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Gaddameedi SR, Untalan AD, Rathod M, Cherukuri PB, Bandari V, Ashok M, Du D. A Rare Case of Adrenal Carcinoma With Isolated Hypercortisolism Mimicking Hyperaldosteronism. Cureus 2024; 16:e61481. [PMID: 38827415 PMCID: PMC11144017 DOI: 10.7759/cureus.61481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2024] [Indexed: 06/04/2024] Open
Abstract
We report a case of a 22-year-old female with pedal edema, hypokalemia, and hypertension. On suspicion of hyperaldosteronism, further workup was pursued, which only revealed a low serum adrenocorticotropic hormone (ACTH) and an inappropriately normal cortisol level after a 1-mg dexamethasone suppression test, suggestive of primary hypercortisolism. CT of the chest, abdomen, and pelvis revealed a left adrenal mass. Based on the clinical findings and biochemical abnormalities, we were expecting this tumor to be aldosterone-secreting, but both serum aldosterone and renin levels were normal in our patient. Eventual surgical resection confirmed initial suspicions of malignancy, as it was found to be adrenal cortical carcinoma. This case highlights the unusual presentation of this rare but aggressive endocrinologic neoplasm and the importance of its prompt diagnosis and treatment.
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Affiliation(s)
| | - Axle D Untalan
- Internal Medicine, Rutgers Health/Monmouth Medical Center, Long Branch, USA
| | - Malay Rathod
- Medicine, Rutgers Health/Monmouth Medical Center, Long Branch, USA
| | | | | | - Manjula Ashok
- Nephrology, Rutgers Health/Monmouth Medical Center, Long Branch, USA
| | - Doantrang Du
- Internal Medicine, Rutgers Health/Monmouth Medical Center, Long Branch, USA
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2
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Ishikawa Y, Yamazaki Y, Tezuka Y, Omata K, Ono Y, Tokodai K, Fujishima F, Kawanabe S, Katabami T, Ikeya A, Yamashita M, Oki Y, Nanjo H, Satoh F, Ito A, Unno M, Kamei T, Sasano H, Suzuki T. Histopathological analysis of tumor microenvironment in adrenocortical carcinoma: Possible effects of in situ disorganized glucocorticoid production on tumor immunity. J Steroid Biochem Mol Biol 2024; 238:106462. [PMID: 38232786 DOI: 10.1016/j.jsbmb.2024.106462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 01/07/2024] [Accepted: 01/11/2024] [Indexed: 01/19/2024]
Abstract
Adrenocortical carcinoma (ACC) patients with glucocorticoid excess have been reported to be associated with decreased tumor-infiltrating immune cells, but the effects of in situ glucocorticoid production on tumor immunity have remained unknown. In addition, ACC was also known to harbor marked intra-tumoral heterogeneity of steroidogenesis or disorganized steroidogenesis. Therefore, in this study, we immune-profiled tumor-infiltrating lymphocytes (TILs) and tumor-associated macrophages (TAMs) and pivotal steroidogenic enzymes of glucocorticoid biosynthesis (CYP17A and CYP11B1) to explore the potential effects of in situ glucocorticoid production and intra-tumoral heterogeneity/disorganized steroidogenesis on tumor immunity of ACC. We also studied the correlations of the status of tumor immunity with that of angiogenesis and tumor grade to further explore the tumor tissue microenvironment of ACC. TILs (CD3, CD4, CD8, and FOXP3), TAMs (CD68 and CD163), key steroidogenic enzymes of glucocorticoid (CYP17A and CYP11B1), angiogenesis (CD31 and vasohibin-1 (VASH-1)), tumor grade (Ki-67 and Weiss score) were immunohistochemically evaluated in 34 ACCs. Increased CYP17A immunoreactivity in the whole tumor area was significantly positively correlated with FOXP3-positive TILs (p = 0.021) and negatively with CD4/CD3 ratio (p = 0.001). Increased CYP11B1 immunoreactivity in the whole tumor area was significantly positively correlated with CD8/CD3 (p = 0.039) and CD163/CD68 ratios (p = 0.006) and negatively with CD4-positive TILs (p = 0.036) and CD4/CD3 ratio (p = 0.001). There were also significant positive correlations between CYP17A and CD8 (r = 0.334, p < 0.001) and FOXP3-positive TILs (r = 0.414, p < 0.001), CD8/CD3 ratio (r = 0.421, p < 0.001), and CD68-positive TAMs (r = 0.298, p < 0.001) in randomly selected areas. Significant positive correlations were also detected between CYP11B1 and CD8/CD3 ratio (r = 0.276, p = 0.001) and negative ones detected between CYP11B1 and CD3- (r = -0.259, p = 0.002) and CD4-positive TILs (r = -0.312, p < 0.001) in those areas above. Increased micro-vessel density (MVD) -VASH-1 was significantly positively correlated with CD68- (p = 0.015) and CD163-positive TAMs (p = 0.009) and CD163/CD68 ratio and the high VASH-1 with CD163-positive TAMs (p = 0.042). Ki-67 labeling index was significantly positively correlated with MAD-VASH-1 (p = 0.006) and VASH-1 (p = 0.006) status. Results of our present study indicated that in situ glucocorticoid production did influence the status of tumor immunity in ACC. In particular, increased levels of CYP17A and CYP11B1, both involved in glucocorticoid producing immunoreactivity played different effects on tumor immunity, i.e., reflecting the involvement of intra-tumoral heterogeneity and disorganized steroidogenesis of ACC, which also did indicate the importance of in situ approaches when analyzing tumor immunity of ACC.
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Affiliation(s)
- Yuki Ishikawa
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yuto Yamazaki
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Yuta Tezuka
- Department of Diabetes, Metabolism and Endocrinology, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8574, Japan; Division of Nephrology, Rheumatology and Endocrinology, Tohoku University Graduate School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8575, Japan
| | - Kei Omata
- Department of Diabetes, Metabolism and Endocrinology, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8574, Japan; Division of Nephrology, Rheumatology and Endocrinology, Tohoku University Graduate School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8575, Japan
| | - Yoshikiyo Ono
- Department of Diabetes, Metabolism and Endocrinology, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8574, Japan; Division of Nephrology, Rheumatology and Endocrinology, Tohoku University Graduate School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8575, Japan
| | - Kazuaki Tokodai
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Fumiyoshi Fujishima
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Shin Kawanabe
- Department of Metabolism and Endocrinology, St. Marianna University Yokohama Seibu Hospital, Yokohama, Japan; Department of Metabolism and Endocrinology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Takuyuki Katabami
- Department of Metabolism and Endocrinology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Akira Ikeya
- Division of Endocrinology & Metabolism, Second Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Miho Yamashita
- Division of Endocrinology & Metabolism, Second Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Yutaka Oki
- Diabetes & Endocrinology Center, Hamamatsu-Kita Hospital, Hamamatsu, Shizuoka, Japan
| | - Hiroshi Nanjo
- Department of Pathology, Akita University Hospital, Akita, Japan
| | - Fumitoshi Satoh
- Division of Clinical Hypertension, Endocrinology and Metabolism, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Akihiro Ito
- Department of Urology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takashi Kamei
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hironobu Sasano
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takashi Suzuki
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan
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Ababneh O, Ghazou A, Alawajneh M, Alhaj Mohammad S, Bani-Hani A, Alrabadi N, Shreenivas A. The Efficacy and Safety of Immune Checkpoint Inhibitors in Adrenocortical Carcinoma: A Systematic Review and Meta-Analysis. Cancers (Basel) 2024; 16:900. [PMID: 38473262 DOI: 10.3390/cancers16050900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 02/16/2024] [Accepted: 02/20/2024] [Indexed: 03/14/2024] Open
Abstract
Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of different malignancies. However, their efficacy in advanced adrenocortical carcinoma (ACC) remains uncertain. Thus, we conducted a systematic review and meta-analysis to summarize the efficacy and tolerability of ICIs in patients with advanced ACC. We searched PubMed, Scopus, and CENTRAL for studies that used ICIs in ACC. Studies with more than five patients were included in the meta-analysis of the objective response rate (ORR), disease control rate (DCR), overall survival (OS), progression-free survival (PFS), and grade 3/4 adverse events. Twenty studies with 23 treatment arms and 250 patients were included. Single-agent anti-PD1 or anti-PD-L1 treatment was utilized in 13 treatment arms, whereas an anti-PD1 or anti-PD-L1 and anti-CTLA4 combination was used in 4 treatment arms. Other anti-PD1- or anti-PD-L1-based combinations were used in five treatment arms. The ORR was 14% (95% CI = 10-19%, I2 = 0%), and the DCR was 43% (95% CI = 37-50%, I2 = 13%). The combination anti-PD1- or anti-PD-L1-based treatment strategies did not correlate with higher responses compared with monotherapy. The median OS was 13.9 months (95% CI = 7.85-23.05), and the median PFS was 2.8 months (95% CI = 1.8-5.4). ICIs have a modest efficacy in advanced ACC but a good OS. Further studies are needed to investigate predictive biomarkers for ICI response and to compare ICI-based strategies with the current standard of care.
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Affiliation(s)
- Obada Ababneh
- Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan
| | - Alina Ghazou
- Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan
| | - Mohmmad Alawajneh
- Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan
| | - Saleh Alhaj Mohammad
- Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan
| | - Abdullah Bani-Hani
- Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan
| | - Nasr Alrabadi
- Department of Pharmacology, Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan
| | - Aditya Shreenivas
- Department of Hematology and Oncology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA
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Zagojska E, Malka M, Gorecka A, Ben-Skowronek I. Case Report: Adrenocortical carcinoma in children-symptoms, diagnosis, and treatment. Front Endocrinol (Lausanne) 2023; 14:1216501. [PMID: 38075063 PMCID: PMC10702754 DOI: 10.3389/fendo.2023.1216501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 10/30/2023] [Indexed: 12/18/2023] Open
Abstract
Adrenocortical carcinomas are extremely rare in the paediatric population. Most of them are hormone-secretive lesions; therefore, they should be taken into consideration in a child with signs of precocious puberty and/or Cushing's syndrome symptoms. Nonetheless, differentiation from benign adrenal tumours is necessary. We report a rare case of adrenocortical carcinoma in a girl and a literature review using the PubMed database. A four-year-old girl presented with rapidly progressing precocious puberty and signs of Cushing's syndrome. Imaging of the abdomen revealed a large heterogeneous solid mass. Histopathologic evaluation confirmed adrenocortical carcinoma with high mitotic activity, atypical mitoses, pleomorphism, necrosis, and vascular invasion. After tumourectomy, a decrease of previously elevated hormonal blood parameters was observed. Genetic tests confirmed Li Fraumeni syndrome. Adrenocortical carcinoma should be suspected in children with premature pubarche and signs of Cushing's syndrome. Diagnosis must be based on clinical presentation, hormonal tests, imaging, and histopathological evaluation. Complete surgical resection of the tumour is the gold standard. Oncological treatment in children is not yet well-studied and should be individually considered, especially in advanced, inoperable carcinomas with metastases. Genetic investigations are useful for determining the prognosis in patients and their siblings.
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Affiliation(s)
| | | | | | - Iwona Ben-Skowronek
- Department of Paediatric Endocrinology and Diabetology, Medical University of Lublin, Lublin, Poland
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Zhang Y, Zhang C, Li K, Deng J, Liu H, Lai G, Xie B, Zhong X. Identification of Molecular Subtypes and Prognostic Characteristics of Adrenocortical Carcinoma Based on Unsupervised Clustering. Int J Mol Sci 2023; 24:15465. [PMID: 37895143 PMCID: PMC10607826 DOI: 10.3390/ijms242015465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 10/11/2023] [Accepted: 10/18/2023] [Indexed: 10/29/2023] Open
Abstract
Adrenocortical carcinoma (ACC) is a rare endocrine malignancy with a poor prognosis. Increasing evidence highlights the significant role of immune-related genes (IRGs) in ACC progression and immunotherapy, but the research is still limited. Based on the Cancer Genome Atlas (TCGA) database, immune-related molecular subtypes were identified by unsupervised consensus clustering. Univariate Cox analysis and Least Absolute Shrinkage and Selection Operator (LASSO) regression were employed to further establish immune-related gene signatures (IRGS). An evaluation of immune cell infiltration, biological function, tumor mutation burden (TMB), predicted immunotherapy response, and drug sensitivity in ACC patients was conducted to elucidate the applicative efficacy of IRGS in precision therapy. ACC patients were divided into two molecular subtypes through consistent clustering. Furthermore, the 3-gene signature (including PRKCA, LTBP1, and BIRC5) based on two molecular subtypes demonstrated consistent prognostic efficacy across the TCGA and GEO datasets and emerged as an independent prognostic factor. The low-risk group exhibited heightened immune cell infiltration, TMB, and immune checkpoint inhibitors (ICIs), associated with a favorable prognosis. Pathways associated with drug metabolism, hormone regulation, and metabolism were activated in the low-risk group. In conclusion, our findings suggest IRGS can be used as an independent prognostic biomarker, providing a foundation for shaping future ACC immunotherapy strategies.
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Affiliation(s)
| | | | | | | | | | | | - Biao Xie
- Department of Epidemiology and Health Statistics, School of Public Health, Chongqing Medical University, Yixue Road, Chongqing 400016, China; (Y.Z.); (C.Z.); (K.L.); (J.D.); (H.L.); (G.L.)
| | - Xiaoni Zhong
- Department of Epidemiology and Health Statistics, School of Public Health, Chongqing Medical University, Yixue Road, Chongqing 400016, China; (Y.Z.); (C.Z.); (K.L.); (J.D.); (H.L.); (G.L.)
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Shen C, Wang Y. Ferroptosis Biomarkers for Predicting Prognosis and Immunotherapy Efficacy in Adrenocortical Carcinoma. Arch Med Res 2023; 54:45-55. [PMID: 36528469 DOI: 10.1016/j.arcmed.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 10/17/2022] [Accepted: 12/05/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Numerous studies have suggested that ferroptosis plays an important regulatory role in cancer cell death. Nonetheless, the potential effects of ferroptosis regulators on the prognosis, the expression of immunomodulatory factors in the tumor microenvironment and on the efficacy of immunotherapy in adrenocortical carcinoma (ACC) remain largely unknown. METHODS Public ACC datasets were used to investigate the relationship between ferroptosis regulators and prognosis and clinical features. A ferroptosis scoring system was established for individual cases of ACC using principal component analysis algorithms. Hub ferroptosis-related genes involved in immunoregulation and immunotherapy efficacy in ACC were further identified. RESULTS Twenty ferroptosis regulators were differentially expressed in ACC and 17 ferroptosis regulators were closely related to prognosis in ACC. A ferroptosis scoring system was developed based on ACSL4, FANCD2, and SLC7A1 expression, and the ferroptosis regulators could serve as an independent prognostic factor for ACC. Further analyses indicated that the ferroptosis score integrated with the tumor mutation burden (TMB), and immune-checkpoint gene expression could predict prognosis in ACC. RNA isolation and reverse transcription‑quantitative polymerase chain reaction (RT-qPCR) demonstrated significant differences in the expression levels of ACSL4, FANCD2, and SLC7A1 between ACC and normal tissues. Furthermore, FANCD2 was significantly related to immunotherapy efficacy and prognosis in ACC. CONCLUSION Our study demonstrated that ferroptosis was significantly associated with prognosis, clinical characteristics, immune-checkpoint gene expression, and tumor microenvironment immune cell infiltration in ACC. The current study provides comprehensive evidence for further research on ferroptosis regulators in ACC and provides new insight into the epigenetic regulation of the antitumor immune response.
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Affiliation(s)
- Chengquan Shen
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China; Key Laboratory of Urology and Andrology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Yonghua Wang
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China; Key Laboratory of Urology and Andrology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China.
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Abstract
Adrenal cortical carcinoma (ACC) is a rare and aggressive malignancy that poses challenging issues regarding the diagnostic workup. Indeed, no presurgical technique or clinical parameters can reliably distinguish between adrenal cortical adenomas, which are more frequent and have a favorable outcome, and ACC, and the final diagnosis largely relies on histopathologic analysis of the surgical specimen. However, even the pathologic assessment of malignancy in an adrenal cortical lesion is not straightforward and requires a combined evaluation of multiple histopathologic features. Starting from the Weiss score, which was developed in 1984, several histopathologic scoring systems have been designed to tackle the difficulties of ACC diagnosis. Dealing with specific histopathologic variants (eg, Liss-Weiss-Bisceglia scoring system for oncocytic ACC) or patient characteristics (eg, Wieneke index in the pediatric setting), these scores remarkably improved the diagnostic workup of ACC and its subtypes. Nevertheless, cases with misleading features or discordant correlations between pathologic findings and clinical behavior still occur. Owing to multicentric collaborative studies integrating morphologic features with ancillary immunohistochemical markers and molecular analysis, ACC has eventually emerged as a multifaceted, heterogenous malignancy, and, while innovative and promising approaches are currently being tested, the future clinical management of patients with ACC will mainly rely on personalized medicine and target-therapy protocols. At the dawn of the new Fifth World Health Organization classification of endocrine tumors, this review will tackle ACC from the pathologist's perspective, thus focusing on the main available diagnostic, prognostic, and predictive tissue-tethered features and biomarkers and providing relevant clinical and molecular correlates.
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Immune checkpoint inhibitor-related endocrinopathies. J Transl Int Med 2022; 10:9-14. [PMID: 35702188 PMCID: PMC8997801 DOI: 10.2478/jtim-2022-0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Al-Ward R, Zsembery C, Habra MA. Adjuvant therapy in adrenocortical carcinoma: prognostic factors and treatment options. ENDOCRINE ONCOLOGY (BRISTOL, ENGLAND) 2022; 2:R90-R101. [PMID: 37435451 PMCID: PMC10259337 DOI: 10.1530/eo-22-0050] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 07/26/2022] [Indexed: 07/13/2023]
Abstract
Adrenocortical carcinoma (ACC) is a rare cancer with high recurrence rates and heterogeneous clinical behavior. The role of adjuvant therapy remains unclear because of the challenges in collecting high-quality data for a rare cancer. The current treatment recommendations and guidelines for adjuvant therapy are mostly derived retrospectively from national databases and the treatment outcomes of patients seen in referral centers. To better select patients for adjuvant therapy, multiple factors need to be considered including staging, markers of cellular proliferation (such as Ki67%), resection margins, hormonal function, and possibly genetic alterations of the tumor as well as patient-related factors such as age and performance status. Adjuvant mitotane remains the most commonly used adjuvant therapy in ACC based on clinical practice guidelines, though emerging data from ADIUVO trial (mitotane vs observation in low-risk ACC) suggest that mitotane use in low-risk patients may not be needed. An ongoing clinical trial (ADIUVO-2) is evaluating the role of mitotane vs mitotane combined with chemotherapy in high-risk ACC. The use of adjuvant therapy has been controversial but can be justified in select patients with positive resection margins or after the resection of localized recurrence. A prospective study is needed to study the role of adjuvant radiation in ACC as radiation is expected to help only with local control without impact on distant microscopic metastases. There are no recommendations or published data about using adjuvant immunotherapy in ACC, but this may be a future study after establishing the efficacy and safety profile of immunotherapy in metastatic ACC.
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Affiliation(s)
- Ruaa Al-Ward
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Endocrinology, Diabetes and Metabolism, Baylor College of Medicine, Houston, Texas, USA
| | - Celeste Zsembery
- Departments of Medicine and Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Mouhammed Amir Habra
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Baechle JJ, Hanna DN, Sekhar KR, Rathmell JC, Rathmell WK, Baregamian N. Integrative computational immunogenomic profiling of cortisol-secreting adrenocortical carcinoma. J Cell Mol Med 2021; 25:10061-10072. [PMID: 34664400 PMCID: PMC8572764 DOI: 10.1111/jcmm.16936] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 07/19/2021] [Accepted: 08/13/2021] [Indexed: 01/08/2023] Open
Abstract
Adrenocortical carcinoma (ACC) is a rare but highly aggressive malignancy. Nearly half of ACC tumours overproduce and secrete adrenal steroids. Excess cortisol secretion, in particular, has been associated with poor prognosis among ACC patients. Furthermore, recent immunotherapy clinical trials have demonstrated significant immunoresistance among cortisol‐secreting ACC (CS‐ACC) patients when compared to their non‐cortisol‐secreting (nonCS‐ACC) counterparts. The immunosuppressive role of excess glucocorticoid therapies and hypersecretion is known; however, the impact of the cortisol hypersecretion on ACC tumour microenvironment (TME), immune expression profiles and immune cell responses remain largely undefined. In this study, we characterized the TME of ACC patients and compared the immunogenomic profiles of nonCS‐ACC and CS‐ACC tumours to assess the impact of differentially expressed genes (DEGs) by utilizing The Cancer Genome Atlas (TCGA) database. Immunogenomic comparison (CS‐ vs. nonCS‐ACC tumour TMEs) demonstrated an immunosuppressive expression profile with a direct impact on patient survival. We identified several primary prognostic indicators and potential targets within ACC tumour immune landscape. Differentially expressed immune genes with prognostic significance provide additional insight into the understanding of potential contributory mechanisms underlying failure of initial immunotherapeutic trials and poor prognosis of patients with CS‐ACC.
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Affiliation(s)
| | - David N Hanna
- Division of Surgical Oncology & Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Konjeti R Sekhar
- Division of Surgical Oncology & Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jeffrey C Rathmell
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - W Kimryn Rathmell
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Naira Baregamian
- Division of Surgical Oncology & Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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Kiesewetter B, Riss P, Scheuba C, Mazal P, Kretschmer-Chott E, Haug A, Raderer M. Management of adrenocortical carcinoma: are we making progress? Ther Adv Med Oncol 2021; 13:17588359211038409. [PMID: 34484430 PMCID: PMC8411624 DOI: 10.1177/17588359211038409] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 07/22/2021] [Indexed: 01/05/2023] Open
Abstract
Adrenocortical carcinoma (ACC) is a rare malignancy characterized by aggressive
biology and potential endocrine activity. Surgery can offer cure for localized
disease but more than half of patients relapse and primary unresectable or
metastasized disease is frequent. Prognosis of metastatic ACC is still limited,
with less than 15% of patients alive at 5 years. Recent advances in
understanding the molecular profile of ACC underline the high complexity of this
disease, which is characterized by limited drugable molecular targets as well as
by a complex interplay between a yet scarcely understood microenvironment and
potential endocrine activity. Particularly steroid-excess further complicates
therapeutic concepts such as immunotherapy, which have markedly improved outcome
in other disease entities. To date, mitotane remains the only approved drug for
adjuvant and palliative care in ACC. Standard chemotherapy-based protocols with
cisplatin, doxorubicin and etoposide offer only marginal improvement in
long-term outcome and the number of clinical trials conducted is low due to the
rarity of the disease. In the current review, we summarize principles of
oncological management for ACC from localized to advanced disease and discuss
novel therapeutic strategies, including targeted therapies such as tyrosine
kinase inhibitors and antibodies, immunotherapy with a focus on checkpoint
inhibitors, individualized treatment concepts based on molecular
characterization by next generation sequencing methods, the role of theranostics
and evolvement of adjuvant therapy.
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Affiliation(s)
- Barbara Kiesewetter
- Department of Medicine I, Division of Oncology, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, A-1090, Austria
| | - Philipp Riss
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria
| | - Christian Scheuba
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria
| | - Peter Mazal
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | | | - Alexander Haug
- Department of Radiology and Nuclear Medicine, Medical University of Vienna, Vienna, Austria
| | - Markus Raderer
- Department of Medicine I, Division of Oncology, Medical University of Vienna, Vienna, Austria
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Abstract
PURPOSE OF REVIEW In this article, we focus on the current and future treatment options for adrenocortical carcinoma (ACC). RECENT FINDINGS Radical surgery remains the only curative treatment for ACC. Recent reports showed a longer overall survival (OS) in patients with high risk of recurrence treated with adjuvant mitotane; the time in target range (14-20 mg/l) is related to low risk of relapse both in adjuvant and in palliative setting. In patients who experience disease progression after etoposide, doxorubicin, cisplatin with mitotane (EDP-M), gemcitabine and metronomic capecitabine, or the less used streptozotocin, represent a second-line chemotherapy option. Temozolomide can be employed as a third-line chemotherapy. To date, unsatisfactory results have been obtained on the efficacy of targeted therapies. Clinical trials are ongoing to evaluate the efficacy of tyrosine kinase and immune checkpoint inhibitors. SUMMARY ACC is a rare disease with a poor prognosis. The main therapy is represented by radical surgery conducted by an expert surgeon. Adjuvant mitotane has to be started in patients with high risk of recurrence. In patients with inoperable disease, the scheme EDP-M is the most employed. Few data are available on second-line and third-line chemotherapy in patients with disease progression after EDP-M. Currently, the role of targeted therapies is under evaluation.
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Shi X, Liu Y, Cheng S, Hu H, Zhang J, Wei M, Zhao L, Xin S. Cancer Stemness Associated With Prognosis and the Efficacy of Immunotherapy in Adrenocortical Carcinoma. Front Oncol 2021; 11:651622. [PMID: 34367952 PMCID: PMC8334864 DOI: 10.3389/fonc.2021.651622] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 05/10/2021] [Indexed: 01/22/2023] Open
Abstract
Background Cancer stem cells (CSCs) have been proven to influence drug resistance, recurrence, and metastasis in tumors. Our study aimed to identify stemness-related prognostic biomarkers for new therapeutic strategies in adrenocortical carcinoma. Methods RNA-seq data and clinical characteristics were downloaded from The Cancer Genome Atlas (TCGA). The stemness indexes, mDNAsi and mRNAsi, were calculated to classify all samples into low-score and high-score groups. Two algorithms, based on the R language, ESTIMATE and single-sample Gene Set Enrichment Analysis (ssGSEA) were used to assess the immune cell infiltration states of adrenocortical carcinoma patients. Weighted Gene Co-expression Network Analysis (WGCNA) was used to find genes that were related to the stemness of cancer. By bioinformatics methods, the correlations between biomarkers capable of predicting immune checkpoint inhibitors (ICIs) responses and stemness of cancer were explored. Results High-mRNAsi predicted shorter overall survival (OS) and a higher metastatic trend in adrenocortical carcinoma (ACC) patients. Compared with the low-mRNAsi group, the high-mRNAsi group had a lower ImmuneScore and StromalScroe. Twenty-two stemness-related prognostic genes were obtained by WGCNA, which focused on the function of the cell cycle and cell mitosis. Immune cell infiltration, especially CD8+T cell, increased in the low-mRNAsi group compared with the high-mRNAsi group. Lower expression of PD-L1, CTLA-4, and TIGHT was evaluated in the high-mRNAsi group. Conclusions ACC patients with high-mRNAsi have poor prognosis and less immune cell infiltration. Combined with the finding of lower expression of CTLA-4, TIGHT, and PD-L1 in the high-mRNAsi group, we came to the conclusion that stemness index is a potential biomarker to predict the effectiveness of ICIs.
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Affiliation(s)
- Xiaoxi Shi
- Department of Vascular and Thyroid Surgery, The First Hospital, China Medical University, Shenyang, China
| | - Yuanlin Liu
- Department of Vascular and Thyroid Surgery, The First Hospital, China Medical University, Shenyang, China
| | - Shuai Cheng
- Department of Vascular and Thyroid Surgery, The First Hospital, China Medical University, Shenyang, China
| | - Haidi Hu
- Department of Vascular and Thyroid Surgery, The First Hospital, China Medical University, Shenyang, China
| | - Jian Zhang
- Department of Vascular and Thyroid Surgery, The First Hospital, China Medical University, Shenyang, China
| | - Minjie Wei
- Department of Pharmacology, School of Pharmacy, China Medical University, Shenyang, China
| | - Lin Zhao
- Department of Pharmacology, School of Pharmacy, China Medical University, Shenyang, China
| | - Shijie Xin
- Department of Vascular and Thyroid Surgery, The First Hospital, China Medical University, Shenyang, China
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Abstract
Adrenocortical carcinoma (ACC) is a rare and aggressive malignancy. For stage I and II tumors, surgery is a curative option, but even in these cases recurrence is frequent. Practical guidelines advocate a combination of mitotane with etoposide, doxorubicin, and cisplatin as first-line therapy for metastatic adrenocortical carcinoma. However, this scheme presents limited efficacy and high toxicity. The use of Immune Checkpoint Inhibitors (ICI) and multi-Tyrosine Kinase Inhibitors (mTKI) has modified the approach of multiple malignancies. The expectation of their applicability on advanced adrenocortical carcinoma is high but the role of these new therapies persists unclear. This article provides a short summary of last years' findings targeting outcomes, limitations, and adverse effects of these new therapeutic approaches. The results of recent trials and case series pointed pembrolizumab as the most promising drug among these new therapies. It is the most often used ICI and the one presenting the best results with less related adverse effects when in comparison to the standard treatment with mitotane. Hereafter, the identification of specific molecular biomarkers or immune profiles associated with ICI or mTKI good response will facilitate the selection of candidates for these therapies. So far, microsatellite instability and Lynch Syndrome related germline mutations are suggested as predictive biomarkers of good response. Contrarywise, cortisol secretion has been associated with more aggressive ACC tumors and potentially poor responses to immunotherapy.
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Affiliation(s)
- Alexandra Novais Araújo
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Maria João Bugalho
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
- Faculty of Medicine, Lisbon University, Lisbon, Portugal
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Mizdrak M, Tičinović Kurir T, Božić J. The Role of Biomarkers in Adrenocortical Carcinoma: A Review of Current Evidence and Future Perspectives. Biomedicines 2021; 9:174. [PMID: 33578890 PMCID: PMC7916711 DOI: 10.3390/biomedicines9020174] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/07/2021] [Accepted: 02/08/2021] [Indexed: 12/18/2022] Open
Abstract
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.
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Affiliation(s)
- Maja Mizdrak
- Department of Nephrology and Hemodialysis, University Hospital of Split, 21000 Split, Croatia;
- Department of Pathophysiology, University of Split School of Medicine, 21000 Split, Croatia;
| | - Tina Tičinović Kurir
- Department of Pathophysiology, University of Split School of Medicine, 21000 Split, Croatia;
- Department of Endocrinology, Diabetes and Metabolic Disorders, University Hospital of Split, 21000 Split, Croatia
| | - Joško Božić
- Department of Pathophysiology, University of Split School of Medicine, 21000 Split, Croatia;
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Paragliola RM, Corsello A, Locantore P, Papi G, Pontecorvi A, Corsello SM. Medical Approaches in Adrenocortical Carcinoma. Biomedicines 2020; 8:biomedicines8120551. [PMID: 33260476 PMCID: PMC7760807 DOI: 10.3390/biomedicines8120551] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 11/15/2020] [Accepted: 11/27/2020] [Indexed: 12/15/2022] Open
Abstract
Adrenocortical carcinoma (ACC) represents one of the most aggressive endocrine tumors. In spite of a correct therapeutic strategy based on a multidisciplinary approach between endocrinologist, surgeon and oncologist, the prognosis is often poor. Surgery is the mainstay treatment in ACC. Mitotane, a dichloro-diphenyl-trichloro-ethane derivate, represents the main medical treatment of ACC in consideration of its adrenocytolitic activity and it is mainly employed as adjuvant treatment after complete surgical resection and for the treatment of advanced ACC. However, the use of mitotane as adjuvant therapy is still controversial, also in consideration of the retrospective nature of several studies. The recurrence of disease is frequent, especially in advanced disease at the diagnosis. Therefore, in these contexts, conventional chemotherapy must be considered in association with mitotane, being the combination etoposide, doxorubicin and cisplatin (EDP) the standard of care in this setting. A more modern therapeutic approach, based on the need of a salvage therapy for advanced ACC that progresses through first-line EDP, is focused on molecular-targeted therapies. However, robust clinical trials are necessary to assess the real efficacy of these treatments.
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Grisanti S, Cosentini D, Laganà M, Volta AD, Palumbo C, Massimo Tiberio GA, Sigala S, Berruti A. The long and winding road to effective immunotherapy in patients with adrenocortical carcinoma. Future Oncol 2020; 16:3017-3020. [PMID: 32857613 DOI: 10.2217/fon-2020-0686] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Salvatore Grisanti
- Medical Oncology Unit, Department of Medical & Surgical Specialties, Radiological Sciences & Public Health, University of Brescia, ASST Spedali Civili of Brescia, Brescia, 25123, Italy
| | - Deborah Cosentini
- Medical Oncology Unit, Department of Medical & Surgical Specialties, Radiological Sciences & Public Health, University of Brescia, ASST Spedali Civili of Brescia, Brescia, 25123, Italy
| | - Marta Laganà
- Medical Oncology Unit, Department of Medical & Surgical Specialties, Radiological Sciences & Public Health, University of Brescia, ASST Spedali Civili of Brescia, Brescia, 25123, Italy
| | - Alberto Dalla Volta
- Medical Oncology Unit, Department of Medical & Surgical Specialties, Radiological Sciences & Public Health, University of Brescia, ASST Spedali Civili of Brescia, Brescia, 25123, Italy
| | - Carlotta Palumbo
- Urology Unit, Department of Medical & Surgical Specialties, Radiological Sciences & Public Health, University of Brescia, ASST Spedali Civili of Brescia, Brescia, 25123, Italy
| | - Guido Alberto Massimo Tiberio
- Surgical Unit, Department of Medical & Surgical Specialties, Radiological Sciences & Public Health, University of Brescia, ASST Spedali Civili of Brescia, Brescia, 25123, Italy
| | - Sandra Sigala
- Department of Molecular & Translational Medicine, Section of Pharmacology, University of Brescia, Brescia, 25123, Italy
| | - Alfredo Berruti
- Medical Oncology Unit, Department of Medical & Surgical Specialties, Radiological Sciences & Public Health, University of Brescia, ASST Spedali Civili of Brescia, Brescia, 25123, Italy
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