Primary malignant tumors of the adrenal glands

Bimodal genomic approach predicting Semaphorin 7A (SEMA7A) as prognostic biomarker in adrenocortical carcinoma

Adrenocortical carcinoma (ACC) is a rare and aggressive endocrine malignancy with high mortality and poor prognosis. To elucidate the genetic underpinnings of ACCs, we have analyzed the transcriptome data of 112 ACC tumor samples from patients enrolled in the TCGA and NCI. Among 72 bimodally expressed genes stratifying patients into prognostic groups, we focused on SEMA7A , as it encodes a glycosylphosphatidylinositol-anchored membrane glycoprotein (Semaphorin 7a) regulating integrin-mediated signaling, cell migration and immune responses. We find that high SEMA7A gene expression is associated with poor prognosis (hazard ratio = 4.27; p-value < 0.001). In hormone-producing ACCs, SEMA7A expression is elevated and positively correlated with genes driving steroidogenesis, aldosterone and cortisol synthesis, including CYP17A1, CYP11A1, INHA, DLK1, NR5A1 and MC2R . Correlation analyses show that SEMA7A is co-expressed with the integrin-β1, FAK (focal adhesion kinase) and MAPK/ERK (mitogen-activated protein kinase/extracellular signal regulated kinases) signaling pathways. Immunohistochemistry (IHC) staining demonstrates the feasibility of evaluating SEMA7A in ACC tissues and shows significant correlation between gene expression (RNA-Seq) and protein expression (IHC). These findings suggest SEMA7A as a candidate for further research in ACC biology, a candidate for cancer therapy, as well as a potential prognosis biomarker for ACC patients.

Translational relevance

Adrenocortical cancer (ACC) remains a challenging disease primarily due to the scarcity of reliable biomarkers for predicting patient outcomes and informing innovative therapeutic strategies, as well as its rarity, which restricts the scope of clinical trials. In our study, we performed RNAseq and IHC analyses of ACC samples sourced from The Cancer Genome Atlas (TCGA), tissue microarray slide, and National Cancer Institute (NCI) cancer patient samples. Our findings indicate that a substantial proportion of ACC tumors exhibit expression of SEMA7A, a glycoprotein involved in Semaphorin cell surface signaling. Notably, elevated levels of SEMA7A were identified as a poor prognostic biomarker and were associated with activation of the integrin-ERK-MAPK kinase signaling pathways. These results suggest that ACC tumors with high SEMA7A expression should be considered at elevated risk, and SEMA7A may serve as a potential target for immunotherapeutic strategies, including antibody-drug conjugates, T-cell engagers, and/or small molecule inhibitors targeting the MAPK pathway.

L, Heredia-Espín M, Arias-Intriago M, Izquierdo-Condoy JS. Pheochromocytoma: an updated scoping review from clinical presentation to management and treatment

Pheochromocytomas and paragangliomas (PPGLs) are rare neuroendocrine tumors derived from chromaffin cells, with 80-85% originating in the adrenal medulla and 15-20% from extra-adrenal chromaffin tissues (paragangliomas). Approximately 30-40% of PPGLs have a hereditary component, making them one of the most genetically predisposed tumor types. Recent advances in genetic research have classified PPGLs into three molecular clusters: pseudohypoxia-related, kinase-signaling, and WNT-signaling pathway variants. Specifically, the detection of SDHB-related tumors indicates an increased risk of metastatic disease, which may impact decisions regarding functional imaging in patients with high suspicion of metastasis and influence targeted treatment strategies. Diagnosis of PPGLs primarily relies on biochemical testing, measuring catecholamines or their metabolites in plasma or urine. However, molecular testing, functional imaging, and targeted therapies have greatly enhanced diagnostic precision and management. Personalized treatment approaches based on genetic profiling are becoming integral to the clinical management of these tumors. In South American countries like Colombia, functional imaging techniques such as positron emission tomography/computed tomography (PET/CT) with tracers like 18F-DOPA, 18F-fluorodeoxyglucose (18F-FDG), and 68Ga-DOTA-conjugated somatostatin receptor-targeting peptides (68Ga-DOTA-SST) are used to guide follow-up and treatment strategies. Radionuclide therapy with lutetium-177 DOTATATE is employed for patients showing uptake in 68Ga-DOTA-SST PET/CT scans, while access to 131-MIBG therapy remains limited due to high costs and availability. Recent clinical trials have shown promise for systemic therapies such as sunitinib and cabozantinib, offering potential new options for patients with slow or moderate progression of PPGLs. These advancements underscore the potential of personalized and targeted therapies to improve outcomes in this challenging patient population.

Adrenal indeterminate nodules: CT-based radiomics analysis of different machine learning models for predicting adrenal metastases in lung cancer patients

Objective

There is a paucity of research using different machine learning algorithms for distinguishing between adrenal metastases and benign tumors in lung cancer patients with adrenal indeterminate nodules based on plain and biphasic-enhanced CT radiomics.

Materials and Methods

This study retrospectively enrolled 292 lung cancer patients with adrenal indeterminate nodules (training dataset, 205 (benign, 96; metastases, 109); testing dataset, 87 (benign, 42; metastases, 45)). Radiomics features were extracted from the plain, arterial, and portal CT images, respectively. The independent risk radiomics features selected by least absolute shrinkage and selection operator (LASSO) and multivariate logistic regression (LR) were used to construct the single-phase and combined-phase radiomics models, respectively, by support vector machine (SVM), decision tree (DT), random forest (RF), and LR. The independent clinical-pathological and radiological risk factors for predicting adrenal metastases selected by using univariate and multivariate LR were used to develop the traditional model. The optimal model was selected by ROC curve, and the models' clinical values were estimated by decision curve analysis (DCA).

Results

In the testing dataset, all SVM radiomics models showed the best robustness and efficiency, and then RF, LR, and DT models. The combined radiomics model had the best ability in predicting adrenal metastases (AUC=0.938), and then the plain (AUC=0.935), arterial (AUC=0.870), and portal radiomics model (AUC=0.851). Besides, compared to clinical-pathological-radiological model (AUC=0.870), the discriminatory capability of the plain and combined radiomics model were further improved. All radiomics models had good calibration curves and DCA showed the plain and combined radiomics models had more optimal clinical efficacy compared to other models, with the combined radiomics model having the largest net benefit.

Conclusions

The combined SVM radiomics model can non-invasively and efficiently predict adrenal metastatic nodules in lung cancer patients. In addition, the plain radiomics model with high predictive performance provides a convenient and accurate new method for patients with contraindications in enhanced CT.

Lower fluorodeoxyglucose positron emission tomography maximum standardized uptake value may show a better response to stereotactic body radiotherapy of adrenals in oligometastatic disease

Introduction

Stereotactic body radiotherapy (SBRT) is well established for oligometastatic disease, and it is increasingly used to treat adrenal metastases.

Material and methods

In this retrospective study we performed an analysis of 75 metastatic adrenal lesions in 64 patients with oligometastatic disease. According to the fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) maximum standardized uptake value (SUVmax) of adrenal metastases, patients were categorized into three groups: low, intermediate, and high SUVmax.

Results

For all clinicopathological characteristics we found significant relationships for levels of SUVmax and objective response rate (Kendall Tau-c = 0.290; p = 0.017). Patients who responded to SBRT had a significantly lower SUVmax value than those who did not respond (7.6 ±2.4 vs. 9.7 ±3.8; p = 0.015). At the appropriate SUVmax cut-off values, the biomarker distinguished between patients with and without a response significantly and moderately (area under the curve = 0.670, 95% confidence intervals: 0.540-0.790; p = 0.015).

Conclusions

Lower SUVmax is associated with a better response to SBRT in patients whose disease progressed mainly in the adrenal glands.

Three-dimensional CT cinematic rendering of adrenal masses: Role in tumor analysis and management

The adrenal gland is home to an array of complex physiological and neoplastic disease processes. While dedicated adrenal computed tomography (CT) is the gold standard imaging modality for adrenal lesions, there exists significant overlap among imaging features of adrenal pathology. This can often make radiological diagnosis and subsequent determination of the optimal surgical approach challenging. Cinematic rendering (CR) is a novel CT post-processing technique that utilizes advanced light modeling to generate highly photorealistic anatomic visualization. This generates unique prospects in the evaluation of adrenal masses. As one of the first large tertiary care centers to incorporate CR into routine diagnostic workup, our preliminary experience with using CR has been positive, and we have found CR to be a valuable adjunct during surgical planning. Herein, we highlight the unique utility of CR techniques in the workup of adrenal lesions and provide commentary on the opportunities and obstacles associated with the application of this novel display method in this setting.

18F-FDG-PET/CT-based machine learning model evaluates indeterminate adrenal nodules in patients with extra-adrenal malignancies

BACKGROUND

To assess the value of an 18F-FDG-positron emission tomography/computed tomography (PET/CT)-based machine learning model for distinguishing between adrenal benign nodules (ABNs) and adrenal metastases (AMs) in patients with indeterminate adrenal nodules and extra-adrenal malignancies.

METHODS

A total of 303 patients who underwent 18F-FDG-PET/CT with indeterminate adrenal nodules and extra-adrenal malignancies from March 2015 to June 2021 were included in this retrospective study (training dataset (n = 182): AMs (n = 97), ABNs (n = 85); testing dataset (n = 121): AMs (n = 68), ABNs (n = 55)). The clinical and PET/CT imaging features of the two groups were analyzed. The predictive model and simplified scoring system for distinguishing between AMs and ABNs were built based on clinical and PET/CT risk factors using multivariable logistic regression in the training cohort. The performances of the predictive model and simplified scoring system in both the training and testing cohorts were evaluated by the areas under the receiver operating characteristic curves (AUCs) and calibration curves. The comparison of AUCs was evaluated by the DeLong test.

RESULTS

The predictive model included four risk factors: sex, the ratio of the maximum standardized uptake value (SUVmax) of adrenal lesions to the mean liver standardized uptake value, the value on unenhanced CT (CTU), and the clinical stage of extra-adrenal malignancies. The model achieved an AUC of 0.936 with a specificity, sensitivity and accuracy of 0.918, 0.835, and 0.874 in the training dataset, respectively, while it yielded an AUC of 0.931 with a specificity, sensitivity, and accuracy of 1.00, 0.735, and 0.851 in the testing dataset, respectively. The simplified scoring system had comparable diagnostic value to the predictive model in both the training (AUC 0.938, sensitivity: 0.825, specificity 0.953, accuracy 0.885; P = 0.5733) and testing (AUC 0.931, sensitivity 0.735, specificity 1.000, accuracy 0.851; P = 1.00) datasets.

CONCLUSIONS

Our study showed the potential ability of a machine learning model and a simplified scoring system based on clinical and 18F-FDG-PET/CT imaging features to predict AMs in patients with indeterminate adrenal nodules and extra-adrenal malignancies. The simplified scoring system is simple, convenient, and easy to popularize.

Small hyperattenuating adrenal nodules in patients with lung cancer: Differentiation of metastases from adenomas on biphasic contrast-enhanced computed tomography

Objective

The objective of this study was to evaluate the value of biphasic contrast-enhanced computed tomography (CECT) in the differential diagnosis of metastasis and lipid-poor adenomas (LPAs) in lung cancer patients with unilateral small hyperattenuating adrenal nodule.

Materials and methods

This retrospective study included 241 lung cancer patients with unilateral small hyperattenuating adrenal nodule (metastases, 123; LPAs, 118). All patients underwent plain chest or abdominal computed tomography (CT) scan and biphasic CECT scan, including arterial and venous phases. Qualitative and quantitative clinical and radiological characteristics of the two groups were compared using univariate analysis. An original diagnostic model was developed using multivariable logistic regression, and then, according to odds ratio (OR) of the risk factors of metastases, a diagnostic scoring model was developed. The areas under the receiver operating characteristic curves (AUCs) of the two diagnostic models were compared by DeLong test.

Results

Compared with LAPs, metastases were older and showed more frequently irregular in shape and cystic degeneration/necrosis (all p < 0.05). Enhancement ratios on venous (ERV) and arterial (ERA) phase of LAPs were noticeably higher than that of metastases, whereas CT values in unenhanced phase (UP) of LPAs were noticeably lower than that of metastases (all p < 0.05). Compared with LAPs, the proportions of male and III/IV clinical stage and small-cell lung cancer (SCLL) were significantly higher for metastases (all p < 0.05). As for peak enhancement phase, LPAs showed relatively faster wash-in and earlier wash-out enhancement pattern than metastases (p < 0.001). Multivariate analysis revealed age ≥ 59.5 years (OR: 2.269; p = 0.04), male (OR: 3.511; p = 0.002), CT values in UP ≥ 27.5 HU (OR: 6.968; p < 0.001), cystic degeneration/necrosis (OR: 3.076; p = 0.031), ERV ≤ 1.44 (OR: 4.835; p < 0.001), venous phase or equally enhanced (OR: 16.907; p < 0.001 or OR: 14.036; p < 0.001), and clinical stage II or III or IV (OR: 3.550; p = 0.208 or OR: 17.535; p = 0.002 or OR: 20.241; p = 0.001) were risk factors for diagnosis of metastases. AUCs of the original diagnostic model and the diagnostic scoring model for metastases were 0.919 (0.883-0.955) and 0.914 (0.880-0.948), respectively. There was no statistical significance of AUC between the two diagnostic model (p = 0.644).

Conclusions

Biphasic CECT performed well diagnostic ability in differentiating metastases from LAPs. The diagnostic scoring model is easy to popularize due to simplicity and convenience.

Surgical management and outcomes of spinal metastasis of malignant adrenal tumor: A retrospective study of six cases and literature review

Purpose

Spinal metastasis of malignant adrenal tumor (SMMAT) is an extremely rare and poorly understood malignant tumor originating from the adrenal gland. The objective of this study is to elucidate the clinical characteristics and discuss surgical management and outcomes of SMMAT.

Methods

Included in this study were six SMMAT patients who received surgical treatment in our center between February 2013 and May 2022. Their clinical data and outcomes were retrospectively analyzed to gain a better understanding of SMMAT. In addition, ten cases from the literature focusing on SMMAT were also reviewed.

Results

Surgery was performed successfully, and the associated symptoms were relieved significantly in all patients postoperatively. The mean follow-up duration was 26.2 (range 3-55) months. Two patients died of tumor recurrence 12 and 48 months after operation respectively. The other four patients were alive at the last follow-up.

Conclusions

The prognosis of SMMAT is usually poor. Preoperative embolization and early surgical radical resection can offer satisfactory clinical outcomes. The patient's health status, preoperative neurological function, tumor location and the resection mode are potential prognostic factors of SMMAT.

Construction and validation of a prognostic model for predicting overall survival of primary adrenal malignant tumor patients: A population-based study with 1,080 patients

Objective

Primary adrenal malignant tumor is rare. The factors affecting the prognosis remain poorly defined. This study targeted to construct and corroborate a model for predicting the overall survival of adrenal malignant tumor patients.

Methods

We investigated the SEER database for patients with primary adrenal malignant tumor. 1,080 patients were divided into a construction cohort (n = 756) and a validation cohort (n = 324), randomly. The prognostic factors for overall survival were evaluated using univariate and multivariate Cox analyses. The nomogram was constructed and then validated with C-index, calibration curve, time-dependent ROC curve, and decision curve analysis in both cohorts. Then we divided the patients into 3 different risk groups according to the total points of the nomogram and analyzed their survival status by Kaplan-Meier curve with log-rank test.

Results

The baseline characteristics of these two cohorts were not statistically different (P > 0.05). Using univariate and multivariate Cox analyses, 5 variables, including age, tumor size, histological type, tumor stage, and surgery of primary site, were distinguished as prognostic factors (P < 0.05). Based on these variables, we constructed a nomogram to predict the 3- year, 5- year, and 10-year overall survival. The C-indexes were 0.780 (0.760–0.800) in the construction cohort and 0.780 (0.751–0.809) in the validation cohort. In both cohorts, the AUC reached a fairly high level at all time points. The internal and external calibration curves and ROC analysis showed outstanding accuracy and discrimination. The decision curves indicated excellent clinical usefulness. The best cut-off values for the total points of the nomogram were 165.4 and 243.1, and the prognosis was significantly different for the three different risk groups (P < 0.001).

Conclusion

We successfully constructed a model to predict the overall survival of primary adrenal malignant tumor patients. This model was validated to perform brilliantly internally and externally, which can assist us in individualized clinical management.

Identification of prognostic factors for predicting survival of patients with malignant adrenal tumors: A population-based study

Background

This study aimed to identify the prognostic factors for overall survival (OS) and cancer-specific survival (CSS) in patients with malignant adrenal tumors and establish a predictive nomogram for patient survival.

Methods

The clinical characteristics of patients diagnosed with malignant adrenal tumors between 1988 and 2015 were retrieved from the Surveillance, Epidemiology and End Results (SEER) database. As the external validation set, we included 110 real-world patients from our medical centers. Univariate and multivariate Cox regressions were implemented to determine the prognostic factors of patients. The results from Cox regression were applied to establish the nomogram.

Results

A total of 2,206 eligible patients were included in our study. Patients were randomly assigned to the training set (1,544; 70%) and the validation set (662; 30%). It was determined that gender, age, marital status, histological type, tumor size, SEER stage, surgery, and chemotherapy were prognostic factors that affected patient survival. The OS prediction nomogram contained all the risk factors, while gender was excluded in the CSS prediction nomogram. The receiver operating characteristic (ROC) curve and decision curve analysis (DCA) indicated that the nomogram had a better predictive performance than SEER stage. Moreover, the clinical impact curve (CIC) showed that the nomograms functioned as effective predictive models in clinical application. The C-index of nomogram for OS and CSS prediction was 0.773 (95% confidence interval [CI]: 0.761–0.785) and 0.689 (95% CI: 0.675–0.703) in the training set. The calibration curves exhibited significant agreement between the nomogram and actual observation. Additionally, the results from the external validation set also presented that established nomograms functioned well in predicting the survival of patients with malignant adrenal tumors.

Conclusions

The following clinical variables were identified as prognostic factors: age, marital status, histological type, tumor size, SEER stage, surgery, and chemotherapy. The nomogram for patients with malignant adrenal tumors contained the accurate predictive performance of OS and CSS, contributing to optimizing individualized clinical treatments.

Serum Visfatin/NAMPT as a Potential Risk Predictor for Malignancy of Adrenal Tumors

Adrenocortical carcinomas (ACC) are rare endocrine malignancies, often with a poor prognosis. Visfatin/NAMPT regulates a variety of signaling pathway components, and its overexpression has been found in carcinogenesis. Our study aimed to assess the clinical usefulness of visfatin/NAMPT serum level in discriminating between ACC and benign adrenocortical tumors. Twenty-two patients with ACC and twenty-six patients with benign adrenocortical tumors were recruited. Fasting blood samples were collected from each patient, and visfatin serum levels were measured with the ELISA Kit. Clinical stage, tumor size, Ki67 proliferation index, hormonal secretion pattern, and follow-up were determined in ACC patients. Patients with ACC had significantly higher visfatin serum concentrations (7.81 ± 2.25 vs. 6.08 ± 1.32 ng/mL, p-value = 0.003). The most advanced clinical stage with metastases was associated with significantly elevated visfatin levels (p-value = 0.022). Based on ROC analysis, visfatin serum concentrations higher than 8.05 ng/mL could discriminate ACC with a sensitivity of 50.0% and specificity of 92.3%. Univariate Cox regression indicated that tumor size was significantly related to shorter survival, and the visfatin level was borderline significant in all patients (HR = 1.013, p-value = 0.002, HR = 1.321, p-value = 0.058). In the Kaplan-Meier method, patients with visfatin serum concentrations higher than 6.3 ng/mL presented significantly lower survival probability (p-value = 0.006). Serum visfatin/NAMPT could be a potential risk predictor for the malignancy of adrenal tumors. However, further studies are needed on this subject.

Binary Particle Swarm Optimization Intelligent Feature Optimization Algorithm-Based Magnetic Resonance Image in the Diagnosis of Adrenal Tumor

This research was aimed to explore the application value of magnetic resonance imaging (MRI) based on binary particle swarm optimization algorithm (BPSO) in the diagnosis of adrenal tumors. 120 patients with adrenal tumors admitted to the hospital were selected and randomly divided into the control group (conventional MRI examination) and the observation group (MRI examination based on the BPSO intelligent feature optimization algorithm), with 60 cases in each group. The sensitivity, specificity, accuracy, and Kappa of the diagnostic methods were compared between the two groups. The results showed that the calculation rate of the BPSO algorithm was the best under the same processing effect (P < 0.05). Optimization algorithm-based MRI is used in the diagnosis of adrenal tumors, and the results showed that the sensitivity, specificity, accuracy, and Kappa (83.33%, 79.17%, 81.67%, and 0.69) of the observation group were higher than those of the control group (50%, 75%, 58.33%, and 0.45). The similarity of tumor location results in the observation group (89.24%) was significantly higher than that in the control group (65.9%) (P < 0.05). In conclusion, compared with SFFS and other algorithms, the BPSO algorithm has more advantages in calculation speed. MRI based on the BPSO intelligent feature optimization algorithm has a good diagnostic effect and higher accuracy in adrenal tumors, showing the good development prospects of computer intelligence technology in the field of medicine.

The prognosis of different distant metastases pattern in malignant tumors of the adrenal glands: A population-based retrospective study

Introduction

The present existing data on the association of metastatic sites and prognosis of patients with metastatic adrenal malignancy are limited. This study aims to investigate the impact of different distant metastases pattern on the survival of patients with adrenal malignancy.

Methods

A dataset from the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) 18 Registries (2000–2017) was selected for a retrospective metastatic adrenal malignancy cohort study. There was information on distribution of metastatic lesions in bone, brain, liver, and lung in the SEER database. Kaplan-Meier analysis and nomogram analyses were applied to compare the survival distribution of cases. Univariate and multivariate cox regression models were used to analyze survival outcomes.

Results

From the SEER database, a total of 980 patients with primary metastatic adrenal malignancy from 2010 to 2017 were enrolled in this cohort study. Based on the initial metastatic sites, 42.3%, 38.4%, 30.5%, and 4.9% of patients were found bone, liver, lung, and brain metastasis, respectively. Patients who had a single site of distant metastases accounted for 52.6% (515/980) and had a better overall survival (OS) and cancer-specific survival (CSS) (both P < 0.001). In contrast with the tumor arising from the cortex, the tumor from the medulla showed better survival outcomes in both OS and CSS (P < 0.001).

Conclusion

Different histological types possess various metastatic features and prognostic values. Understanding these differences may contribute to designing targeted pre-treatment assessment of primary metastatic adrenal malignancy and creating a personalized curative intervention.

A Descriptive Comparative Analysis of the Surgical Management of Adrenal Tumors: The Open, Robotic, and Laparoscopic Approaches

Background

Currently, adrenalectomies are trending toward minimally invasive approach including robotic and laparoscopic surgery. We aimed to describe the clinical presentation and outcomes associated with the 3 different surgical approaches in patients who underwent adrenalectomy for adrenal mass at a single tertiary center.

Methods

A retrospective descriptive observational study was conducted to include all patients who underwent surgical interventions for adrenal gland mass between 2004 and 2019. Patients were categorized into three groups according to the interventional approach (open, robotic vs. laparoscopic adrenalectomy) and data were analyzed and compared.

Results

A total of 124 patients underwent adrenalectomies (61.3% robotic, 22.6% open, and 16.1% laparoscopic approach). Incidentally discovered adrenal mass was reported in 67% of patients, and hypertension was the most prevalent comorbidity (53%). The tendency for malignancy increased with increasing tumor size while the functioning tumors were more in the smaller tumor size. Larger tumors were more common in younger patients. The robotic approach showed shorter surgical intensive care and hospital length of stay. Patients in the open adrenalectomy group frequently presented with abdominal pain (p = 0.001), had more nonfunctional adrenal mass (p = 0.04), larger mean tumor size (p = 0.001), and were frequently operated on the right side (p = 0.03). There was no post-operative mortality; however, during follow-up, 8 patients died (3 open, 3 laparoscopic and, 2 robotic approach). The median follow-up was 746 days (range 7–5,840).

Conclusions

The study explored the three surgical adrenalectomy approaches in a dedicated center for patients with adrenal pathology. It showed that robotic adrenalectomy could be safe and effective surgical approach for patients with benign functioning adrenal tumors of a diameter &lt;6 cm. However, the choice of a surgical approach varies according to the adrenal mass presentation, patient fitness for surgery, type and sizes of the tumor, surgeon's experience, and hospital resources. Open surgery is considered the first choice for larger, ruptured adrenal tumor or malignancy. However, the recent restructuring of the surgical department resulted in selection bias in favor of the robotic surgery. Further studies are required to address the risk factors, selection criteria for appropriate management, cost, and quality of life.

Biological response of adrenal carcinoma and melanoma cells to mitotane treatment

A previous case report described an adrenal incidentaloma initially misdiagnosed as adrenocortical carcinoma (ACC), which was treated with mitotane. The final diagnosis was metastatic melanoma of unknown primary origin. However, the patient developed rapid disease progression after mitotane withdrawal, suggesting a protective role for mitotane in a non-adrenal-derived tumor. The aim of the present study was to determine the biological response of primary melanoma cells obtained from that patient, and that of other established melanoma and ACC cell lines, to mitotane treatment using a proliferation assay, flow cytometry, quantitative PCR and microarrays. Although mitotane inhibited the proliferation of both ACC and melanoma cells, its role in melanoma treatment appears to be limited. Flow cytometry analysis and transcriptomic studies indicated that the ACC cell line was highly responsive to mitotane treatment, while the primary melanoma cells showed a moderate response in vitro. Mitotane modified the activity of several key biological processes, including ‘mitotic nuclear division’, ‘DNA repair’, ‘angiogenesis’ and ‘negative regulation of ERK1 and ERK2 cascade’. Mitotane administration led to elevated levels of DNA double-strand breaks, necrosis and apoptosis. The present study provides a comprehensive insight into the biological response of mitotane-treated cells at the molecular level. Notably, the present findings offer new knowledge on the effects of mitotane on ACC and melanoma cells.

Reactive Oxygen Species: A Promising Therapeutic Target for SDHx-Mutated Pheochromocytoma and Paraganglioma

Simple Summary

Pheochromocytoma and paraganglioma are rare neuroendocrine tumors that arise from chromaffin cells of the adrenal medulla or their neural crest progenitors located outside the adrenal gland, respectively. About 10–15% of patients develop metastatic disease for whom treatment options and availability are extremely limited. The risk of developing metastatic disease is increased for patients with mutations in succinate dehydrogenase subunit B, which leads to metabolic reprogramming and redox imbalance. From this perspective, we focus on redox imbalance caused by this mutation and explore potential opportunities to therapeutically target reactive oxygen species production in these rare tumors.

Abstract

Pheochromocytoma (PHEO) and paraganglioma (PGL) are rare neuroendocrine tumors derived from neural crest cells. Germline variants in approximately 20 PHEO/PGL susceptibility genes are found in about 40% of patients, half of which are found in the genes that encode succinate dehydrogenase (SDH). Patients with SDH subunit B (SDHB)-mutated PHEO/PGL exhibit a higher likelihood of developing metastatic disease, which can be partially explained by the metabolic cell reprogramming and redox imbalance caused by the mutation. Reactive oxygen species (ROS) are highly reactive molecules involved in a multitude of important signaling pathways. A moderate level of ROS production can help regulate cellular physiology; however, an excessive level of oxidative stress can lead to tumorigenic processes including stimulation of growth factor-dependent pathways and the induction of genetic instability. Tumor cells effectively exploit antioxidant enzymes in order to protect themselves against harmful intracellular ROS accumulation, which highlights the essential balance between ROS production and scavenging. Exploiting ROS accumulation can be used as a possible therapeutic strategy in ROS-scavenging tumor cells. Here, we focus on the role of ROS production in PHEO and PGL, predominantly in SDHB-mutated cases. We discuss potential strategies and approaches to anticancer therapies by enhancing ROS production in these difficult-to-treat tumors.

The epidemiology of primary and secondary adrenal malignancies and associated adrenal insufficiency in hospitalised patients: an analysis of hospital admission data, NSW, Australia

BACKGROUND

Adrenal insufficiency (AI) causes considerable morbidity but may remain undiagnosed in patients with adrenal malignancy (AM). The epidemiology of AI and adrenal crises (AC) in AM is uncertain.

METHODS

This was a retrospective study examining hospital admission data from 2006 to 2017. All admissions to all hospitals in NSW, Australia over this period with a principal or comorbid diagnosis of an adrenal malignancy were selected. Data were examined for trends in admissions for AM and associated AI/AC using population data from the corresponding years.

RESULTS

There were 15,376 hospital admissions with a diagnosis of AM in NSW over the study period, corresponding to 1281 admissions/year. The AM admission rate increased significantly over the study period from 129.9/million to 215.7/million (p < 0.01). An AI diagnosis was recorded in 182 (1.2%) admissions, corresponding to an average of 2.1/million/year. This rate increased significantly over the years of the study from 1.2/million in 2006 to 3.4/million in 2017 (p < 0.01). An AC was identified in 24 (13.2%) admissions with an AI diagnosis. Four patients (16.7%) with an AC died during the hospitalisation.

CONCLUSION

Admission with a diagnosis of AM has increased over recent years and has been accompanied by an increase in AI diagnoses. While AI is diagnosed in a small proportion of patients with AM, ACs do occur in affected patients.

An unusual case of Adrenocortical Adenocarcinoma with Biochemical Masquerade of Pheochromocytoma

Adrenocortical carcinoma (ACC) is a rare malignancy that arises from the adrenal cortex and often presents as adrenal incidentaloma on abdominal scans with rise in the use of imaging modalities. ACC often presents as Cushing’s syndrome or virilization. On the other hand, pheochromocytoma is an adrenal medullary tumor. It is rare for ACC to present as pheochromocytoma even though both may coexist. Moreover, ACC tumors have radiological and histological features suggestive of aggressive nature of the disease.

We present a case of a 65-year-old lady who initially presented with a 3cm left adrenal incidentaloma. All of her adrenal hormones were in normal range. She was lost to follow up for several years and returned with a much enlarged lesion. Biochemical work up showed mildly increased catecholamines and metanephrines suggestive of pheochromocytoma. She didn’t have any signs or symptoms of pheochromocytoma. She was treated with alpha blockers before surgery as a prophylactic measure. Surgical pathology was consistent with the diagnosis of primary adrenal adenocarcinoma. We recommend that adrenal incidentalomas should be followed annually for up to five years as per American association of Endocrinology and the Endocrine Society guidelines to prevent morbidity and mortality in patients.

The Role of Biomarkers in Adrenocortical Carcinoma: A Review of Current Evidence and Future Perspectives

Adrenocortical carcinoma (ACC) is a rare endocrine malignancy arising from the adrenal cortex often with unexpected biological behavior. It can occur at any age, with two peaks of incidence: in the first and between fifth and seventh decades of life. Although ACC are mostly hormonally active, precursors and metabolites, rather than end products of steroidogenesis are produced by dedifferentiated and immature malignant cells. Distinguishing the etiology of adrenal mass, between benign adenomas, which are quite frequent in general population, and malignant carcinomas with dismal prognosis is often unfeasible. Even after pathohistological analysis, diagnosis of adrenocortical carcinomas is not always straightforward and represents a great challenge for experienced and multidisciplinary expert teams. No single imaging method, hormonal work-up or immunohistochemical labelling can definitively prove the diagnosis of ACC. Over several decades' great efforts have been made in finding novel reliable and available diagnostic and prognostic factors including steroid metabolome profiling or target gene identification. Despite these achievements, the 5-year mortality rate still accounts for approximately 75% to 90%, ACC is frequently diagnosed in advanced stages and therapeutic options are unfortunately limited. Therefore, imperative is to identify new biological markers that can predict patient prognosis and provide new therapeutic options.

Large adrenal tumours mimicking hepatic malignancy: the role of concurrent adrenalectomy and anterior approach hepatectomy

BACKGROUND

Large right adrenal tumours may invade the liver and mimic primary hepatic malignancy, presenting diagnostic and management challenges. The 'anterior approach hepatectomy' (AAH) using hanging manoeuvre may be safe for resection of such tumours.

METHODS

Prospectively maintained database was analysed to identify the large tumours of adreno-hepatic region subjected to hepatectomy. Clinico-biochemical, radiological and surgical details were reviewed. AAH and hanging manoeuvre was adopted for the patients requiring right hepatectomy.

RESULTS

Out of the eight patients with adreno-hepatic tumour, four had indeterminate origin of the mass, two had complex cysts, and two were diagnosed as hepatocellular carcinoma on the pre-operative imaging. The median age was 38 years (23-66); male:female ratio was 5:3. AAH was performed in four patients, while others underwent non-anatomical resection of involved segment(s). This accounted for 1.01% of 789 hepatectomies performed during the study period. The median intra-operative blood loss was 525 mL (150-2200 mL) and the median tumour size was 9 cm (6-17 cm). All patients underwent R0 resection. The final histopathological diagnoses were: three phaeochromocytomas (two malignant and one benign), two adrenocortical carcinomas, one malignant paraganglionomas and two adrenal cysts. Major complication (grade IVa) was experienced in one patient. On median follow-up of 67.5 months (7-84), all were alive and one patient had tumour recurrence.

CONCLUSION

Adrenal tumours mimicking primary hepatic malignancy are rare but pose diagnostic challenges. The AAH is a safe approach with acceptable R0 resection, blood loss, surgical complications and overall outcome for the patients requiring right hepatectomy.

Adrenocortical carcinoma in a young adult male with chronic urticaria: A case report and literature review

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Adrenocortical carcinoma (ACC) is a rare, aggressive tumor arising from the adrenal cortex.

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Recognition of the typical clinical, biochemical, and imaging findings is crucial for rapid diagnosis.

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Complete surgical resection is currently the curative treatment of localized ACC.

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Adjuvant mitotane may prolong recurrence-free survival in patients with radically resected ACC.

Background

Adrenocortical carcinoma (ACC) is a rare endocrine malignancy, often with an unfavorable prognosis. Radical adrenalectomy is the gold standard of treatment of localized disease.

Case description

We report a case of a 23-year-old male patient who presented with persistent left flank pain and urticaria for 3 months. Imaging studies confirmed the presence of a large left adrenal mass with malignant features. The biochemical workup was unremarkable. Open left radical adrenalectomy was performed, the final pathologic examination showed ACC with negative surgical margins. The patient remained disease-free for eighteen months period of follow up after surgery.

Discussion

ACC is a rare neoplasm with poor prognosis and with an incidence of one in one million population. There is a slight female predilection. The ACC may be functional with a clinically pure endocrine syndrome like Cushing syndrome. Most of patients with ACC present with symptoms and signs of hormonal secretion. Adrenal computed tomography (CT) scanning and magnetic resonance imaging (MRI) are the imaging studies of choice in ACC. When feasible, total resection remains the treatment of choice for the definitive treatment of ACC. The benefit of the use of mitotane as an adjuvant treatment has been considered controversial. Adjuvant mitotane significantly decreases the recurrence and mortality rate after resection of ACC in patients without distant metastasis as proved by some studies, but these findings need further validation.

Conclusion

ACC is a rare neoplasm characterized by a high risk of recurrence after surgical resection.

Clinical analysis of adrenal lesions larger than 5 cm in diameter (an analysis of 251 cases)

Background

To describe the pathological distribution, imaging manifestations, and surgical managements and prognosis of large adrenal tumors (LATs) ≥ 5 cm

Methods

A total of 251 patients with LATs were analyzed on the basis of pathological or clinical diagnosis. Regarding surgery, open adrenalectomy was performed on 89 patients, and laparoscopic adrenalectomy was performed on 89 patients. Thirty-two patients with bilateral tumors were analyzed in terms of clinical characteristics. The survival rate was determined for 43 patients with adrenal metastases and 29 patients with primary adrenal malignancies. The CT characteristics including tumor diameter, shape, edge, heterogeneity, necrosis, calcification, pre-contrast attenuation, and contrast attenuation were analyzed for 117 patients.

Results

The majority of LATs were still benign, but they had a higher probability to be malignant. Benign LATs made up 68.13% of all cases, mainly adrenal cysts (19.52%), pheochromocytoma (18.73%), benign adenoma (16.73%), and myelolipoma (7.17%). Malignant LATs accounted for 28.69% of cases, mainly including adrenocortical carcinoma (8.76%) and metastases (17.13%). Laparoscopic surgery was found to involve less trauma than open surgery. It was also safer and postoperative recovery was faster, but it had drawbacks and could not completely replace open surgery. CT features had obvious specificity for the diagnosis of benign and malignant tumors. For example, benign adenomas had a smaller pre-contrast (< 10 Hu) whereas malignant adrenal tumors had, on the contrary, higher attenuation. Regarding adrenal malignant carcinoma, adrenal primary malignant tumors showed a better prognosis than adrenal metastases (mean survival of 19.17 months vs 9.49 months). Primary adrenal cortical carcinoma without metastasis had a better prognosis than primary adrenal cortical carcinoma metastasis (mean survival of 23.71 months vs 12.75 months), and adrenal solitary metastasis had a better prognosis than general multiple metastatic carcinoma (mean survival of 14.95 months vs 5.17 months).

Conclusion

LATs were more likely to be benign; however, they still had a high probability of being a malignant tumor. Understanding the clinicopathological characteristics of LATs can facilitate selection of more effective clinical treatment options.