AMR Seminar Symposium Split, Croatia Case #63 Vania Nosé, MD, PhD Professor of Pathology Associate Chief and Director, Anatomic and Molecular Pathology

Clinical History 68-year-old male, former smoker He has been undergoing a CT chest which incidentally noted a large left adrenal lesion He subsequently underwent an abdominal CAT scan which confirmed a 7.6 cm enhancing left adrenal mass with adenopathy

Pathological Findings Left adrenal gland: 264 g, 9.0 x 8.0 x 6.0 cm Sectioned to reveal a tan- yellow, firm lobulated mass that appears to abut the inked black margin The mass appears to be expanding and arising from the cortex, possibly extending into the extraadrenal soft tissue

Microscopic Findings H&E shows an ACC composed of large eosinophilic cytoplasm with pleomorphic nuclei and with prominent nucleoli This area of the tumor shows dyscohesive cells with edematous stroma with degenerative changes

Ki-67 Proliferative index is >60%

Immunohistochemistry Positive for Synaptophysin, Melan-A, Inhibin, SF1 stains

Final Diagnosis: Left adrenal gland, 264 grams, 9 cm: Adrenal cortical carcinoma, oncocytic type Stage 3  

Epidemiology Incidence: 1 in every 4,000 adrenal tumors 0.5-2.0 cases per million per year Comprises ~ 3% of endocrine neoplasms Age: Bimodal distribution 60-70 years Peak in 5th decade Early childhood 0.21 per million per year 0.3-0.4% of all neoplasms in this age

Etiology/Pathogenesis Adrenal cortical neoplasms are thought to arise through acquired genetic mutations in driver genes Li-Fraumeni syndrome Beckwith-Wiedemann syndrome Lynch syndrome Multiple endocrine neoplasia 1 Familial adenomatous polyposis Carney complex Neurofibromatosis type 1

Hereditary syndromes associated with adrenal cortical carcinoma

Gross photo shows the external surface of an oncocytic neoplasm with the brown/mahogany tumor showing from behind the translucent capsule (white open arrow). Adjacent to the tumor, there is normal adrenal (white solid arrow). The tumor is well circumscribed within the gland.

These oncocytic neoplasms may sometimes have lymphoid infiltrates, another characteristic of this type of tumor. The tumor is composed of large eosinophilic, polygonal cells, in sheets, with a focal lymphoid infiltrate (cyan open arrow).

H&E shows one of the cytologic characteristics of oncocytic neoplasms, which is the classic eosinophilic nuclear pseudoinclusion (white curved arrow) typically seen in this tumor.

Synaptophysin immunostaining shows both membranous and granular cytoplasmic positivity, a pattern seen in other adrenal neoplasms.

The picture illustrates a strong synaptophysin immunoreactivity in the adrenal carcinoma in a patient with Li-Fraumeni syndrome. This stain is usually patchy. The tumors in these patients also stain positive for p53.

Discussion: The pathological diagnosis of adrenocortical carcinoma is challenging for its scarcity and the presence of special variants, as pediatric, oncocytic, myxoid, and sarcomatoid variants The diagnosis of ACC is based on the recognition at light microscopy of at least three among nine morphological parameters, per the Weiss scoring system

Weiss criteria for malignancy in adrenal cortical tumors: Presence of ≥ 3 of these criteria correlates with malignant behavior High-nuclear grade (Fuhrman grade IV) Mitotic rate > 5 mitotic figures/50 HPF Atypical mitotic figures < 25% of tumor cells with clear/vacuolated cytoplasm Diffuse architecture (> 1/3 of tumor) Confluent tumor necrosis Venous invasion (of smooth muscle walled vessels) Sinusoidal invasion (no smooth muscle in vessel wall) Capsular invasion Weiss criteria for malignancy in adrenal cortical tumors:

Oncocytoma x Oncocytic Adrenal Cortical Carcinoma Tumor is composed of polygonal cells with abundant, granular, intensely eosinophilic cytoplasm Most have diffuse, sheet-like pattern Prominent nuclear pleomorphism Eosinophilic nuclear pseudoinclusions Weiss system cannot be directly applied to oncocytic adrenal cortical neoplasms Due to constant presence of diffuse growth pattern, eosinophilic cytoplasm, and high-grade nuclear features To diagnose tumor as adrenocortical oncocytoma, it must be considered benign according to Lin-Weiss-Bisceglia criteria Malignant: Presence of any major criteria Borderline malignant potential: Presence of any minor criteria Benign: Absence of all criteria Lymphoid infiltrates can be seen Oncocytoma x Oncocytic Adrenal Cortical Carcinoma

Low grade: ≤ 20 mitosis/50 HPF High grade: > 20 mitosis/50 HPF Microscopic Adrenal cortical carcinomas (ACCs) are subdivided on basis of mitotic frequency in Low grade: ≤ 20 mitosis/50 HPF High grade: > 20 mitosis/50 HPF Adrenal cortical carcinomas can be subdivided on the basis of mitotic frequency into low grade (≤ 20 mitoses per 50 HPF) and high grade (> 20 mitoses per 50 HPF).

Integrated Genomic Characterization (WHO 2017) (1) the highly prevalent role of IGF2 overexpression (2) the frequency of TP53 mutations, their dominance in the pediatric cohort, and their association with aggressive disease (3) the frequency and diversity of WNT pathway defects (CTNNB1 point mutations and ZNRF3 deletions), which are found in as many as 50% of cases (4) the important role of copy-number alterations and whole-ge-nome doubling as a mechanism for disease progression (5) the important role of telomeres and telomerase reactivation and (6) the relative lack of targetable hot-spot mutations (WHO 2017)

Prognosis Aggressive disease with dismal prognosis Overall 5-year survival: 37-47% Key prognostic factors: Clinically relevant hypercortisolism Resection margin status Tumor stage correlates with survival Tumor grade Age > 50 years Mitotic rate: Low grade ( ≤20/50 HPF) and high grade (> 20/50 HPF) KI67 proliferative index: Significant prognostic and predictive power High expression of SF1 correlates with poorer outcome

European Network for Study of Adrenal Tumors (ENSAT) Accepted by WHO 2017 Stage I: Confined to gland, ≤ 5 cm 1 Stage II: Confined to gland, > 5 cm 2 Stage III: Extends beyond gland, into surrounding tissues but not into adjacent organs; positive regional lymph nodes or involvement of regional veins 3 Stage IV: Distant metastases or adjacent organ involvement 4

Coronal graphic demonstrates T1 disease Coronal graphic demonstrates T1 disease. The primary tumor (black solid arrow) is ≤ 5 cm in its greatest dimension, limited to the adrenal gland without invasion of adjacent organs, including the kidney (white curved arrow) or the inferior vena cava (white solid arrow).

Coronal graphic demonstrates T4 disease Coronal graphic demonstrates T4 disease. The primary tumor can be any size with local invasion beyond the confines of the adrenal capsule and into adjacent organs, including the kidney (black solid arrow). Direct extension into the inferior vena cava is illustrated (white solid arrow).

AMR Seminar Symposium Split, Croatia Case #63 Vania Nosé, MD, PhD Professor of Pathology Associate Chief and Director, Anatomic and Molecular Pathology

Questions? Vania Nosé, MD, PhD Thank you! Questions? Vania Nosé, MD, PhD