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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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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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The Characteristics of Tumor Microenvironment Predict Survival and Response to Immunotherapy in Adrenocortical Carcinomas. Cells 2023; 12:cells12050755. [PMID: 36899891 PMCID: PMC10000893 DOI: 10.3390/cells12050755] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 02/23/2023] [Accepted: 02/24/2023] [Indexed: 03/02/2023] Open
Abstract
Increasing evidence confirms that tumor microenvironment (TME) can influence tumor progression and treatment, but TME is still understudied in adrenocortical carcinoma (ACC). In this study, we first scored TME using the xCell algorithm, then defined genes associated with TME, and then used consensus unsupervised clustering analysis to construct TME-related subtypes. Meanwhile, weighted gene co-expression network analysis was used to identify modules correlated with TME-related subtypes. Ultimately, the LASSO-Cox approach was used to establish a TME-related signature. The results showed that TME-related scores in ACC may not correlate with clinical features but do promote a better overall survival. Patients were classified into two TME-related subtypes. Subtype 2 had more immune signaling features, higher expression of immune checkpoints and MHC molecules, no CTNNB1 mutations, higher infiltration of macrophages and endothelial cells, lower tumor immune dysfunction and exclusion scores, and higher immunophenoscore, suggesting that subtype 2 may be more sensitive to immunotherapy. 231 modular genes highly relevant to TME-related subtypes were identified, and a 7-gene TME-related signature that independently predicted patient prognosis was established. Our study revealed an integrated role of TME in ACC and helped to identify those patients who really responded to immunotherapy, while providing new strategies on risk management and prognosis prediction.
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Identifying Immune-Specific Subtypes of Adrenocortical Carcinoma Based on Immunogenomic Profiling. Biomolecules 2023; 13:biom13010104. [PMID: 36671489 PMCID: PMC9855412 DOI: 10.3390/biom13010104] [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] [Received: 10/06/2022] [Revised: 12/14/2022] [Accepted: 12/23/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND The tumor immune microenvironment (TIME) of adrenocortical carcinoma (ACC) is heterogeneous. However, a classification of ACC based on the TIME remains unexplored. METHODS We hierarchically clustered ACC based on the enrichment levels of twenty-three immune signatures to identify its immune-specific subtypes. Furthermore, we comprehensively compared the clinical and molecular profiles between the subtypes. RESULTS We identified two immune-specific subtypes of ACC: Immunity-H and Immunity-L, which had high and low immune signature scores, respectively. We demonstrated that this subtyping method was stable and reproducible by analyzing five different ACC cohorts. Compared with Immunity-H, Immunity-L had lower levels of immune cell infiltration, worse overall and disease-free survival prognosis, and higher tumor stemness, genomic instability, proliferation potential, and intratumor heterogeneity. Furthermore, the ACC driver gene CTNNB1 was more frequently mutated in Immunity-L than in Immunity-H. Several proteins, such as mTOR, ERCC1, Akt, ACC1, Cyclin_E1, β-catenin, FASN, and GAPDH, were more highly expressed in Immunity-L than in Immunity-H. In contrast, p53, Syk, Lck, PREX1, and MAPK were more highly expressed in Immunity-H. Pathway and gene ontology analysis showed that the immune, stromal, and apoptosis pathways were highly enriched in Immunity-H, while the cell cycle, steroid biosynthesis, and DNA damage repair pathways were highly enriched in Immunity-L. CONCLUSIONS ACC can be classified into two stable immune-related subtypes, which have significantly different antitumor responses, molecular characteristics, and clinical outcomes. This subtyping may provide clinical implications for prognostic and immunotherapeutic stratification of ACC.
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Muzzi JCD, Magno JM, Souza JS, Alvarenga LM, de Moura JF, Figueiredo BC, Castro MAA. Comprehensive Characterization of the Regulatory Landscape of Adrenocortical Carcinoma: Novel Transcription Factors and Targets Associated with Prognosis. Cancers (Basel) 2022; 14:5279. [PMID: 36358698 PMCID: PMC9657296 DOI: 10.3390/cancers14215279] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 10/24/2022] [Accepted: 10/25/2022] [Indexed: 08/31/2023] Open
Abstract
We reconstructed a transcriptional regulatory network for adrenocortical carcinoma (ACC) using transcriptomic and clinical data from The Cancer Genome Atlas (TCGA)-ACC cohort. We investigated the association of transcriptional regulatory units (regulons) with overall survival, molecular phenotypes, and immune signatures. We annotated the ACC regulons with cancer hallmarks and assessed single sample regulon activities in the European Network for the Study of Adrenal Tumors (ENSAT) cohort. We found 369 regulons associated with overall survival and subdivided them into four clusters: RC1 and RC2, associated with good prognosis, and RC3 and RC4, associated with worse outcomes. The RC1 and RC3 regulons were highly correlated with the 'Steroid Phenotype,' while the RC2 and RC4 regulons were highly correlated with a molecular proliferation signature. We selected two regulons, NR5A1 (steroidogenic factor 1, SF-1) and CENPA (Centromeric Protein A), that were consistently associated with overall survival for further downstream analyses. The CENPA regulon was the primary regulator of MKI-67 (a marker of proliferation KI-67), while the NR5A1 regulon is a well-described transcription factor (TF) in ACC tumorigenesis. We also found that the ZBTB4 (Zinc finger and BTB domain-containing protein 4) regulon, which is negatively associated with CENPA in our transcriptional regulatory network, is also a druggable anti-tumorigenic TF. We anticipate that the ACC regulons may be used as a reference for further investigations concerning the complex molecular interactions in ACC tumors.
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Affiliation(s)
- João C. D. Muzzi
- Laboratório de Imunoquímica (LIMQ), Pós-Graduação em Microbiologia, Parasitologia e Patologia, Departamento de Patologia Básica, Universidade Federal do Paraná (UFPR), Curitiba 81530-990, Brazil
- Laboratório de Bioinformática e Biologia de Sistemas, Pós-Graduação em Bioinformática, Universidade Federal do Paraná (UFPR), Curitiba 81520-260, Brazil
- Oncology Division, Instituto de Pesquisa Pelé Pequeno Príncipe, Curitiba 80250-060, Brazil
| | - Jéssica M. Magno
- Laboratório de Bioinformática e Biologia de Sistemas, Pós-Graduação em Bioinformática, Universidade Federal do Paraná (UFPR), Curitiba 81520-260, Brazil
- Oncology Division, Instituto de Pesquisa Pelé Pequeno Príncipe, Curitiba 80250-060, Brazil
| | - Jean S. Souza
- Oncology Division, Instituto de Pesquisa Pelé Pequeno Príncipe, Curitiba 80250-060, Brazil
| | - Larissa M. Alvarenga
- Laboratório de Imunoquímica (LIMQ), Pós-Graduação em Microbiologia, Parasitologia e Patologia, Departamento de Patologia Básica, Universidade Federal do Paraná (UFPR), Curitiba 81530-990, Brazil
| | - Juliana F. de Moura
- Laboratório de Imunoquímica (LIMQ), Pós-Graduação em Microbiologia, Parasitologia e Patologia, Departamento de Patologia Básica, Universidade Federal do Paraná (UFPR), Curitiba 81530-990, Brazil
| | - Bonald C. Figueiredo
- Oncology Division, Instituto de Pesquisa Pelé Pequeno Príncipe, Curitiba 80250-060, Brazil
- Molecular Oncology Laboratory, Centro de Genética Molecular e Pesquisa do Câncer em Crianças (CEGEMPAC), Curitiba 80030-110, Brazil
| | - Mauro A. A. Castro
- Laboratório de Bioinformática e Biologia de Sistemas, Pós-Graduação em Bioinformática, Universidade Federal do Paraná (UFPR), Curitiba 81520-260, Brazil
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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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