Flow cytometry in feminizing adrenocortical carcinoma

Feminizing adrenocortical tumors: Literature review

Feminizing adrenal tumors (FAT) are extremely rare tumors prevailing in males. Clinical manifestations are gynecomastia and/or other hypogonadism features in adults. They are rarer in pediatric population and their main manifestation is peripheral sexual precocity. In women genital bleeding, uterus hypertrophy, high blood pressure and/or abdomen mass may be the only manifestations. On the biological point, estrogen overproduction with or without increase in other adrenal hormones are the main abnormalities. Radiological examination usually shows the tumor, describes its limits and its eventual metastases. Adrenal and endocrine origins are confirmed by biochemical assessments and histology, but that one is unable to distinguish between benign and malignant tumors, except if metastases are already present. Immunostaining using anti-aromatase antibodies is the only tool that distinguishes FAT from other adrenocortical tumors. Abdominal surgery is the best and the first line treatment. For large tumors (≥10 cm), an open access is preferred to coeliosurgery, but for the small ones, or when the surgeon is experienced, endoscopic surgery seems to give excellent results. Surgery can be preceded by adrenolytic agents such as ortho paraprime dichloro diphenyl dichloroethane (Mitotane), ketoconazole or by aromatase inhibitors, but till now there is not any controlled study to compare the benefit of different drugs. New anti-estrogens can be used too, but their results need to be confirmed in malignant tumors resistant to classical chemotherapy and to conventional radiotherapy. Targeted therapy can be used too, as in other adrenocortical tumors, but the results need to be confirmed.

Feminizing adreno-cortical carcinomas in male adults. A dire prognosis. Three cases in a series of 801 adrenalectomies and review of the literature

We describe the clinical presentation, biochemical features, diagnostic criteria, clinical course and differential diagnosis in three cases of feminizing adreno-cortical carcinoma (FACC) with a review of the literature.

PATIENTS

From 1970 throughout December 2003 among a series of 801 adrenalectomies, three had been performed for FACC.

RESULTS

Age at presentation was 74, 63 and 23 years. Estradiol hypersecretion was observed in 3/3 patients, 17 OH progesterone was elevated in 2/3 patients and both of them had a diminution of testosterone, delta 4 androstenedione was elevated in 1/3 patients. Imaging studies suggested malignancy in 3/3 patients by the presence of necrosis, heterogeneity, calcifications, size of the tumor and compression of adjacent organs. All patients were stage III at presentation and had a Weiss score >or=6. Size and weight of the tumors were 30, 20, 15cm and 3750, 480 and 275g respectively. All 3 patients received mitotane and cortisone post-operatively and at follow up (7, 3 and 2 years) all 3 died of the disease.

CONCLUSIONS

Feminizing adreno-cortical carcinomas in adults are exceedingly rare (1-2% of adreno-cortical carcinomas). Tumors are huge and even after surgery for cure their prognosis is worse than for other varieties of adreno-cortical carcinomas either secreting or non secreting. Early diagnosis and treatment may improve overall prognosis.

Dexamethasone-suppressible feminizing adrenal adenoma

A 39 year old man presented with gynaecomastia, loss of libido and high blood pressure. Hormone studies revealed elevated plasma levels of oestradiol and its precursors, which increased in response to adrenocorticotrophic hormone and were reduced to normal levels with dexamethasone. Computed tomography disclosed a left adrenal mass and surgery was performed. The removed tumour weighed 84 g and the histological diagnosis was of adenoma. Nine years after surgery, he is asymptomatic, without hypertension, and radiological and or hormonal evidence of recurrence. We discuss the hormone profile in this case and the dynamics of steroid production by the tumour which, in contrast to the classical concept of tumour autonomy, showed dependence of oestradiol secretion on endogenous adrenocorticotrophic hormone.

Adrenocortical neoplasms in childhood and adolescence: Analysis of prognostic factors including DNA content

Thirty-two adrenocortical neoplasms in children and adolescents were evaluated for prognostic factors including clinical and morphological parameters and DNA ploidy. The patients were segregated into two groups according to clinical outcome: group A, represented by patients with clinically benign neoplasms (n = 15), and group B, patients with clinically malignant tumors as evidenced by local recurrence, metastases, or fatal outcome (n = 17). Clinical and morphological parameters in these two groups were evaluated using appropriate statistical methods. Parameters with a significant predictive value in terms of prognosis were age [p = .04], tumor size (p = .0003), median tumor weight (p = .0001), mitotic count (p = 0.04), and 25% tumor necrosis or more (p = .03). Twenty-three cases were studied for DNA ploidy: 10 cases by image analysis and 13 by both image analysis and flow cytometry. By ploidy analysis, 17 of 23 cases-12 of 14 in group A and 5 of 9 in group B-were found to be aneuploid. Multiple aneuploid peaks were found in 5 of 23 cases-4 of 14 cases in group A and 1 of 9 cases in group B. In tumors studied by both image analysis and flow cytometry, there was no discrepancy between results of ploidy analysis. There was no statistically significant association demonstrated between clinical outcome and DNA ploidy pattern. DNA ploidy heterogeneity, characterized by multiple aneuploid populations of cells, was also detected in both benign and malignant neoplasms. Based on our results, aneuploidy is relatively frequent in pediatrie adrenocortical tumors and does not appear to have predictive value for biological behavior.

The study of endocrine tumors by flow and image cytometry

Both DNA flow and image cytometry are methods that can be used for the quantitative determination of cellular DNA content. Objective, quantitative analysis of cellular morphology can also be obtained using image cytometry. Data thus generated have been shown to be of diagnostic and prognostic use in the study of many solid tumors and would be of particular value in the evaluation of endocrine tumors that show a poor correlation between their histology and biological behavior. The main application of these techniques to endocrine tumors has been in the analysis of thyroid nodules, although a limited number of studies of parathyroid, pituitary, adrenal, and pancreatic neuroendocrine tumors and tumors of the dispersed neuroendocrine system have been reported. Review of these studies shows that in the endocrine organs DNA and morphometric measurements have a very limited role in the diagnosis of individual cases, but are important as prognostic variables. The high incidence of abnormal DNA content in histologically benign lesions of the endocrine glands has important biological implications. Further investigation of this phenomenon may help to elucidate the process of endocrine tumorigenesis.

Adrenal cortical carcinoma: flow cytometric study of 22 cases, an ECOG study

Flow cytometric studies of archival material from 22 adrenal carcinomas demonstrated aneuploidy in 21 of 22 cases. Heterogeneity of nuclear DNA was found in 14 of the 22 cases. Eight of these showed distinct aneuploid and diploid populations, and 6 showed multiple aneuploid cell lines. The heterogeneity was detected because numerous paraffin-embedded samples of each tumor could be examined. No correlation was found between either aneuploidy or heterogeneous DNA content and patient survival, response to therapy, or hormone secretion.

Spontaneously regressing adrenocortical carcinoma in a newborn. A case report with DNA ploidy analysis

Adrenal cortical carcinoma is an uncommon neoplasm in children. Only a handful of congenital adrenal cortical carcinoma cases have been described. A newborn who had metastatic adrenal cortical carcinoma (skin metastases and cerebral lesions) is described. This patient underwent surgical resection of the right adrenal primary, but no further treatment was given. Hemihypertrophy developed in this patient by 2 months of age, and at 4 months of age spontaneous regression of all skin nodules and central nervous system (CNS) lesions was observed. Follow-up at 1 year shows the patient to be alive, well, and disease-free. Evaluation of the tumor included DNA ploidy analysis that showed the tumor to be polyploid, a pattern recently associated with nonmetastasizing adrenal cortical neoplasm. The observation of apparent metastatic disease that regressed spontaneously highlights the prognostic value of DNA ploidy analysis and raises the possibility of an adrenal tumor with properties similar to those of Stage IV-S neuroblastoma.

Flow cytometric determination of nuclear DNA content in benign adrenal pheochromocytomas

Nuclear DNA content of paraffin-embedded tissue from 19 clinically benign adrenal pheochromocytomas and 18 control adrenal glands was analyzed using flow cytometry. All control adrenal glands and 6 pheochromocytomas were diploid. Four tumors were tetraploid. Nine were aneuploid with relative DNA indices in the near diploid range in 2, in the peritriploid range in 5, and in the near tetraploid range in 2. These results indicate that aneuploid DNA content is a frequent occurrence in benign adrenal pheochromocytomas. Aneuploidy per se is not a specific marker of malignancy in these tumors as has been suggested by previous reports.

Flow cytometric DNA analysis of adrenocortical tumors in children

Flow cytometric DNA analysis of isolated nuclei was performed on 14 lesions occurring in ten children with adrenocortical tumors. Unimodal DNA content distributions were obtained from seven tumors occurring in patients without metastases 2 to 18 years after diagnosis. Abnormal DNA contents were detected in all four primary lesions, which subsequently metastasized, and in the tumor of one patient who was followed for less than 2 years. Paraffin and frozen preparations were virtually identical, as were the analyses of the primary, recurrent, and metastatic disease occurring in one patient. These observations suggest that DNA content abnormalities detected by flow cytometry correlate with metastases, and may provide an objective measure of the biologic potential of these tumors.

Flow cytometric analysis of nuclear DNA from adrenocortical neoplasms. A retrospective study using paraffin-embedded tissue

Nuclear DNA content of paraffin-embedded tissue from 48 adrenocortical neoplasms, 18 histologically normal control adrenal glands, and five hyperplastic adrenal glands was analyzed retrospectively using flow cytometry. Aneuploidy was compared with morphologic criteria as a predictor of recurrence. All 18 controls, five hyperplastic glands, and 39 neoplasms were diploid. Nine neoplasms were aneuploid. Compared with their diploid counterparts, aneuploid neoplasms were more likely to weigh more than 50 g (P less than 0.0001) and to have three or more histologic features of carcinoma (P less than 0.0001). Thirty-six neoplasms were followed clinically for at least 2 years (range 24 to 120 months, mean = 64.6 months) or until local recurrence, metastasis, or death. Five were clinically malignant. Neoplasms which recurred or metastasized were more apt to be aneuploid (P less than 0.005) than those showing no evidence of further disease during the follow-up period. They were also more likely to weigh more than 50 g (P less than 0.005) and to have three or more histologic features of carcinoma (P less than 0.0025). However, neither aneuploidy, large size, nor unfavorable histology result was a consistent feature in every malignant neoplasm. Flow cytometric DNA content analysis appears to be as effective a predictor of clinical outcome as size and histology and may be of particular value when the morphologic features are ambiguous.