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Costa J, Jácome M, Souteiro P, Santos C, Cunha AL. Composite pheochromocytoma of the adrenal gland-a review of published cases. Virchows Arch 2023; 483:267-275. [PMID: 36645463 DOI: 10.1007/s00428-023-03492-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/26/2022] [Accepted: 01/09/2023] [Indexed: 01/17/2023]
Abstract
Composite pheochromocytoma (CP) is a rare adrenal tumor, composed of ordinary pheochromocytoma and neuroblastic components. There is a paucity of information in the literature regarding this entity. We report the case of a 56-year-old woman with a CP of the left adrenal gland with a ganglioneuroma component. A review of the published literature found 110 cases of CP. The median age was 51.5 (5.86) years, and 59/110 (53.6%) were female. Association with genetic predisposition syndromes was found in 22/110 (20%), the most common of which was neurofibromatosis type 1, in 15/110 (13.6%). The most common histologic type of the neuroblastic component was ganglioneuroma in 83/110 (75.5%). Twenty-seven cases reported SDHB immunohistochemistry results; none of which was positive. Nine patients (8.2%) presented/developed metastatic disease, and 9 patients (8.2%) died from disease. To our knowledge, this is the largest review describing clinical, histopathological, molecular, and prognostic features of CP.
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Affiliation(s)
- João Costa
- Department of Pathology, Portuguese Institute of Oncology-Porto, Porto, Portugal.
| | - Manuel Jácome
- Department of Pathology, Portuguese Institute of Oncology-Porto, Porto, Portugal
| | - Pedro Souteiro
- Department of Endocrinology, Portuguese Institute of Oncology-Porto, Porto, Portugal
| | - Catarina Santos
- Department of Genetics, Portuguese Institute of Oncology-Porto, Porto, Portugal
- Cancer Genetics Group, IPO-Porto Research Center (CI-IPOP), Portuguese Oncology Institute of Porto (IPO-Porto), Porto, Portugal
| | - Ana Luísa Cunha
- Department of Pathology, Portuguese Institute of Oncology-Porto, Porto, Portugal
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Mete O, Asa SL, Gill AJ, Kimura N, de Krijger RR, Tischler A. Overview of the 2022 WHO Classification of Paragangliomas and Pheochromocytomas. Endocr Pathol 2022; 33:90-114. [PMID: 35285002 DOI: 10.1007/s12022-022-09704-6] [Citation(s) in RCA: 121] [Impact Index Per Article: 60.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/15/2022] [Indexed: 12/12/2022]
Abstract
This review summarizes the classification of tumors of the adrenal medulla and extra-adrenal paraganglia as outlined in the 5th series of the WHO Classification of Endocrine and Neuroendocrine Tumors. The non-epithelial neuroendocrine neoplasms (NENs) known as paragangliomas produce predominantly catecholamines and secrete them into the bloodstream like hormones, and they represent a group of NENs that have exceptionally high genetic predisposition. This classification discusses the embryologic derivation of the cells that give rise to these lesions and the historical evolution of the terminology used to classify their tumors; paragangliomas can be sympathetic or parasympathetic and the term pheochromocytoma is used specifically for intra-adrenal paragangliomas that represent the classical sympathetic form. In addition to the general neuroendocrine cell biomarkers INSM1, synaptophysin, and chromogranins, these tumors are typically negative for keratins and instead have highly specific biomarkers, including the GATA3 transcription factor and enzymes involved in catecholamine biosynthesis: tyrosine hydroxylase that converts L-tyrosine to L-DOPA as the rate-limiting step in catecholamine biosynthesis, dopamine beta-hydroxylase that is present in cells expressing norepinephrine, and phenylethanolamine N-methyltransferase, which converts norepinephrine to epinephrine and therefore can be used to distinguish tumors that make epinephrine. In addition to these important tools that can be used to confirm the diagnosis of a paraganglioma, new tools are recommended to determine genetic predisposition syndromes; in addition to the identification of precursor lesions, molecular immunohistochemistry can serve to identify associations with SDHx, VHL, FH, MAX, and MEN1 mutations, as well as pseudohypoxia-related pathogenesis. Paragangliomas have a well-formed network of sustentacular cells that express SOX10 and S100, but this is not a distinctive feature, as other epithelial NENs also have sustentacular cells. Indeed, it is the presence of such cells and the association with ganglion cells that led to a misinterpretation of several unusual lesions as paragangliomas; in the 2022 WHO classification, the tumor formerly known as cauda equina paraganglioma is now classified as cauda equina neuroendocrine tumor and the lesion known as gangliocytic paraganglioma has been renamed composite gangliocytoma/neuroma and neuroendocrine tumor (CoGNET). Since the 4th edition of the WHO, paragangliomas have no longer been classified as benign and malignant, as any lesion can have metastatic potential and there are no clear-cut features that can predict metastatic behavior. Moreover, some tumors are lethal without metastatic spread, by nature of local invasion involving critical structures. Nevertheless, there are features that can be used to identify more aggressive lesions; the WHO does not endorse the various scoring systems that are reviewed but also does not discourage their use. The identification of metastases is also complex, particularly in patients with germline predisposition syndromes, since multiple lesions may represent multifocal primary tumors rather than metastatic spread; the identification of paragangliomas in unusual locations such as lung or liver is not diagnostic of metastasis, since these may be primary sites. The value of sustentacular cells and Ki67 labeling as prognostic features is also discussed in this new classification. A staging system for pheochromocytoma and extra-adrenal sympathetic PGLs, introduced in the 8th Edition AJCC Cancer Staging Manual, is now included. This paper also provides a summary of the criteria for the diagnosis of a composite paragangliomas and summarizes the classification of neuroblastic tumors. This review adopts a practical question-answer framework to provide members of the multidisciplinary endocrine oncology team with a most up-to-date approach to tumors of the adrenal medulla and extra-adrenal paraganglia.
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Affiliation(s)
- Ozgur Mete
- Department of Pathology, University Health Network, Toronto, ON, Canada.
- Endocrine Oncology Site, Princess Margaret Cancer Centre, Toronto, ON, Canada.
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada.
| | - Sylvia L Asa
- Department of Pathology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Anthony J Gill
- Sydney Medical School, University of Sydney, Sydney, NSW, 2006, Australia
- Department of Anatomical Pathology, NSW Health Pathology, Royal North Shore Hospital, St Leonards, NSW, Sydney, Australia
| | - Noriko Kimura
- Department of Clinical Research, Division of Diagnostic Pathology, National Hospital Organization Hakodate Hospital, Hakodate, Japan
| | - Ronald R de Krijger
- Princess Maxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Arthur Tischler
- Department of Pathology and Laboratory Medicine, Tufts Medical Center, Boston, MA, USA
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Eisenhofer G, Peitzsch M, Bechmann N, Huebner A. Biochemical Diagnosis of Catecholamine-Producing Tumors of Childhood: Neuroblastoma, Pheochromocytoma and Paraganglioma. Front Endocrinol (Lausanne) 2022; 13:901760. [PMID: 35957826 PMCID: PMC9360409 DOI: 10.3389/fendo.2022.901760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 06/09/2022] [Indexed: 11/13/2022] Open
Abstract
Catecholamine-producing tumors of childhood include most notably neuroblastoma, but also pheochromocytoma and paraganglioma (PPGL). Diagnosis of the former depends largely on biopsy-dependent histopathology, but this is contraindicated in PPGL where diagnosis depends crucially on biochemical tests of catecholamine excess. Such tests retain some importance in neuroblastoma though continue to largely rely on measurements of homovanillic acid (HVA) and vanillylmandelic acid (VMA), which are no longer recommended for PPGL. For PPGL, urinary or plasma metanephrines are the recommended most accurate tests. Addition of methoxytyramine to the plasma panel is particularly useful to identify dopamine-producing tumors and combined with normetanephrine also shows superior diagnostic performance over HVA and VMA for neuroblastoma. While use of metanephrines and methoxytyramine for diagnosis of PPGL in adults is established, there are numerous pitfalls for use of these tests in children. The establishment of pediatric reference intervals is particularly difficult and complicated by dynamic changes in metabolites during childhood, especially in infants for both plasma and urinary measurements, and extending to adolescence for urinary measurements. Interpretation of test results is further complicated in children by difficulties in following recommended preanalytical precautions. Due to this, the slow growing nature of PPGL and neglected consideration of the tumors in childhood the true pediatric prevalence of PPGL is likely underappreciated. Earlier identification of disease, as facilitated by surveillance programs, may uncover the true prevalence and improve therapeutic outcomes of childhood PPGL. For neuroblastoma there remain considerable obstacles in moving from entrenched to more accurate tests of catecholamine excess.
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Affiliation(s)
- Graeme Eisenhofer
- Institute of Clinical Chemistry and Laboratory Medicine, Universitätsklinikum Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Germany
- Department of Internal Medicine III, Universitätsklinikum Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Germany
- *Correspondence: Graeme Eisenhofer,
| | - Mirko Peitzsch
- Institute of Clinical Chemistry and Laboratory Medicine, Universitätsklinikum Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Germany
| | - Nicole Bechmann
- Institute of Clinical Chemistry and Laboratory Medicine, Universitätsklinikum Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Germany
| | - Angela Huebner
- Department of Pediatrics, Universitätsklinikum Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Germany
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Tasaka K, Ueno H, Yamasaki K, Okuno T, Isobe T, Kimura S, Umeda K, Hara J, Ogawa S, Takita J. Oncogenic FGFR1 mutation and amplification in common cellular origin in a composite tumor with neuroblastoma and pheochromocytoma. Cancer Sci 2021; 113:1535-1541. [PMID: 34971484 PMCID: PMC8990717 DOI: 10.1111/cas.15260] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 12/16/2021] [Accepted: 12/19/2021] [Indexed: 11/24/2022] Open
Abstract
Neuroblastoma (NB) and pheochromocytoma (PCC) are derived from neural crest cells (NCCs); however, composite tumors with NB and PCC are rare, and their underlying molecular mechanisms remain unknown. To address this issue, we performed exome and transcriptome sequencing with formalin‐fixed paraffin‐embedded (FFPE) samples from the NB, PCC, and mixed lesions in a patient with a composite tumor. Whole‐exome sequencing revealed that most mutations (80%) were shared by all samples, indicating that NB and PCC evolved from the same clone. Notably, all samples harbored both mutation and focal amplification in the FGFR1 oncogene, resulting in an extraordinarily high expression, likely to be the main driver of this tumor. Transcriptome sequencing revealed undifferentiated expression profiles for the NB lesions. Considering that a metastatic lesion was also composite, most likely, the primitive founding lesions should differentiate into both NB and PCC. This is the first reported case with composite‐NB and PCC genetically proven to harbor an oncogenic FGFR1 alteration of a common cellular origin.
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Affiliation(s)
- Keiji Tasaka
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hiroo Ueno
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kai Yamasaki
- Department of Pediatric Hematology and Oncology, Osaka City General Hospital
| | | | - Tomoya Isobe
- Department of Pediatrics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shunsuke Kimura
- Department of Pediatrics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Pediatrics, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan
| | - Katsutsugu Umeda
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Junichi Hara
- Cancer Consultation and Support Center, Osaka City General Hospital
| | - Seishi Ogawa
- Department of Pathology and Tumor Biology, Graduate School of Medicine, Kyoto University, Kyoto, Japan.,Institute for the Advanced Study of Human Biology (WPI-ASHBi), Kyoto University, Kyoto, Japan.,Department of Medicine, Center for Hematology and Regenerative Medicine, Karolinska Institute, Stockholm, Sweden
| | - Junko Takita
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Dhanasekar K, Visakan V, Tahir F, Balasubramanian SP. Composite phaeochromocytomas-a systematic review of published literature. Langenbecks Arch Surg 2021; 407:517-527. [PMID: 33651160 PMCID: PMC8933353 DOI: 10.1007/s00423-021-02129-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 02/09/2021] [Indexed: 01/09/2023]
Abstract
Introduction Composite phaeochromocytoma is a tumour containing a separate tumour of neuronal origin in addition to a chromaffin cell tumour. This study reports on two cases from a single centre’s records and presents a systematic literature review of composite phaeochromocytomas. Methods In addition to describing 2 case reports, a systematic search of the Medline database from inception up to April 2020 was done for human case reports on composite phaeochromocytomas. Relevant titles and/or abstracts were screened, and full texts were reviewed to identify appropriate studies. Data was extracted and a descriptive analysis of presentation, clinical features, management strategies and outcomes was performed. The quality of included studies was assessed using a critical appraisal checklist. Results There were 62 studies included, with a total of 94 patients. Of 91 patients where data was available, the median (range) age of patients was 48 (4–86) years. Of 90 patients where information was provided, 57% were female. In at least 28% of patients, a genetic cause was identified. Common presenting features include abdominal pain, palpable mass, cardiovascular and gastrointestinal symptoms. The most common tumour component with phaeochromocytoma is ganglioneuroma; other components include ganglioneuroblastoma, neuroblastoma and malignant peripheral nerve sheath tumours. In patients with follow-up data (n=48), 85% of patients were alive and well at a median (range) follow-up time of 18 (0.5–168) months. Conclusion Composite phaeochromocytoma is a rare tumour, with a significant genetic predisposition. This review summarises available epidemiological data, which will be useful for clinicians managing this rare condition.
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Affiliation(s)
| | - V Visakan
- Newcastle University, Newcastle upon Tyne, UK
| | - F Tahir
- Sheffield Teaching Hospitals NHS Trust UK, Sheffield, UK
| | - S P Balasubramanian
- University of Sheffield, Sheffield, UK.,Sheffield Teaching Hospitals NHS Trust UK, Sheffield, UK
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Rai SK, Bril F, Hatch HM, Xu Y, Shelton L, Kalavalapalli S, Click A, Lee D, Beecher C, Kirby A, Kong K, Trevino J, Jha A, Jatav S, Kriti K, Luthra S, Garrett TJ, Guingab-Cagmat J, Plant D, Bose P, Cusi K, Hromas RA, Tischler AS, Powers JF, Gupta P, Bibb J, Beuschlein F, Robledo M, Calsina B, Timmers H, Taieb D, Kroiss M, Richter S, Langton K, Eisenhofer G, Bergeron R, Pacak K, Tevosian SG, Ghayee HK. Targeting pheochromocytoma/paraganglioma with polyamine inhibitors. Metabolism 2020; 110:154297. [PMID: 32562798 PMCID: PMC7482423 DOI: 10.1016/j.metabol.2020.154297] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 06/12/2020] [Accepted: 06/17/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Pheochromocytomas (PCCs) and paragangliomas (PGLs) are neuroendocrine tumors that are mostly benign. Metastatic disease does occur in about 10% of cases of PCC and up to 25% of PGL, and for these patients no effective therapies are available. Patients with mutations in the succinate dehydrogenase subunit B (SDHB) gene tend to have metastatic disease. We hypothesized that a down-regulation in the active succinate dehydrogenase B subunit should result in notable changes in cellular metabolic profile and could present a vulnerability point for successful pharmacological targeting. METHODS Metabolomic analysis was performed on human hPheo1 cells and shRNA SDHB knockdown hPheo1 (hPheo1 SDHB KD) cells. Additional analysis of 115 human fresh frozen samples was conducted. In vitro studies using N1,N11-diethylnorspermine (DENSPM) and N1,N12- diethylspermine (DESPM) treatments were carried out. DENSPM efficacy was assessed in human cell line derived mouse xenografts. RESULTS Components of the polyamine pathway were elevated in hPheo1 SDHB KD cells compared to wild-type cells. A similar observation was noted in SDHx PCC/PGLs tissues compared to their non-mutated counterparts. Specifically, spermidine, and spermine were significantly elevated in SDHx-mutated PCC/PGLs, with a similar trend in hPheo1 SDHB KD cells. Polyamine pathway inhibitors DENSPM and DESPM effectively inhibited growth of hPheo1 cells in vitro as well in mouse xenografts. CONCLUSIONS This study demonstrates overactive polyamine pathway in PCC/PGL with SDHB mutations. Treatment with polyamine pathway inhibitors significantly inhibited hPheo1 cell growth and led to growth suppression in xenograft mice treated with DENSPM. These studies strongly implicate the polyamine pathway in PCC/PGL pathophysiology and provide new foundation for exploring the role for polyamine analogue inhibitors in treating metastatic PCC/PGL. PRéCIS: Cell line metabolomics on hPheo1 cells and PCC/PGL tumor tissue indicate that the polyamine pathway is activated. Polyamine inhibitors in vitro and in vivo demonstrate that polyamine inhibitors are promising for malignant PCC/PGL treatment. However, further research is warranted.
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Affiliation(s)
- Sudhir Kumar Rai
- Department of Medicine, Division of Endocrinology, University of Florida, Gainesville, FL, USA
| | - Fernando Bril
- Department of Medicine, Division of Endocrinology, University of Florida and Malcom Randall VA Medical Center, Gainesville, FL, USA
| | - Heather M Hatch
- Department of Physiological Sciences, University of Florida, Gainesville, FL, USA
| | - Yiling Xu
- Department of Medicine, Division of Endocrinology, University of Florida, Gainesville, FL, USA
| | - Laura Shelton
- Scientific Project Development, Human Metabolome Technologies, Boston, MA, USA
| | - Srilaxmi Kalavalapalli
- Department of Medicine, Division of Endocrinology, University of Florida, Gainesville, FL, USA
| | - Arielle Click
- Department of Immunology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | | | - Austin Kirby
- Department of Medicine, University of Texas Health Science Center, San Antonio, TX, USA
| | - Kimi Kong
- Department of Medicine, University of Texas Health Science Center, San Antonio, TX, USA
| | - Jose Trevino
- Department of Surgery, University of Florida, Gainesville, FL, USA
| | | | | | | | | | - Timothy J Garrett
- Department of Pathology, Immunology, and Laboratory Medicine, University of Florida, Gainesville, FL, USA
| | - Joy Guingab-Cagmat
- Department of Pathology, Immunology, and Laboratory Medicine, University of Florida, Gainesville, FL, USA
| | - Daniel Plant
- Department of Physiological Sciences, University of Florida, Malcom Randall VA Medical Center, Gainesville, FL, USA
| | - Prodip Bose
- Department of Physiological Sciences, University of Florida, Malcom Randall VA Medical Center, Gainesville, FL, USA
| | - Kenneth Cusi
- Department of Medicine, Division of Endocrinology, University of Florida and Malcom Randall VA Medical Center, Gainesville, FL, USA
| | - Robert A Hromas
- Department of Medicine, University of Texas Health Science Center, San Antonio, TX, USA
| | - Arthur S Tischler
- Department of Pathology and Laboratory Medicine, Tufts Medical Center, Boston, MA, USA
| | - James F Powers
- Department of Pathology and Laboratory Medicine, Tufts Medical Center, Boston, MA, USA
| | - Priyanka Gupta
- Department of Surgery, University of Alabama, Birmingham, AL, USA
| | - James Bibb
- Department of Surgery, University of Alabama, Birmingham, AL, USA
| | - Felix Beuschlein
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, UniversitätsSpital Zurich, Zurich, Switzerland
| | - Mercedes Robledo
- Hereditary Endocrine Cancer Group, Spanish National Cancer Research Center (CNIO), and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Madrid, Spain
| | - Bruna Calsina
- Hereditary Endocrine Cancer Group, Spanish National Cancer Research Center (CNIO), and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Madrid, Spain
| | - Henri Timmers
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - David Taieb
- Department of Nuclear Medicine, La Timone University Hospital, European Center for Research in Medical Imaging, Aix Marseille Université, Marseille, France
| | - Matthias Kroiss
- Department of Internal Medicine, Division of Endocrinology and Diabetology, University Hospital Würzburg, University of Würzburg, Würzburg, Germany
| | - Susan Richter
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Katharina Langton
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Graeme Eisenhofer
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany; Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany; Division of Clinical Neurochemistry, Institute of Clinical Chemistry and Laboratory Medicine, and Department of Medicine, Faculty of Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Raymond Bergeron
- Department of Medicinal Chemistry, University of Florida, Gainesville, FL, USA
| | - Karel Pacak
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Sergei G Tevosian
- Department of Physiological Sciences, University of Florida, Gainesville, FL, USA.
| | - Hans K Ghayee
- Department of Medicine, Division of Endocrinology, University of Florida and Malcom Randall VA Medical Center, Gainesville, FL, USA.
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