger tumor diameters alongside shorter durations of hypertension compared to their counterparts in the nonimprovement group (NIG). Untargeted metabolomic analysis identified 89 differentially abundant metabolites in the serum between the IG and NIG. In particular, we found that guanidinoacetic acid (GAA), a precursor of creatine synthesis that possibly participates in the occurrence of hypertension, was enriched in patients in the IG and reduced after surgery.

Discussion

The findings of our study indicated that duration of hypertension and tumor diameter may exert an influence on the extent of postoperative blood pressure improvement, and NFAs might promote hypertension through GAA-related creatine metabolism.

A rare manifestation of adrenocortical carcinoma as a mimic of pheochromocytoma: a case report and literature review

The primary management in the care of patients with adrenal incidentalomas is to determine the oncologic risk, namely, the possibility of malignancy. The first place among adrenal incidentaloma lesions requiring diagnosis and treatment promptly is adrenocortical carcinoma (ACC). Similarly, in the case of pheochromocytoma, the lack of early diagnosis worsens the patient's prognosis. Even though both ACC and pheochromocytoma are among the less frequent adrenal lesions, neither should be excluded during differential diagnostics, especially in patients with an equivocal clinical presentation and non-typical adenoma radiological features. ACC presenting as pheochromocytoma is one of the few cases described in the literature, some of which could not collect exhaustive clinical data. Herein, in this article, we would like to provide an overview of reported ACC cases clinically manifesting as pheochromocytoma, based on the clinical image of a 59-year-old female patient with unintentional weight loss, non-specific abdominal pain, a diagnosis of hypertension, and significantly elevated excretion of 3-methoxytyramine in a 24-h urine collection, histopathologically diagnosed with ACC. The case presented emphasizes how crucial a comprehensive diagnostics and individual approach to the patient would be.

Differentiation of multiple adrenal adenoma subtypes based on a radiomics and clinico-radiological model: a dual-center study

BACKGROUND

The prevalence and detection rates of adrenal incidentalomas have been on the rise globally, with more than 90% of these lesions pathologically classified as adrenocortical adenomas. Among these, approximately 30% of patients present with hormone-secreting adenomas, leading to the deterioration of their health, with some requiring surgical resection. The available methods for adrenal function evaluation are invasive and costly. Moreover, their accuracy is influenced by numerous factors. Therefore, it is imperative to develop non-invasive and simplified preoperative diagnostic approach.

METHODS

A retrospective study was performed on 169 patients from two tertiary medical centers. Subsequently, radiomics features were extracted after tumor margins were delineated layer-by-layer using a semi-automatic contouring approach. Feature selection was achieved in two cycles, with the first round utilizing a support vector machine (SVM) and the second round using a LASSO-based recursive feature elimination algorithm. Finally, logistic regression models were constructed using the clinico-radiological, radiomics, and a combination of both.

RESULTS

After a comprehensive evaluation of the predictive indicators, the logistic regression classifier model based on the combined clinico-radiological and radiomic features had an AUC of (0.945, 0.927, 0.856) for aldosterone-producing adenoma (APA), (0.963, 0.889, 0.887) for cortisol-producing adenoma (CPA), and (0.940, 0.765, 0.816) for non-functioning adrenal adenoma (NAA) in the training set, validation set, and external test set, respectively. This model exhibited superior predictive performance in differentiating between the three adrenal adenoma subtypes.

CONCLUSIONS

A logistic regression model was constructed using radiomics and clinico-radiological features derived from multi-phase enhanced CT images and conducted external validation. The combined model showed good overall performance, highlighting the feasibility of applying the model for preoperative differentiation and prediction of various types of ACA.

KDM1A genetic alterations, a rare cause of primary bilateral macronodular adrenal hyperplasia, strongly associated with food-dependent Cushing's syndrome: results of its systematic germline screening in 301 index cases and genotype/phenotype correlation

OBJECTIVE

ARMC5 is the most prevalent gene predisposing to primary bilateral macronodular adrenal hyperplasia (PBMAH), but germline KDM1A variants have been identified in the rare PBMAH associated with food-dependent Cushing's syndrome (FDCS). The purpose of this work was to assess the frequency of KDM1A variants in a large series of PBMAH patients.

DESIGN

A total of 301 consecutive PBMAH index cases from 8 international endocrinology departments were included. Clinical, biological, and imaging data were collected retrospectively.

RESULTS

Ten (3.3%) patients carried a germline KDM1A pathogenic or likely pathogenic variant, 60 (19.9%) carried a germline ARMC5 alteration, and 231 (76.8%) had no identified genetic predisposition. Food-dependent Cushing's syndrome was present in all patients with KDM1A variants and absent in the 2 other groups. KDM1A patients had a higher 24-h urinary free cortisol (3.0-fold upper limit of normal vs 1.36 for ARMC5 patients and 0.66 for wild-type patients, respectively, P = .0001). In accordance with FDCS pathophysiology, patients with KDM1A variants had a lower morning fasting plasma cortisol (192 nmol/L vs 407 and 428, respectively, P = .0003) and a higher midnight plasma cortisol (487 nmol/L vs 297 and 171.96, respectively, P = .0004). Morning/midnight plasma cortisol ratio below 0.65 holds 100% sensitivity and specificity for the detection of FDCS. All patients with KDM1A variants were women, vs 65% of ARMC5 patients and 67% of wild-type patients (P = .0337).

CONCLUSIONS

KDM1A germline pathogenic variants are rare in PBMAH and account for <5% of index cases. KDM1A seems constantly associated with FDCS, which can be evoked in front of a morning/midnight plasma cortisol ratio below 0.65.

Adrenal Myelolipoma Inside an Adrenal Cortical Adenoma

A case of an incidental adrenal myelolipoma inside a non-functioning adrenal cortical adenoma is reported. A 65-year-old woman with a history of right-sided clear cell renal cell carcinoma presented for a follow-up of a left-sided adrenal mass first noted incidentally on a previous renal cell carcinoma workup. Macroscopically, it was a well-circumscribed, tan-yellow mass with gritty hemorrhage. Histopathologic evaluation showed the proliferation of clear to eosinophilic cells, filled with small vacuoles with a well-delineated lesion composed of mature adipose tissue and bone marrow elements. Also, this focus of myelolipoma revealed adenoma cells inside its borders; and interestingly, trilineage hematopoiesis was mostly observed near the adenoma-myelolipoma interfaces. To our knowledge, this is a unique report mentioning some additional features about the interfaces of these lesions. It can be suggested that the presence of adrenal cortical adenoma played the main stressor role in giving rise to myelolipoma and myelolipoma, being closer to the adenoma's vascular network, caused the different interface features.

The relationship between tissue inhibitor of metalloproteinases-1 and KCNJ5 mutation in aldosterone-producing adenoma patients

KCNJ5 somatic mutations in aldosterone-producing adenoma (APA) are linked to higher left ventricular mass index (LVMI) and worse diastolic function. We previously identified an association between plasma tissue inhibitor of metalloproteinases-1 (TIMP-1) and an aldosterone-induced increase in LVMI and diastolic dysfunction. This study aimed to investigate the association between the presence of KCNJ5 somatic mutation and plasma TIMP-1 in APA patients. We enrolled 60 APA patients undergoing adrenalectomy, including 30 with KCNJ5 mutations (KCNJ5(+)) and 30 without (KCNJ5(-)). Clinical characteristics, echocardiographic data (including LVMI, inappropriately excessive LVMI (ieLVMI), and diastolic function) and plasma TIMP-1 levels were measured before surgery and 1 year postoperatively. The results showed that the KCNJ5(+) group had higher plasma TIMP-1 levels (P = 0.004) compared to the KCNJ5(-) group. The correlation between the KCNJ5 mutations and TIMP-1 levels remained significant after multiple regression analysis. To detect KCNJ5 mutations, receiver operating characteristic curve analysis showed TIMP-1 had the best area under the curve (AUC) value among various clinical parameters (AUC = 0.682, 95% confidence interval = 0.549-0.796, P = 0.008). Post-adrenalectomy, only the KCNJ5(+) group showed significant decrease in LVMI (P = 0.001) and log-transformed TIMP-1 levels (P = 0.035). Changes in ieLVMI before and after surgery were consistently correlated with changes in TIMP-1 levels in multivariable regression analysis. In conclusion, KCNJ5 somatic mutations in APA are associated with higher plasma TIMP-1 levels. In addition, TIMP-1 is an effective biomarker for detecting the presence of KCNJ5 mutations in APA patients.

Whole genome profiling of primary and metastatic adrenocortical carcinoma unravels significant molecular events

Adrenocortical carcinoma (ACC) is a rare, aggressive malignancy with limited treatment options and poor prognosis, with a 5-year survival rate of about 15 %. This study used whole genome sequencing to characterize the genomic landscape of five patients, one of them with both primary and metastatic samples. Key driver mutations were detected, including APC, JAK1, RFWD3 as well as other genes. Notably, a primary tumor harbored a RAD51 biallelic deleterious translocation, associated with homologous recombination deficiency signature. Large-scale copy neutral loss of heterozygosity (LOH) was identified in four tumors, three had TP53 mutations, with structural variants impacting genes as RB1, CDKN2A, and NF1. A genomic signature specific to mismatch repair was observed in a sample with MHS6 mutation. Two tumors presented novel fusions at TERT locus, including TERT::ZNF521. Comparative analysis between conventional and oncocytic ACC subtypes revealed no significant differences in mutation load, microsatellite instability, or specific gene enrichment. This comprehensive WGS analysis broadens the spectrum of genomic alterations in ACC, highlighting potential molecular targets and differences across subtypes that may inform future therapeutic strategies.

Adrenal Volume Quantitative Visualization Tool by Multiple Parameters and an nnU-Net Deep Learning Automatic Segmentation Model

Abnormalities in adrenal gland size may be associated with various diseases. Monitoring the volume of adrenal gland can provide a quantitative imaging indicator for such conditions as adrenal hyperplasia, adrenal adenoma, and adrenal cortical adenocarcinoma. However, current adrenal gland segmentation models have notable limitations in sample selection and imaging parameters, particularly the need for more training on low-dose imaging parameters, which limits the generalization ability of the models, restricting their widespread application in routine clinical practice. We developed a fully automated adrenal gland volume quantification and visualization tool based on the no new U-Net (nnU-Net) for the automatic segmentation of deep learning models to address these issues. We established this tool by using a large dataset with multiple parameters, machine types, radiation doses, slice thicknesses, scanning modes, phases, and adrenal gland morphologies to achieve high accuracy and broad adaptability. The tool can meet clinical needs such as screening, monitoring, and preoperative visualization assistance for adrenal gland diseases. Experimental results demonstrate that our model achieves an overall dice coefficient of 0.88 on all images and 0.87 on low-dose CT scans. Compared to other deep learning models and nnU-Net model tools, our model exhibits higher accuracy and broader adaptability in adrenal gland segmentation.

Approach to Endocrine Hypertension: A Case-Based Discussion

PURPOSE OF REVIEW

Hypertension remains a major chronic disease morbidity across the world, even in the twenty-first century, affecting ≈40% of the global population, adversely impacting the healthcare budgets in managing the high incidence of cardiovascular disease (CVD) complications and mortality because of elevated blood pressure (BP). However, evaluation and management of endocrine hypertension are not optimal in clinical practice. With three unique clinical case scenarios, we update the evidence base for diagnostic evaluation and management of endocrine hypertension in this review to inform appropriate day-to-day clinical practice decisions.

RECENT FINDINGS

Although most individuals with high BP suffer from essential hypertension (≈85%), some patients may have a clear underlying etiology (termed secondary hypertension), and a significant proportion of these patients have endocrine hypertension (≈10%) consequent to hormone excess from dysfunction of one or more endocrine glands. Even if a relatively common disease in the general population, the correct diagnosis and appropriate treatment of endocrine hypertension is often delayed because of poor awareness among clinicians, including primary care providers and physicians in the secondary care settings. An accurate and timely diagnosis of endocrine hypertension is crucial to potentially cure or at least properly manage these patients because the consequences of delays in diagnosis can be catastrophic, with markedly higher end-organ complications such as CVD, chronic kidney disease, and even premature mortality among sufferers.

More than meets the eye: predicting adrenocortical carcinoma outcomes with pathomics

BACKGROUND

Adrenocortical carcinoma (ACC) is a rare, aggressive malignancy with high recurrence rates and poor prognosis. Current prognostic models are inadequate, highlighting the need for innovative diagnostic tools. Pathomics, which utilizes computer algorithms to analyze whole-slide images, offers a promising approach to enhance prognostic models for ACC.

METHODS

A retrospective cohort of 159 patients who underwent radical adrenalectomy between 2002 and 2019 was analyzed. Patients were divided into training (N = 111) and validation (N = 48) cohorts. Pathomics features were extracted using an unsupervised segmentation method. A pathomics signature (PSACC) was developed through LASSO-Cox regression, incorporating 5 specific pathomics features.

RESULTS

The PSACC showed a strong correlation with ACC prognosis. In the training cohort, the hazard ratio was 3.380 (95% CI, 1.687-6.772, P < .001), and in the validation cohort, it was 3.904 (95% CI, 1.039-14.669, P < .001). A comprehensive nomogram integrating PSACC and M stage significantly outperformed the conventional clinicopathological model in prediction accuracy, with concordance indexes of 0.779 versus 0.668 in the training cohort (P = .002) and 0.752 versus 0.603 in the validation cohort (P = .003).

CONCLUSIONS

The development of a pathomics-based nomogram for ACC presents a superior prognostic tool, enhancing personalized clinical decision making. This study highlights the potential of pathomics in refining prognostic models for complex malignancies like ACC, with implications for improving prognosis prediction and guiding treatment strategies in clinical practice.

Multiple-Instance Learning for thyroid gland disease classification: A hands-on experience

The morphological diagnosis of thyroid gland neoplasms presents a dual challenge: it requires the expertise of highly trained specialists and considerable time, particularly when evaluating multiple whole slide images (WSIs) from a single patient. The integration of artificial intelligence (AI) techniques into the diagnostic workflow is a hot area of research. However, most studies rely on meticulously curated datasets, the preparation of which is both costly and fraught with complexities. This paper investigates the development of machine learning models using weakly-annotated "real-world" data, devoid of the selective preprocessing typical in common research datasets. Our study demonstrates that a Multiple-Instance Learning (MIL) model, trained on a weak patient-level annotations of 1102 patients encompassing 5104 WSIs, successfully discriminates between benign and malignant conditions at the patient level, achieving an average test set F1-Score of 0.85 with a standard deviation of 0.05. This study is, to our knowledge, the first to report findings from an AI model trained on patient-level data without prior labeling refinement. Additionally, we identify potential pitfalls in data quality that could induce model overfitting, such as the inadvertent inclusion of dye used to highlight resection margins, which correlates with the target variable. We also assessed the impact of detailed slide-level versus coarse patient-level annotations on classification accuracy using a smaller, more precisely annotated dataset of 36 laboratory cases (91 WSIs). The results indicate that detailed annotations substantially enhance classification performance in smaller datasets.

Necrosis in Preoperative Cross-Sectional Imaging and Postoperative Histology Is a Diagnostic Marker for Malignancy of Adrenocortical Tumors

Necrosis in postoperative histology has been reported as being specific for adrenocortical carcinoma (ACC) compared to adenoma. We therefore retrospectively analyzed the diagnostic accuracy of the finding of necrosis in preoperative cross-sectional imaging and postoperative histology as a marker for ACC in our patient cohort. Among the 411 adrenalectomies in 396 patients performed between 2008 and April 2022, 30 cases of ACC (7.6%) were identified, with one tumor measuring less than 40 mm excluded. All 45 benign adrenocortical tumors of at least 40 mm in diameter, including Cushing, Conn, and hormonally inactive adenomas, served as controls. Preoperative imaging was available for 40 benign and 27 malignant adrenocortical tumors. In total, 10 of 40 (25%) benign adrenocortical tumors and 22 of 27 (81%) ACCs showed signs of possible necrosis in preoperative imaging. Pathologic examination confirmed necrosis in 1 of 40 (2.5%) benign tumors and in 26 out of 27 (96%) malignant tumors. The specificities of possible necrosis in preoperative imaging and necrosis in histology for diagnosing ACC were 75% and 97.5%, respectively, whereas the sensitivities were 81% and 96%, respectively. Signs of possible necrosis in radiologic imaging and tumor necrosis in histology proved to be very good predictive markers for the diagnosis of malignant adrenocortical tumors.

The road ahead: a brief guide to navigating the 2022 WHO classification of endocrine and neuroendocrine tumours

The most recent WHO classification of endocrine and neuroendocrine tumours has brought about significant changes in the diagnosis and grading of these lesions. For instance, pathologists now have the ability to stratify subsets of thyroid and adrenal neoplasms using various histological features and composite risk assessment models. Moreover, novel recommendations on how to approach endocrine neoplasia involve additional immunohistochemical analyses, and the recognition and implementation of these key markers is essential for modernising diagnostic capabilities. Additionally, an improved understanding of tumour origin has led to the renaming of several entities, resulting in the emergence of terminology not yet universally recognised. The adjustments in nomenclature and prognostication may pose a challenge for the clinical team, and care providers might be eager to engage in a dialogue with the diagnosing pathologist, as treatment guidelines have not fully caught up with these recent changes. Therefore, it is crucial for a surgical pathologist to be aware of the knowledge behind the implementation of changes in the WHO classification scheme. This review article will delve into the most significant diagnostic and prognostic changes related to lesions in the parathyroid, thyroid, adrenal glands and the gastroenteropancreatic neuroendocrine system. Additionally, the author will briefly share his personal reflections on the clinical implementation, drawing from a couple of years of experience with these new algorithms.

Integrated 68 Ga-Pentixafor and 68 Ga-FAPI-04 PET/MR for Diagnosing Adrenal Aldosterone-Producing Adenoma and Accessory Splenic Nodules

ABSTRACT

A 57-year-old man with primary aldosteronism exhibited multiple nodules in the left adrenal, pancreatic tail, and splenic region. The left adrenal nodule showed positive 68 Ga-pentixafor and negative 68 Ga-FAPI-04 uptake, suggesting an aldosterone-producing adrenal adenoma. The nodule in the pancreatic tail exhibited high 68 Ga-pentixafor and low 68 Ga-FAPI-04 uptake, similarity with the nodule in splenic region, indicating accessory splenic nodule. Postoperative pathology confirmed an adrenal cortical adenoma and an accessory splenic nodule in the pancreas. This case underscores the complementary role of 68 Ga-pentixafor and 68 Ga-FAPI-04 PET/MR in diagnosing complex adrenal and pancreatic pathologies.

The molecular genetics of adrenal cushing

Adrenal Cushing represents 20% of cases of endogenous hypercorticism. Unilateral cortisol-producing adenoma (CPA), a benign tumor, and adrenocortical carcinoma (ACC), a malignant tumor, are more frequent than bilateral adrenal nodular diseases (primary bilateral macronodular adrenal hyperplasia (PBMAH) and primary pigmented nodular adrenal disease (PPNAD)).In cortisol-producing adrenal tumors, the signaling pathways mainly altered are the protein kinase A and Wnt/β-catenin pathways. Studying components of these pathways and exploring syndromic and familial cases of these tumors has historically enabled identification of many of the predisposing genes. More recently, pangenomic sequencing revealed alterations in sporadic tumors.In ACC, mainly due to TP53 alterations causing Li-Fraumeni syndrome, germline predisposition is frequent in children, while it is rare in adults. Pathogenic variants in the DNA mismatch repair genes MLH1, MSH2, MSH6, and PMS2, which cause Lynch syndrome or alterations of IGF2 and CDKN1C (11p15 locus) in Beckwith-Wiedemann syndrome, can also cause ACC. Rarely, ACC is described in other hereditary tumor syndromes due to germline pathogenic variants in MEN1 or APC and, in very rare cases, NF1, SDH, PRKAR1A, or BRCA2. Concerning ACC somatic alterations, TP53 and genetic or epigenetic alterations at the 11p15 locus are also frequently described, as well as CTNNB1 and ZNRF3 pathogenic variants.CPAs mainly harbor somatic pathogenic variants in PRKACA and CTNNB1 and, less frequently, PRKAR1A, PRKACB, or GNAS1 pathogenic variants. Isolated PBMAH is due to ARMC5 inactivating pathogenic variants in 20 to 25% of cases and to KDM1A pathogenic variants in food-dependent Cushing. Syndromic PBMAH may be due to germline pathogenic variants in MEN1, APC, or FH, causing type 1 multiple endocrine neoplasia, familial adenomatous polyposis, or hereditary leiomyomatosis-kidney cancer syndrome, respectively. PRKAR1A germline pathogenic variants are the main alteration causing PPNAD (isolated or part of Carney complex).

Identifying prognostic hub genes and key pathways in pediatric adrenocortical tumors through RNA sequencing and Co-expression analysis

Pediatric adrenocortical tumors (ACTs), rare conditions with uncertain prognoses, have high incidence in southern and southeastern Brazil. Pediatric ACTs are highly heterogeneous, so establishing prognostic markers for these tumors is challenging. We have conducted transcriptomic analysis on 14 pediatric ACT samples and compared cases with favorable and unfavorable clinical outcomes to identify prognostically significant genes. This comparison showed 1257 differentially expressed genes in favorable and unfavorable cases. Among these genes, 15 out of 60 hub genes were significantly associated with five-year event-free survival (EFS), and 10 had significant diagnostic value for predicting ACT outcomes in an independent microarray dataset of pediatric adrenocortical carcinomas (GSE76019). Overexpression of N4BP2, HSPB6, JUN, APBB1IP, STK17B, CSNK1D, and KDM3A was associated with poorer EFS, whereas lower expression of ISCU, PTPR, PRKAB2, CD48, PRF1, ITGAL, KLK15, and HIST1H3J was associated with worse outcomes. Collectively, these findings underscore the prognostic significance of these hub genes and suggest that they play a potential role in pediatric ACT progression and are useful predictors of clinical outcomes.

Molecular and Genetics Perspectives on Primary Adrenocortical Hyperfunction Disorders

Adrenocortical disorders encompass a broad spectrum of conditions ranging from benign hyperplasia to malignant tumors, significantly disrupting hormone balance and causing a variety of clinical manifestations. By leveraging next-generation sequencing and in silico analyses, recent studies have uncovered the genetic and molecular pathways implicated in these transitions. In this review, we explored the molecular and genetic alterations in adrenocortical disorders, with a particular focus on the transitions from normal adrenal function to hyperfunction. The insights gained are intended to enhance diagnostic and therapeutic strategies, offering up-to-date knowledge for managing these complex conditions effectively.

Respiratory failure and rhabdomyolysis caused by severe hypokalemia in a young female with hypertension: a rare critical condition in primary aldosteronism

BACKGROUND

The two classic manifestations of primary aldosteronism are hypertension and hypokalemia. However, acute respiratory failure due to hypokalemia in primary hyperaldosteronism is rare.

CASE PRESENTATION

The patient was a 27-year-old female who presented with drowsiness and weakness in all extremities. She had been diagnosed with hypertension three years prior, with irregular follow-up, and had a history of preeclampsia one year later. She exhibited high blood pressure and severe hypokalemia (2 mEq/L), leading to respiratory depression and impending respiratory arrest. Consequently, the patient was intubated and transferred to the intensive care unit (ICU). She also developed rhabdomyolysis. Blood pressure tests, including hormonal tests (aldosterone: 13.2 ng/dL, plasma renin activity: 0.32 ng/mL/h), were conducted. Due to the high aldosterone-renin ratio, an abdominopelvic computed tomography (CT) scan was performed. The CT scan revealed a 14 × 12 mm round mass with a washout value above 60%, consistent with an adrenal adenoma, leading to a diagnosis of primary aldosteronism. The patient was discharged after stabilization, and one and a half months after ICU admission, a laparoscopic left adrenalectomy was successfully performed without post-operative complications. Histopathology showed encapsulated hypertrophy of the adrenal cortex with a predominance of large clear cells, confirming the diagnosis of adrenal adenoma. At the most recent follow-up, the patient had normal potassium levels, was normotensive without any medications, and exhibited no alarming signs or symptoms.

CONCLUSION

Respiratory depression to the extent of impending respiratory failure and rhabdomyolysis as a result of hypokalemia in primary aldosteronism are extremely rare. In this patient, who developed respiratory depression due to resistant hypokalemia, timely investigation of secondary causes and diagnosis of adrenal adenoma were crucial. The surgery provided definitive treatment for the patient's blood pressure and prevented the recurrence of life-threatening complications.

Gut microbiota causally impacts adrenal function: a two-sample mendelian randomization study

Some studies have reported that the gut microbiota can influence adrenal-related hormone levels. However, the causal effects of the gut microbiota on adrenal function remain unknown. Therefore, we employed a two-sample Mendelian randomization (MR) study to systematically investigate the impact of gut microbiota on the function of different regions of the adrenal gland. The summary statistics for gut microbiota and adrenal-related hormones used in the two-sample MR analysis were derived from publicly available genome-wide association studies (GWAS). In the MR analysis, inverse variance weighting (IVW) was used as the primary method, with MR-Egger, weighted median, and cML-MA serving as supplementary methods for causal inference. Sensitivity analyses such as the MR-Egger intercept test, Cochran's Q test, and leave-one-out analysis were used to assess pleiotropy and heterogeneity. We identified 27 causal relationships between 23 gut microbiota and adrenal function using the IVW method. Among these, Sellimonas enhanced the function of the adrenal cortex reticularis zone (beta = 0.008, 95% CI: 0.002-0.013, P = 0.0057). The cML-MA method supported our estimate (beta = 0.009, 95% CI: 0.004-0.013, P = 2 × 10- 4). Parasutterella, Sutterella, and Anaerofilum affect the functioning of different regions of the adrenal gland. Notably, pleiotropy was not observed. Our findings revealed that the gut microbiota is causally associated with adrenal function. This enhances our understanding of the gut-microbiota-brain axis and provides assistance in the early diagnosis and treatment of adrenal-related diseases in clinical practice.