**Adrenal Incidentaloma and Adrenocortical Carcinoma: A Clinical Guideline on Treating the Unexpected and a Plea for Specialized Care**

S.H.A. Brouns, T.M.A. Kerkhofs, I.G.C. Hermsen and H.R. Haak *Máxima Medical Center, Eindhoven The Netherlands* 

## **1. Introduction**

An adrenal incidentaloma is an important clinical finding that is often considered harmless, but can be the tip of the iceberg. The term incidentaloma indicates an adrenal mass larger than 1 cm, incidentally discovered during imaging studies performed for reasons other than suspicion of adrenal pathology. Lesions identified during staging procedure or work-up for patients with a known extra-adrenal malignancy are not considered to be an incidentaloma (Young, Jr. 2000; Grumbach et al. 2003; Young, Jr. 2007; Singh & Buch 2008; Terzolo et al. 2009; Androulakis et al. 2011).

The entity incidentaloma is not a new finding and has been reported for many years (Grumbach et al. 2003; Young, Jr. 2007; Singh & Buch 2008; Terzolo et al. 2009; Androulakis et al. 2011). Because of the increased use of imaging techniques and improvement in abdominal imaging, the frequency of incidentaloma findings is increasing as well. Recent studies using high-resolution computed tomography (CT) have reported an estimated prevalence of 4% (Young, Jr. 2007; Singh & Buch 2008). In autopsy studies the prevalence ranged 0.2%-8.7%, depending on definitions used and age group, as there is an agedependent occurrence of adrenal incidentalomas (Young, Jr. 2000; Grumbach et al. 2003; Young, Jr. 2007; Singh & Buch 2008; Terzolo et al. 2009; Androulakis et al. 2011). The estimated prevalence in patients younger than 30 years is < 1%, in contrast to a 7% frequency in patients 70 years of age or older (Young, Jr. 2007). With an aging population and advanced radiological techniques becoming more widely available, the increasing frequency of adrenal incidentalomas is of growing importance.

When an incidentaloma is found, it is of vital importance to make an early and reliable differentiation between benign and (potentially) malignant lesions, but also to assess tumor functionality. The mass can originate from either the adrenal medulla or cortex (Androulakis et al. 2011). Consequently, a spectrum of different pathological conditions may underlie an incidentaloma, all requiring a different therapeutic approach. As much as 38 different diagnoses have been reported in patients with a serendipitous discovered adrenal tumor (Young, Jr. 2000). Most adrenal incidentalomas are clinically nonhypersecretory benign adenomas, with an estimated frequency of 70-80%, which cause no health problems. However, in 5-20% of patients who have no endocrinological signs or symptoms, analysis reveals subclinical hypercortisolism (Grumbach et al. 2003; Young, Jr. 2007; Singh & Buch

Adrenal Incidentaloma and Adrenocortical Carcinoma:

al. 2011).

Adenoma

**2.1.2 Physical examination** 

**Causes Estimated** 

Syndrome 9 %

Nonfunctioning 73.9 % -

incidentaloma (Young, Jr. 2007, Singh and Buch 2008)

Subclinical Cushing's

Androgen

Adrenocortical

**2.2 Hormonal evaluation** 

Androulakis et al. 2011).

Malignancy

A Clinical Guideline on Treating the Unexpected and a Plea for Specialized Care 293

frequently present (Young, Jr. 2007; Singh & Buch 2008; Terzolo et al. 2009; Androulakis et

Clinical features of Cushing's syndrome detected during physical examination are hypertension, central obesity, striae, facial rounding ('moon face'), supraclavicular and dorsocervical fat pads ('buffalo hump'), proximal muscle weakness, clitoris hypertrophy, acne and hirsutism. Primary aldosteronism is characterized by hypertension. In rare cases, female patients can present with signs of virilization (e.g. acne, hirsutism) as a result of testosterone excess. In contrast, an estrogen secreting adrenal lesion can produce signs of feminization, such as gynaecomasty in the male patient. A pheochromocytoma may present with hypertension (paroxysmal or sustained), orthostatic hypotension, pallor and sweating on physical examination. Adrenocortical carcinoma may as well present signs of hormonal overproduction mentioned above. In addition, a palpable mass may be present at abdominal examination (Young, Jr. 2007; Singh & Buch 2008; Terzolo et al. 2009; Androulakis et al. 2011).

**prevalence Clinical presentation** 

changes Primary aldosteronism 1.2 % Nocturia, muscle cramps, polyuria, palpitations

overproduction Rare Hirsutism, acne, oligomenorrhoe

Pheochromocytoma 4.7 % Episodic headaches, tachycardia, generalized

carcinoma 4.8 % Symptoms of functioning mass (see above),

Table 1. Prevalence and clinical presentation of the most frequent types of adrenal

Metastasis 2.3 % Cancer-related symptoms (fever, unintentional weight loss)

Additional hormonal work-up is necessary in the evaluation of tumor functionality. Although an adrenal mass may appear clinically nonhypersecretory, up to 20% of patients with an incidentaloma may have hormonal dysfunction, which might be associated with a higher risk of morbidity, such as metabolic disorders and cardiovascular disease (Singh & Buch 2008;

Weight gain with central obesity, flushes,

sweating, pallor, dyspnea, anxiety

abdominal pain or fullness

proximal muscle weakness, polydipsia, cognitive

2008; Terzolo et al. 2009). Other frequently reported diagnoses besides a nonfunctioning adenoma include adrenocortical carcinoma (ACC), pheochromocytoma, metastasis and aldosterone-producing adenoma. Although malignancy is rare, it is of great clinical concern because of the poor prognosis (Grumbach et al. 2003; Terzolo et al. 2009).

After recognition of an incidentaloma both patient and physician are faced with uncertainties regarding the course, likelihood of a malignancy and treatment of the adrenal mass. Unfortunately, no diagnostic or therapeutic strategy has been validated in prospective clinical trials. Thus, the diagnostic work-up as well as management of an incidentaloma is a growing public health challenge (Young, Jr. 2007; Singh & Buch 2008; Terzolo et al. 2009).

The goal of this chapter is to provide a diagnostic guideline, which contains information about clinical presentation, biochemical work-up and radiological imaging. In addition, this chapter offers practical recommendations for the management of adrenal incidentaloma, including surgery and follow-up. Also, therapeutic options for adrenal carcinoma are discussed. Furthermore, we present organisational recommendations concerning the management of adrenal incidentaloma and emphasize the need for centralization of adrenal disease-research and patient care. This will provide patients with an opportunity to receive optimal care, as the beneficial effects of specialization have been proven multiple times in other rare diseases.

## **2. Diagnostics of incidentaloma**

The first step in the evaluation of adrenal incidentalomas is establishing the definition of the tumor type, beginning with a thorough history taking and extensive physical examination, with attention to signs or symptoms of hormonal overproduction, a malignancy or pheochromocytoma. Furthermore, hormonal work-up and radiological imaging is required in the diagnostic evaluation of the adrenal mass.

## **2.1 History and physical examination**

## **2.1.1 History**

Signs suggestive of hormonal overproduction may include Cushing's characteristics, symptoms of hyperaldosteronism or sex hormone excess. Cushing's syndrome may be asymptomatic in the event of subclinical disease or present with weight gain and central obesity, flushes, proximal muscle weakness, and polydipsia. Furthermore, cognitive changes, such as irritability, depression or restlessness, may also be present. Hirsutism, acne, gynaecomastia and oligomenorrhoe may be symptoms of hypercortisolism or sex hormone overproduction. Features of primary hyperaldosteronism are nocturia, muscle cramps and polyuria in case of hypokalaemia and palpitations (Young, Jr. 2007; Singh & Buch 2008; Androulakis et al. 2011).

The classic triad of symptoms associated with a pheochromocytoma includes episodic headaches of variable duration, tachycardia and generalized sweating. However, this combination of symptoms is present in only a small percentage of patients (10%) (Nieman 2010). Characteristics less commonly present are pallor, dyspnea and anxiety and secondary, complaints of hyperglycemia, unintentional weight loss, arrhythmias and cardiomyopathy (Young, Jr. 2007; Androulakis et al. 2011).

An adrenocortical carcinoma may either present with signs of adrenal hypersecretion as mentioned above or symptoms related to mass effect, such as abdominal fullness or abdominal pain. Cancer-related signs (e.g. fever, unintentional weight loss) are less frequently present (Young, Jr. 2007; Singh & Buch 2008; Terzolo et al. 2009; Androulakis et al. 2011).

## **2.1.2 Physical examination**

292 Contemporary Aspects of Endocrinology

2008; Terzolo et al. 2009). Other frequently reported diagnoses besides a nonfunctioning adenoma include adrenocortical carcinoma (ACC), pheochromocytoma, metastasis and aldosterone-producing adenoma. Although malignancy is rare, it is of great clinical concern

After recognition of an incidentaloma both patient and physician are faced with uncertainties regarding the course, likelihood of a malignancy and treatment of the adrenal mass. Unfortunately, no diagnostic or therapeutic strategy has been validated in prospective clinical trials. Thus, the diagnostic work-up as well as management of an incidentaloma is a growing public health challenge (Young, Jr. 2007; Singh & Buch 2008;

The goal of this chapter is to provide a diagnostic guideline, which contains information about clinical presentation, biochemical work-up and radiological imaging. In addition, this chapter offers practical recommendations for the management of adrenal incidentaloma, including surgery and follow-up. Also, therapeutic options for adrenal carcinoma are discussed. Furthermore, we present organisational recommendations concerning the management of adrenal incidentaloma and emphasize the need for centralization of adrenal disease-research and patient care. This will provide patients with an opportunity to receive optimal care, as the beneficial effects of specialization have been proven multiple times in other rare diseases.

The first step in the evaluation of adrenal incidentalomas is establishing the definition of the tumor type, beginning with a thorough history taking and extensive physical examination, with attention to signs or symptoms of hormonal overproduction, a malignancy or pheochromocytoma. Furthermore, hormonal work-up and radiological imaging is required

Signs suggestive of hormonal overproduction may include Cushing's characteristics, symptoms of hyperaldosteronism or sex hormone excess. Cushing's syndrome may be asymptomatic in the event of subclinical disease or present with weight gain and central obesity, flushes, proximal muscle weakness, and polydipsia. Furthermore, cognitive changes, such as irritability, depression or restlessness, may also be present. Hirsutism, acne, gynaecomastia and oligomenorrhoe may be symptoms of hypercortisolism or sex hormone overproduction. Features of primary hyperaldosteronism are nocturia, muscle cramps and polyuria in case of hypokalaemia and palpitations (Young, Jr. 2007; Singh &

The classic triad of symptoms associated with a pheochromocytoma includes episodic headaches of variable duration, tachycardia and generalized sweating. However, this combination of symptoms is present in only a small percentage of patients (10%) (Nieman 2010). Characteristics less commonly present are pallor, dyspnea and anxiety and secondary, complaints of hyperglycemia, unintentional weight loss, arrhythmias and cardiomyopathy

An adrenocortical carcinoma may either present with signs of adrenal hypersecretion as mentioned above or symptoms related to mass effect, such as abdominal fullness or abdominal pain. Cancer-related signs (e.g. fever, unintentional weight loss) are less

because of the poor prognosis (Grumbach et al. 2003; Terzolo et al. 2009).

Terzolo et al. 2009).

**2. Diagnostics of incidentaloma** 

**2.1 History and physical examination** 

Buch 2008; Androulakis et al. 2011).

(Young, Jr. 2007; Androulakis et al. 2011).

**2.1.1 History** 

in the diagnostic evaluation of the adrenal mass.

Clinical features of Cushing's syndrome detected during physical examination are hypertension, central obesity, striae, facial rounding ('moon face'), supraclavicular and dorsocervical fat pads ('buffalo hump'), proximal muscle weakness, clitoris hypertrophy, acne and hirsutism. Primary aldosteronism is characterized by hypertension. In rare cases, female patients can present with signs of virilization (e.g. acne, hirsutism) as a result of testosterone excess. In contrast, an estrogen secreting adrenal lesion can produce signs of feminization, such as gynaecomasty in the male patient. A pheochromocytoma may present with hypertension (paroxysmal or sustained), orthostatic hypotension, pallor and sweating on physical examination. Adrenocortical carcinoma may as well present signs of hormonal overproduction mentioned above. In addition, a palpable mass may be present at abdominal examination (Young, Jr. 2007; Singh & Buch 2008; Terzolo et al. 2009; Androulakis et al. 2011).


Table 1. Prevalence and clinical presentation of the most frequent types of adrenal incidentaloma (Young, Jr. 2007, Singh and Buch 2008)

## **2.2 Hormonal evaluation**

Additional hormonal work-up is necessary in the evaluation of tumor functionality. Although an adrenal mass may appear clinically nonhypersecretory, up to 20% of patients with an incidentaloma may have hormonal dysfunction, which might be associated with a higher risk of morbidity, such as metabolic disorders and cardiovascular disease (Singh & Buch 2008; Androulakis et al. 2011).

Adrenal Incidentaloma and Adrenocortical Carcinoma:

incidentaloma (Young, Jr. 2000; Young, Jr. 2007)

Nieman 2010).

al. 2011).

nonadenomas.

2010).

**2.3 Radiologic evaluation** 

**2.3.1 Computed Tomography** 

**2.2.4 Silent pheochromocytoma** 

A Clinical Guideline on Treating the Unexpected and a Plea for Specialized Care 295

may be a feature of ACC, but measurement of androgens and their precursors in serum has a low diagnostic accuracy in differentiating malignant from benign adrenal masses. Routine measurement of androgen or estrogen production is not necessary in patients with an

Nonclassical congenital adrenal hyperplasia may cause unilateral or bilateral adrenal lesions and is an uncommon cause (< 1%) of incidentalomas. Routine cosyntropinstimulation testing with measurement of cortisol precursors is not warranted, unless the diagnosis is suspected based on clinical manifestation (hirsutism, acne, menstrual irregularities) or the presence of bilateral adrenal masses (Young, Jr. 2000; Young, Jr. 2007;

The estimated prevalence of a pheochromocytoma among patients with an adrenal incidentaloma is 4-7% Although it is mostly a benign condition, it may cause significant morbidity and mortality. Hypertension is constantly present in only half of the patients and paroxysmal in approximately 30%. It is essential to diagnose a catecholamine-secreting pheochromocytoma, since it has the potential to cause cardiac arrhythmias and hemodynamic instability even in asymptomatic patients. Therefore, routine measurement of fractionated metanephrines and catecholamines in 24-hour urine specimen is indicated in all patients presenting with an incidentaloma. Recent research reported the superiority of determination of fractionated plasma free metanaphrines, with a diagnostic sensitivity of 99% and specificity of 89%. However, this method is not widely available (Grumbach et al. 2003; Young, Jr. 2007; Singh & Buch 2008; Terzolo et al. 2009; Nieman 2010; Androulakis et

Imaging studies that brought the incidentaloma to light should be reviewed with a focus on the adrenal glands, but will often be insufficient. The goal is to distinguish adenomas from malignant masses. Several imaging characteristics are used to assess the malignant potential

It is advised to perform an unenhanced CT-scan to help distinguish adenomas from nonadenomas, followed by a delayed contrast-enhanced sequence and computed wash-out percentage (Hamrahian et al. 2005). Attenuation of adrenal masses is measured in Hounsfield Units. A low attenuation on CT before contrast administration indicates high lipid content and is found in adenomas. However, around 30% (range 10-40%) of adenomas do not have a large lipid content and consequently may be difficult to discriminate from

Furthermore, size and appearance of the adrenal lesion may as well help to differentiate between benign and malignant tumors. The probability of an incidentaloma being an ACC is directly related to size of the lesion. A diameter greater than 4 cm is reported to have 90% sensitivity for identifying ACC, but a low specificity, since only approximately 25% of lesions greater than 4 cm are malignant. In addition, calcifications, necrosis and hemorrhage are indicative of a malignancy (Young, Jr. 2000; Terzolo et al. 2009; Nieman

and to provide information concerning appropriate management.

## **2.2.1 Subclinical Cushing's Syndrome**

The most frequently diagnosed endocrine alteration in patients with an incidentaloma is Subclinical Cushing's Syndrome (SCS), which refers to autonomous and dysregulated cortisol secretion by the tumor, which may cause mild cortisol excess without typical signs and symptoms of hypercortisolism (Young, Jr. 2007; Singh & Buch 2008; Androulakis et al. 2011). It is also known as subclinical autonomous glucocorticoid hypersecretion (Grumbach et al. 2003). The average prevalence is 9% (range 1-29%, depending on criteria used)(Singh and Buch 2008). It is difficult to characterize, since clinical Cushing's syndrome is not present and patients may have normal 24-hour urinary free cortisol secretion (Terzolo et al. 2009). Therefore, late-night salivary cortisol and/or overnight dexamethasone (1 mg) suppression test is recommended to detect subclinical hypercortisolism (Grumbach et al. 2003; Nieman 2010). The optimal cut-off value is much discussed. A cortisol value greater than 138 nmol per liter (5 microg/dL) in response to 1mg dexamethasone overnight is associated with glucocorticoid overproduction and has an estimated sensitivity of 98% and specificity of 80-98% (Singh and Buch 2008). When a level between 50-70 nmol/L (1.8-2.5 microg/dL) is used as cutoff value, confirmatory testing is indicated, such as midnight plasma cortisol or serum ACTH level (Grumbach et al. 2003; Young, Jr. 2007; Singh & Buch 2008; Terzolo et al. 2009).

Recent studies and own observations identify urinary steroid profiling as a very promising screening instrument for early differentiation between benign and malignant tumors. A quantitative analysis of steroid precursors by gas chromatography and mass spectrometry reveals steroid patterns associated with particular clinical problems. A recently designed algorithm screens for nine metabolites in a 24-hour urine sample and has impressive test characteristics with high sensitivity and specificity (Taylor A & Arlt 2010).

## **2.2.2 Primary aldosteronism**

Primary aldosteronism (Conn's syndrome) is present in approximately 1.2% of patients with an adrenal incidentaloma (Androulakis et al. 2011). The textbook presentation comprises hypertension and hypokalaemia, however almost 40% of patients are normokalaemic (Young, Jr. 2000; Singh & Buch 2008). Therefore, serum potassium level is not considered a reliable screening method. Hormonal work-up includes routine measurement of ambulatory morning plasma aldosterone concentration to plasma renin activity ratio (PAC/PRA ratio) in hypertensive patients. This can be performed during treatment with antihypertensive drugs with the exception of beta blockers and aldosterone antagonists. A PAC/PRA ratio ≥ 30 and plasma aldosterone concentration greater than 0.5 nmol/L is indicative of autonomous aldosterone secretion. Since the PAC/PRA ratio is influenced by time of sampling and posture of the patient, the diagnosis needs to be confirmed by additional measurement of mineralocorticoid secretory autonomy (e.g. saline infusion test) (Young, Jr. 2000; Grumbach et al. 2003; Young, Jr. 2007; Singh & Buch 2008; Nieman 2010).

## **2.2.3 Sex hormone overproduction**

Sex hormone-secreting adrenal tumors rarely present as an incidentaloma, since they are usually symptomatic (e.g. hirsutism, virilization, gynaecomasty). Androgen overproduction may be a feature of ACC, but measurement of androgens and their precursors in serum has a low diagnostic accuracy in differentiating malignant from benign adrenal masses. Routine measurement of androgen or estrogen production is not necessary in patients with an incidentaloma (Young, Jr. 2000; Young, Jr. 2007)

Nonclassical congenital adrenal hyperplasia may cause unilateral or bilateral adrenal lesions and is an uncommon cause (< 1%) of incidentalomas. Routine cosyntropinstimulation testing with measurement of cortisol precursors is not warranted, unless the diagnosis is suspected based on clinical manifestation (hirsutism, acne, menstrual irregularities) or the presence of bilateral adrenal masses (Young, Jr. 2000; Young, Jr. 2007; Nieman 2010).

## **2.2.4 Silent pheochromocytoma**

294 Contemporary Aspects of Endocrinology

The most frequently diagnosed endocrine alteration in patients with an incidentaloma is Subclinical Cushing's Syndrome (SCS), which refers to autonomous and dysregulated cortisol secretion by the tumor, which may cause mild cortisol excess without typical signs and symptoms of hypercortisolism (Young, Jr. 2007; Singh & Buch 2008; Androulakis et al. 2011). It is also known as subclinical autonomous glucocorticoid hypersecretion (Grumbach et al. 2003). The average prevalence is 9% (range 1-29%, depending on criteria used)(Singh and Buch 2008). It is difficult to characterize, since clinical Cushing's syndrome is not present and patients may have normal 24-hour urinary free cortisol secretion (Terzolo et al. 2009). Therefore, late-night salivary cortisol and/or overnight dexamethasone (1 mg) suppression test is recommended to detect subclinical hypercortisolism (Grumbach et al. 2003; Nieman 2010). The optimal cut-off value is much discussed. A cortisol value greater than 138 nmol per liter (5 microg/dL) in response to 1mg dexamethasone overnight is associated with glucocorticoid overproduction and has an estimated sensitivity of 98% and specificity of 80-98% (Singh and Buch 2008). When a level between 50-70 nmol/L (1.8-2.5 microg/dL) is used as cutoff value, confirmatory testing is indicated, such as midnight plasma cortisol or serum ACTH level (Grumbach et al. 2003; Young, Jr. 2007; Singh & Buch 2008; Terzolo et al.

Recent studies and own observations identify urinary steroid profiling as a very promising screening instrument for early differentiation between benign and malignant tumors. A quantitative analysis of steroid precursors by gas chromatography and mass spectrometry reveals steroid patterns associated with particular clinical problems. A recently designed algorithm screens for nine metabolites in a 24-hour urine sample and has impressive test characteristics with high sensitivity and specificity (Taylor A & Arlt

Primary aldosteronism (Conn's syndrome) is present in approximately 1.2% of patients with an adrenal incidentaloma (Androulakis et al. 2011). The textbook presentation comprises hypertension and hypokalaemia, however almost 40% of patients are normokalaemic (Young, Jr. 2000; Singh & Buch 2008). Therefore, serum potassium level is not considered a reliable screening method. Hormonal work-up includes routine measurement of ambulatory morning plasma aldosterone concentration to plasma renin activity ratio (PAC/PRA ratio) in hypertensive patients. This can be performed during treatment with antihypertensive drugs with the exception of beta blockers and aldosterone antagonists. A PAC/PRA ratio ≥ 30 and plasma aldosterone concentration greater than 0.5 nmol/L is indicative of autonomous aldosterone secretion. Since the PAC/PRA ratio is influenced by time of sampling and posture of the patient, the diagnosis needs to be confirmed by additional measurement of mineralocorticoid secretory autonomy (e.g. saline infusion test) (Young, Jr. 2000; Grumbach et al. 2003;

Sex hormone-secreting adrenal tumors rarely present as an incidentaloma, since they are usually symptomatic (e.g. hirsutism, virilization, gynaecomasty). Androgen overproduction

**2.2.1 Subclinical Cushing's Syndrome** 

2009).

2010).

**2.2.2 Primary aldosteronism** 

Young, Jr. 2007; Singh & Buch 2008; Nieman 2010).

**2.2.3 Sex hormone overproduction** 

The estimated prevalence of a pheochromocytoma among patients with an adrenal incidentaloma is 4-7% Although it is mostly a benign condition, it may cause significant morbidity and mortality. Hypertension is constantly present in only half of the patients and paroxysmal in approximately 30%. It is essential to diagnose a catecholamine-secreting pheochromocytoma, since it has the potential to cause cardiac arrhythmias and hemodynamic instability even in asymptomatic patients. Therefore, routine measurement of fractionated metanephrines and catecholamines in 24-hour urine specimen is indicated in all patients presenting with an incidentaloma. Recent research reported the superiority of determination of fractionated plasma free metanaphrines, with a diagnostic sensitivity of 99% and specificity of 89%. However, this method is not widely available (Grumbach et al. 2003; Young, Jr. 2007; Singh & Buch 2008; Terzolo et al. 2009; Nieman 2010; Androulakis et al. 2011).

## **2.3 Radiologic evaluation**

Imaging studies that brought the incidentaloma to light should be reviewed with a focus on the adrenal glands, but will often be insufficient. The goal is to distinguish adenomas from malignant masses. Several imaging characteristics are used to assess the malignant potential and to provide information concerning appropriate management.

## **2.3.1 Computed Tomography**

It is advised to perform an unenhanced CT-scan to help distinguish adenomas from nonadenomas, followed by a delayed contrast-enhanced sequence and computed wash-out percentage (Hamrahian et al. 2005). Attenuation of adrenal masses is measured in Hounsfield Units. A low attenuation on CT before contrast administration indicates high lipid content and is found in adenomas. However, around 30% (range 10-40%) of adenomas do not have a large lipid content and consequently may be difficult to discriminate from nonadenomas.

Furthermore, size and appearance of the adrenal lesion may as well help to differentiate between benign and malignant tumors. The probability of an incidentaloma being an ACC is directly related to size of the lesion. A diameter greater than 4 cm is reported to have 90% sensitivity for identifying ACC, but a low specificity, since only approximately 25% of lesions greater than 4 cm are malignant. In addition, calcifications, necrosis and hemorrhage are indicative of a malignancy (Young, Jr. 2000; Terzolo et al. 2009; Nieman 2010).

Adrenal Incidentaloma and Adrenocortical Carcinoma:

Terzolo et al. 2009; Nieman 2010).

**3. Diagnostic evaluation** 

pheochromocytoma.

**3.1 Suspect adenoma** 

A Clinical Guideline on Treating the Unexpected and a Plea for Specialized Care 297

Jr. 2000; Grumbach et al. 2003; Young, Jr. 2007; Quayle et al. 2007; Singh & Buch 2008;

The work-up leads to a preliminary conclusion which determines further management. The spectrum varies from benign adenoma to the presumption of malignancy or a

As noted before, the first step in evaluation of an adrenal incidentaloma is discrimination between a benign or malignant adrenal mass, in which radiological imaging by CT-scan has a fundamental role. Most adrenal incidentalomas exhibit characteristic features of adrenocortical adenoma (ACA). Adenomas typically present as small (< 4 cm) lesions, with clear margins and high lipid content, which is characterized by low attenuation (< 10 HU) on unenhanced CT. Furthermore, they display rapid washout of contrast medium (e.g. more

than 50% after 10 minutes) (see figure 1) (Androulakis et al. 2011).

Fig. 1. Washout sequence of an adrenocortical adenoma


HU = Hounsfield Units

Table 2. CT characteristics of the most frequent types of an incidentaloma (Young, Jr. 2000; Young, Jr. 2007; Terzolo et al. 2009)

## **2.3.2 Magnetic Resonance Imaging**

Magnetic Resonance Imaging (MRI) is equally effective as CT in differentiating benign from malignant adrenal masses (Grumbach et al. 2003). A normal adrenal gland is characterized by an equal or slightly lower intensity than that of the liver on T1 and T2. In contrast, malignant lesions are hyperintense on T2-weighted images (Young, Jr. 2000; Androulakis et al. 2011).

## **2.3.3 Positron Emission Tomography**

Additional advanced radiological testing is generally not indicated. 18-Fluoro-2-deoxy-Dglucose positron emission tomography (PET) is highly sensitive in identifying malignant lesions. However, it is of limited use regarding the evaluation of adrenal incidentaloma (in patients without a prior history of malignancy) (Young, Jr. 2007; Singh & Buch 2008; Boland 2011)

## **2.4 Fine-Needle Aspiration**

There is no evidence to support the routine use of computed tomography-guided fineneedle aspiration (FNA) in the diagnostic evaluation of an incidentaloma. It is rarely informative, since it has a high-false negative rate, and there is a risk of complications, such as hemorrhage, abdominal pain, pancreatitis and pneumothorax. Moreover, its added value over radiological imaging has not been established. In case of a suspected pheochromocytoma FNA is contraindicated, since manipulation of the tumor can potentially cause a hypertensive crisis. Furthermore, biopsy of an adrenocortical carcinoma may lead to tumourspill and consequently tumor recurrence along the needle track. The only role of FNA in the evaluation of an incidentaloma is in confirming metastatic disease in patients with a known extra-adrenal malignancy without other signs of metastases (Young, Jr. 2000; Grumbach et al. 2003; Young, Jr. 2007; Quayle et al. 2007; Singh & Buch 2008; Terzolo et al. 2009; Nieman 2010).

## **3. Diagnostic evaluation**

296 Contemporary Aspects of Endocrinology

Round, smooth margins

minutes) Rapid, > 50% Delayed, < 50% Delayed, < 50% Delayed, < 50%

Hemorrhage, cystic necrotic

Table 2. CT characteristics of the most frequent types of an incidentaloma (Young, Jr. 2000;

Magnetic Resonance Imaging (MRI) is equally effective as CT in differentiating benign from malignant adrenal masses (Grumbach et al. 2003). A normal adrenal gland is characterized by an equal or slightly lower intensity than that of the liver on T1 and T2. In contrast, malignant lesions are hyperintense on T2-weighted images (Young, Jr. 2000; Androulakis et

Additional advanced radiological testing is generally not indicated. 18-Fluoro-2-deoxy-Dglucose positron emission tomography (PET) is highly sensitive in identifying malignant lesions. However, it is of limited use regarding the evaluation of adrenal incidentaloma (in patients without a prior history of malignancy) (Young, Jr. 2007; Singh & Buch 2008; Boland

There is no evidence to support the routine use of computed tomography-guided fineneedle aspiration (FNA) in the diagnostic evaluation of an incidentaloma. It is rarely informative, since it has a high-false negative rate, and there is a risk of complications, such as hemorrhage, abdominal pain, pancreatitis and pneumothorax. Moreover, its added value over radiological imaging has not been established. In case of a suspected pheochromocytoma FNA is contraindicated, since manipulation of the tumor can potentially cause a hypertensive crisis. Furthermore, biopsy of an adrenocortical carcinoma may lead to tumourspill and consequently tumor recurrence along the needle track. The only role of FNA in the evaluation of an incidentaloma is in confirming metastatic disease in patients with a known extra-adrenal malignancy without other signs of metastases (Young,

**Adrenocortical** 

Large, usually

> 3 cm

Irregular, unclear margins

Necrosis, hemorrhage, calcification

**carcinoma Metastasis** 

Variable, usually < 3 cm

Oval, irregular margins

Hemorrhage, cystic necrotic

areas

**toma** 

> 3 cm

unenhanced CT < 10 HU > 10 HU > 10 HU > 10 HU

Growth rate Stable Slow (usually) Rapid (usually) Variable

areas

**characteristic Adenoma Pheochromocy**

Size Usually < 4 cm Large, usually

margins

Rarely necrosis, hemorrhage or calcification

Shape Round, smooth

**CT-**

Attenuation on

Washout (in 10

Other features

al. 2011).

2011)

HU = Hounsfield Units

Young, Jr. 2007; Terzolo et al. 2009)

**2.3.2 Magnetic Resonance Imaging** 

**2.3.3 Positron Emission Tomography** 

**2.4 Fine-Needle Aspiration** 

The work-up leads to a preliminary conclusion which determines further management. The spectrum varies from benign adenoma to the presumption of malignancy or a pheochromocytoma.

## **3.1 Suspect adenoma**

As noted before, the first step in evaluation of an adrenal incidentaloma is discrimination between a benign or malignant adrenal mass, in which radiological imaging by CT-scan has a fundamental role. Most adrenal incidentalomas exhibit characteristic features of adrenocortical adenoma (ACA). Adenomas typically present as small (< 4 cm) lesions, with clear margins and high lipid content, which is characterized by low attenuation (< 10 HU) on unenhanced CT. Furthermore, they display rapid washout of contrast medium (e.g. more than 50% after 10 minutes) (see figure 1) (Androulakis et al. 2011).

Fig. 1. Washout sequence of an adrenocortical adenoma

Adrenal Incidentaloma and Adrenocortical Carcinoma:

warranted before directing the patient to surgery.

Fig. 2. Washout sequence of an adrenocortical carcinoma

**3.3.2 Metastasis** 

and urinary steroid profiling reveals presence of hormone excess.

A Clinical Guideline on Treating the Unexpected and a Plea for Specialized Care 299

high attenuation on unenhanced CT (> 10 HU) and slow washout after contrast administration (see figure 2) (Terzolo et al. 2009). Own observations from the authors show that although an ACC may appear clinically non-functioning, in about 80-95% additional hormonal work-up

When an adrenal malignancy is suspected, further investigation concerning cancer staging is

Tumors that frequently metastasize to adrenal glands include carcinomas of lungs, esophagus, kidney, colon, breast, liver, pancreas and stomach (Young, Jr. 2007). Metastases frequently occur bilateral and are variable in size, mostly smaller than 3 cm. Abdominal imaging may also reveal the presence of necrosis, hemorrhage or calcifications (Young, Jr. 2000). Adrenal metastasis may cause beginning adrenal insufficiency. The suspicion of metastasis in an incidentaloma has clinical implications for prognosis and management and the search for a primary neoplasm is indicated. Resection of an isolated adrenal metastasis is associated with improved (disease-free and overall) survival. However, only in a limited number of cases adequate treatment of adrenal metastasis is possible (Terzolo et al. 2009).

In patients with non-functioning ACA, size of the adrenal mass is the major determinant in choice of management (Nieman 2010; Androulakis et al. 2011). Over 60% of incidentalomas less than 4 cm in diameter are ACA, in contrast only 2% are malignant. For a small non-functioning adenoma surgical resection is not necessary, follow-up through CT-imaging and biochemical screening will suffice. In lesions larger than 6 cm the prevalence of ACC increases to approximately 25% and surgery is indicated (Singh & Buch 2008). Management of adrenal masses with a diameter between 4 to 6 cm is less well defined. Because of a higher risk of malignancy in this subgroup of patients, surgical approach is recommended in most cases.

In about 20% of adrenal adenomas hormonal work-up reveals overproduction of aldosterone (0.5-1%) or cortisol (5-20%), which may have a negative influence on patient's health. Primary hyperaldosteronism is associated with increased risk of cardiovascular events. Additionally, patients with SCS may be at risk for potential morbidity attributable to cortisol overproduction. However, progression to clinical overt Cushing's syndrome is uncommon. Surgical resection is considered the treatment of choice when biochemical overproduction is confirmed.

## **3.2 Suspect pheochromocytoma**

It is essential to exclude a pheochromocytoma in patients presenting with an adrenal incidentaloma, because they are potentially lethal even when clinically asymptomatic (Young, Jr. 2007). Increased metanephrines and catecholamines in 24-hour urine specimen or fractionated plasma free metanaphrines in combination with features on CT, such as increased attenuation on unenhanced CT (>10 HU), prominent vascularity of the mass and delayed washout of contrast (<50% after 10 minutes), are highly suggestive of a pheochromocytoma (Terzolo et al. 2009). Characteristics indicative of pheochromocytoma on MRI include hyperintensity on T2-weighted imaging, with approximately 92% sensitivity and 88% specificity (Androulakis et al. 2011). When a pheochromocytoma is suspected, surgical treatment is indicated. Patients should be adequately prepared pre-operatively by adrenergic blockade, to prevent a perioperative hypertensive crisis caused by manipulation of the tumor and subsequent catecholamine-release.

## **3.3 Suspect malignancy**

## **3.3.1 Adrenocortical carcinoma**

The risk of a malignancy is the main concern in patients with an incidentaloma. The prevalence of ACC in these patients without a history of malignancy is estimated at 4.8%, which makes it the most commonly identified adrenal malignancy (Terzolo et al. 2009). It is an aggressive malignancy with a median survival of 19 months (range 8-29 months), as calculated from data of 191 patients diagnosed between 2000 and 2010 in The Netherlands. Prognosis of ACC is still mainly dependent on stage at diagnosis (Fassnacht & Allolio 2009). For that reason it is vital to make accurate decisions regarding the necessary diagnostic and therapeutic measurements.

A smaller tumor size corresponds with a lower tumor stage and consequently better prognosis. The risk of ACC is, as mentioned, associated with mass size. However, because the prevalence of adrenal adenoma is age-dependent, the presence of small adrenal masses in young patients should raise major concern of a potential malignancy. A malignant adrenal lesion typically presents as a larger mass (> 6 cm) and is characterized by an irregular border, high attenuation on unenhanced CT (> 10 HU) and slow washout after contrast administration (see figure 2) (Terzolo et al. 2009). Own observations from the authors show that although an ACC may appear clinically non-functioning, in about 80-95% additional hormonal work-up and urinary steroid profiling reveals presence of hormone excess.

When an adrenal malignancy is suspected, further investigation concerning cancer staging is warranted before directing the patient to surgery.

Fig. 2. Washout sequence of an adrenocortical carcinoma

## **3.3.2 Metastasis**

298 Contemporary Aspects of Endocrinology

In patients with non-functioning ACA, size of the adrenal mass is the major determinant in choice of management (Nieman 2010; Androulakis et al. 2011). Over 60% of incidentalomas less than 4 cm in diameter are ACA, in contrast only 2% are malignant. For a small non-functioning adenoma surgical resection is not necessary, follow-up through CT-imaging and biochemical screening will suffice. In lesions larger than 6 cm the prevalence of ACC increases to approximately 25% and surgery is indicated (Singh & Buch 2008). Management of adrenal masses with a diameter between 4 to 6 cm is less well defined. Because of a higher risk of malignancy in this subgroup of patients, surgical

In about 20% of adrenal adenomas hormonal work-up reveals overproduction of aldosterone (0.5-1%) or cortisol (5-20%), which may have a negative influence on patient's health. Primary hyperaldosteronism is associated with increased risk of cardiovascular events. Additionally, patients with SCS may be at risk for potential morbidity attributable to cortisol overproduction. However, progression to clinical overt Cushing's syndrome is uncommon. Surgical resection is considered the treatment of choice when biochemical

It is essential to exclude a pheochromocytoma in patients presenting with an adrenal incidentaloma, because they are potentially lethal even when clinically asymptomatic (Young, Jr. 2007). Increased metanephrines and catecholamines in 24-hour urine specimen or fractionated plasma free metanaphrines in combination with features on CT, such as increased attenuation on unenhanced CT (>10 HU), prominent vascularity of the mass and delayed washout of contrast (<50% after 10 minutes), are highly suggestive of a pheochromocytoma (Terzolo et al. 2009). Characteristics indicative of pheochromocytoma on MRI include hyperintensity on T2-weighted imaging, with approximately 92% sensitivity and 88% specificity (Androulakis et al. 2011). When a pheochromocytoma is suspected, surgical treatment is indicated. Patients should be adequately prepared pre-operatively by adrenergic blockade, to prevent a perioperative hypertensive crisis caused by manipulation

The risk of a malignancy is the main concern in patients with an incidentaloma. The prevalence of ACC in these patients without a history of malignancy is estimated at 4.8%, which makes it the most commonly identified adrenal malignancy (Terzolo et al. 2009). It is an aggressive malignancy with a median survival of 19 months (range 8-29 months), as calculated from data of 191 patients diagnosed between 2000 and 2010 in The Netherlands. Prognosis of ACC is still mainly dependent on stage at diagnosis (Fassnacht & Allolio 2009). For that reason it is vital to make accurate decisions regarding the necessary diagnostic and

A smaller tumor size corresponds with a lower tumor stage and consequently better prognosis. The risk of ACC is, as mentioned, associated with mass size. However, because the prevalence of adrenal adenoma is age-dependent, the presence of small adrenal masses in young patients should raise major concern of a potential malignancy. A malignant adrenal lesion typically presents as a larger mass (> 6 cm) and is characterized by an irregular border,

approach is recommended in most cases.

overproduction is confirmed.

**3.3 Suspect malignancy** 

therapeutic measurements.

**3.3.1 Adrenocortical carcinoma** 

**3.2 Suspect pheochromocytoma** 

of the tumor and subsequent catecholamine-release.

Tumors that frequently metastasize to adrenal glands include carcinomas of lungs, esophagus, kidney, colon, breast, liver, pancreas and stomach (Young, Jr. 2007). Metastases frequently occur bilateral and are variable in size, mostly smaller than 3 cm. Abdominal imaging may also reveal the presence of necrosis, hemorrhage or calcifications (Young, Jr. 2000). Adrenal metastasis may cause beginning adrenal insufficiency. The suspicion of metastasis in an incidentaloma has clinical implications for prognosis and management and the search for a primary neoplasm is indicated. Resection of an isolated adrenal metastasis is associated with improved (disease-free and overall) survival. However, only in a limited number of cases adequate treatment of adrenal metastasis is possible (Terzolo et al. 2009).

Adrenal Incidentaloma and Adrenocortical Carcinoma:

**4. Surgical treatment of incidentaloma** 

**4.1 Adenoma** 

this can be tapered over time.

this particular subgroup.

**4.2 Pheochromocytoma** 

et al. 2002; Matsuda et al. 2002).

**4.3 Adrenocortical carcinoma** 

A Clinical Guideline on Treating the Unexpected and a Plea for Specialized Care 301

Based on results of the diagnostic evaluation of the adrenal incidentaloma, decisions are made regarding the required therapeutic approach. However, a prospective randomized comparison of laparoscopic versus open adrenalectomy has not yet been performed.

When an adrenocortical adenoma is suspected, subsequent management is founded on size of the mass and functionality. As mentioned, in case of overproduction of cortisol, aldosterone or sex hormones, surgical resection of the mass is the treatment of choice. Mortality associated with adrenalectomy is estimated at less than 2% (Grumbach et al. 2003). Laparoscopic approach allows for a minimal invasive procedure associated with less morbidity in the patient and shorter period of hospitalization, while surgical results are comparable if performed by an experienced surgical team (Gill 2001). An important issue in resection of functioning adrenal masses is steroid suppletion peri- and postoperatively, because of the risk of adrenal insufficiency, hemodynamic crisis and death. In most cases

It is common practice to perform a surgical resection of incidentalomas larger then 6 cm, even if they are non-functioning and there are no signs of malignancy. It is unclear whether this is a good indication for a surgical resection, as follow-up might be sufficient as well. In lesions smaller than 4 cm, surgical resection is deemed not necessary and follow-up is generally accepted as the correct management. For lesions between 4 cm and 6 cm in diameter, a clear recommendation is lacking. In this group, surgery might be the safest option regarding the increasing risk of malignancy, however the number needed to treat with respect to curing a carcinoma will be large. The other option is to repeat medical imaging on a shorter term, for example 3 months. We expect urinary steroid profiling to become a valuable instrument in differentiating between benign and malignant lesions in

In patients with an adrenal incidentaloma and suspicion of a pheochromocytoma, rapid surgical resection is the standard curative option, associated with an excellent prognosis (Terzolo et al. 2009). Due to potential perioperative catecholamine excess, removal of a pheochromocytoma is accompanied with unusual hemodynamic and technical conditions, which require thorough preoperative medical preparation and adrenergic blockade to minimize perioperative cardiovascular morbidity. Furthermore, close perioperative monitoring is mandatory (Gill 2001; Ichikawa et al. 2002). Catecholamine release is suggested to be lower during laparoscopy than open adrenalectomy. Therefore, and because of the other benefits of laparoscopic surgery mentioned earlier, a laparoscopic approach is recommended in patients with an incidentaloma suspected for a pheochromocytoma (Cheah

A radical surgical resection is the only chance of cure for patients with an adrenocortical carcinoma, so an aggressive surgical approach is warranted (Dackiw et al. 2001; Miller et al. 2010). A complete resection is possible in most cases when the diagnosis is suspected pre-

Recommendations are made based on little known evidence and pragmatism.

PPAC/PRA ratio = plasma aldosterone concentration to plasma renin activity ratio. HU = Hounsfield Units. SCS = Subclinical Cushing's Syndrome.

Fig. 3. Algorithm for diagnostic evaluation of adrenal incidentaloma

## **4. Surgical treatment of incidentaloma**

Based on results of the diagnostic evaluation of the adrenal incidentaloma, decisions are made regarding the required therapeutic approach. However, a prospective randomized comparison of laparoscopic versus open adrenalectomy has not yet been performed. Recommendations are made based on little known evidence and pragmatism.

## **4.1 Adenoma**

300 Contemporary Aspects of Endocrinology

PPAC/PRA ratio = plasma aldosterone concentration to plasma renin activity ratio.

Fig. 3. Algorithm for diagnostic evaluation of adrenal incidentaloma

HU = Hounsfield Units. SCS = Subclinical Cushing's Syndrome.

When an adrenocortical adenoma is suspected, subsequent management is founded on size of the mass and functionality. As mentioned, in case of overproduction of cortisol, aldosterone or sex hormones, surgical resection of the mass is the treatment of choice. Mortality associated with adrenalectomy is estimated at less than 2% (Grumbach et al. 2003). Laparoscopic approach allows for a minimal invasive procedure associated with less morbidity in the patient and shorter period of hospitalization, while surgical results are comparable if performed by an experienced surgical team (Gill 2001). An important issue in resection of functioning adrenal masses is steroid suppletion peri- and postoperatively, because of the risk of adrenal insufficiency, hemodynamic crisis and death. In most cases this can be tapered over time.

It is common practice to perform a surgical resection of incidentalomas larger then 6 cm, even if they are non-functioning and there are no signs of malignancy. It is unclear whether this is a good indication for a surgical resection, as follow-up might be sufficient as well. In lesions smaller than 4 cm, surgical resection is deemed not necessary and follow-up is generally accepted as the correct management. For lesions between 4 cm and 6 cm in diameter, a clear recommendation is lacking. In this group, surgery might be the safest option regarding the increasing risk of malignancy, however the number needed to treat with respect to curing a carcinoma will be large. The other option is to repeat medical imaging on a shorter term, for example 3 months. We expect urinary steroid profiling to become a valuable instrument in differentiating between benign and malignant lesions in this particular subgroup.

## **4.2 Pheochromocytoma**

In patients with an adrenal incidentaloma and suspicion of a pheochromocytoma, rapid surgical resection is the standard curative option, associated with an excellent prognosis (Terzolo et al. 2009). Due to potential perioperative catecholamine excess, removal of a pheochromocytoma is accompanied with unusual hemodynamic and technical conditions, which require thorough preoperative medical preparation and adrenergic blockade to minimize perioperative cardiovascular morbidity. Furthermore, close perioperative monitoring is mandatory (Gill 2001; Ichikawa et al. 2002). Catecholamine release is suggested to be lower during laparoscopy than open adrenalectomy. Therefore, and because of the other benefits of laparoscopic surgery mentioned earlier, a laparoscopic approach is recommended in patients with an incidentaloma suspected for a pheochromocytoma (Cheah et al. 2002; Matsuda et al. 2002).

## **4.3 Adrenocortical carcinoma**

A radical surgical resection is the only chance of cure for patients with an adrenocortical carcinoma, so an aggressive surgical approach is warranted (Dackiw et al. 2001; Miller et al. 2010). A complete resection is possible in most cases when the diagnosis is suspected pre-

Adrenal Incidentaloma and Adrenocortical Carcinoma:

Follow-up

Risk group:

centre

> 6 cm Laparoscopic resection

surgical team

**6. Treatment in advanced stages** 

may vary per patient.

not been developed.

Nonfunctioning

< 4 cm

4-6 cm

Adrenocortical carcinoma

**6.1 Introduction** 

Adenoma

A Clinical Guideline on Treating the Unexpected and a Plea for Specialized Care 303

up. Whether measurement of PAC/PRA ratio and determination of fractionated metanephrines and catecholamines in 24-hour urine specimen or fractionated plasma free metanephrines should be repeated, is left to the discretion of the clinician as the indication

Further follow-up is not indicated in patients with an adrenal mass that remains stable on two imaging studies, done at least 6 months apart and do not demonstrate hormonal overproduction during 4 years of follow-up (Grumbach et al. 2003). Recommendations regarding follow-up of patients with a functional adenoma who are surgically treated, have

**Suspicion Management Considerations** 



Pheochromocytoma Laparoscopic resection Pre-operative preparation

The occurrence of metastatic disease in patients with adrenocortical carcinoma is not rare, as 35% of patients present with stage 4 disease. 50% of patients who initially have had a curative resection, ultimately suffer a recurrence (Pommier & Brennan 1992; Stojadinovic et al. 2002). Even in advanced stages, a surgical debulking should be considered as our own observations indicate this might give a survival benefit. The backbone of treatment in advanced stages is formed by drug therapy with mitotane. Cytotoxic chemotherapy may be added, but response percentages vary. The role of radiation therapy remains disputed.

Current experimental treatments include IGF-R blockers (OSI-906) and sunitinib.

during 4 years

Referral to specialized centre Open adrenalectomy by specialized

Fig. 4. Recommendations for management of adrenal incidentaloma

Functioning Laparoscopic resection Post-operative steroid

hormone suppletion

Suspicious imaging phenotype: open adrenalectomy

Post-operative steroid hormone suppletion Additional treatment depending on stage

operatively. Success rates drop significantly in cases where a carcinoma is not recognized before or during surgery, as follows from own observations from the authors. This emphasizes the need of a complete diagnostic work-up before the patient is directed for a surgical resection of an incidentaloma. The surgeon has to be prepared to perform an extensive resection and to keep the tumour capsule intact, as tumour spill is strongly associated with the occurrence of peritoneal carcinomatosis and a poor prognosis (Dackiw et al. 2001; Schteingart et al. 2005). Therefore, several authors recommend an open surgical approach instead of a laparoscopic technique, which is being used increasingly in adrenal surgery (Gonzalez et al. 2005; Zografos et al. 2009; Leboulleux et al. 2010; Miller et al. 2010). This topic is controversial, as prospective studies are lacking and retrospective studies show contradictory results. It is our belief that in general, a laparotomy is the safest option with respect to achieving a complete resection, although an expert surgeon in laparoscopic adrenalectomies might achieve better results than a less experienced surgeon can achieve performing a laparotomy.

We therefore recommend that these patients should be treated by a multidisciplinary team with at least an endocrinologist, a surgeon, an oncologist, a pathologist and an experienced radiologist. The team should evaluate all patients with a suspect adrenal incidentaloma and decide on which patients will be treated surgically. Peri-operative hydrocortisone suppletion is recommended in all patients. The surgical technique should be determined with respect to the preference and specific qualities of the surgeon. The pathological examination of the tumour requires special attention, as carcinomas might be difficult to recognize. Rating systems as the Weiss-score and the Van Slooten score should be applied to all adrenal tumours. Close follow-up using medical imaging is strongly recommended as the risk of recurrence is high, even after complete resection. The debate regarding adjuvant therapy with mitotane is still ongoing, but it is the opinion of the authors that this is recommended if the tumor has a ki-67 index >10% (Terzolo et al. 2007).

## **5. Follow-up of nonfunctioning adenoma**

A much discussed matter in the management of patients with an non-functioning adrenal adenoma is the frequency and duration of follow-up evaluation. Recommendations regarding follow-up are aimed at identifying changes in size or functionality of the adrenal adenoma and to recognize lesions with malignant potential that have escaped detection on primary analysis. Research suggests that approximately 8% of non-functional adrenal incidentalomas increase in size by at least 1 cm during follow-up, whereas 3-4% decrease in size (Singh and Buch 2008, Young, Jr. 2000). The majority of adrenal adenomas remain stable. In contrast, adrenocortical carcinomas usually display rapid growth. It is recommended to repeat adrenal imaging by CTscan in patients with nonfunctioning adenomas smaller than 4 cm within 6-12 months after the initial discovery to detect size changes (Grumbach et al. 2003).

Approximately 20% of adrenal adenomas which displayed no excess hormone secretion at time of discovery, become autonomous during subsequent period of 4 years. Lesions of at least 3 cm in diameter are more likely to develop subclinical hyperfunction in contrast to smaller tumors (Androulakis et al. 2011). It is reported that the risk seems to disappear after 3-4 years follow-up. Hyperaldosteronism or catecholamine hypersecretion occurs rarely during follow-up (Grumbach et al. 2003). Cortisol overproduction is more likely to occur. Hence, annual repetition of hormonal work-up, including late-night salivary cortisol and/or overnight dexamethasone (1 mg) suppression test is recommended during 4 years of followup. Whether measurement of PAC/PRA ratio and determination of fractionated metanephrines and catecholamines in 24-hour urine specimen or fractionated plasma free metanephrines should be repeated, is left to the discretion of the clinician as the indication may vary per patient.

Further follow-up is not indicated in patients with an adrenal mass that remains stable on two imaging studies, done at least 6 months apart and do not demonstrate hormonal overproduction during 4 years of follow-up (Grumbach et al. 2003). Recommendations regarding follow-up of patients with a functional adenoma who are surgically treated, have not been developed.


Fig. 4. Recommendations for management of adrenal incidentaloma

## **6. Treatment in advanced stages**

## **6.1 Introduction**

302 Contemporary Aspects of Endocrinology

operatively. Success rates drop significantly in cases where a carcinoma is not recognized before or during surgery, as follows from own observations from the authors. This emphasizes the need of a complete diagnostic work-up before the patient is directed for a surgical resection of an incidentaloma. The surgeon has to be prepared to perform an extensive resection and to keep the tumour capsule intact, as tumour spill is strongly associated with the occurrence of peritoneal carcinomatosis and a poor prognosis (Dackiw et al. 2001; Schteingart et al. 2005). Therefore, several authors recommend an open surgical approach instead of a laparoscopic technique, which is being used increasingly in adrenal surgery (Gonzalez et al. 2005; Zografos et al. 2009; Leboulleux et al. 2010; Miller et al. 2010). This topic is controversial, as prospective studies are lacking and retrospective studies show contradictory results. It is our belief that in general, a laparotomy is the safest option with respect to achieving a complete resection, although an expert surgeon in laparoscopic adrenalectomies might achieve better results than a less experienced surgeon can achieve

We therefore recommend that these patients should be treated by a multidisciplinary team with at least an endocrinologist, a surgeon, an oncologist, a pathologist and an experienced radiologist. The team should evaluate all patients with a suspect adrenal incidentaloma and decide on which patients will be treated surgically. Peri-operative hydrocortisone suppletion is recommended in all patients. The surgical technique should be determined with respect to the preference and specific qualities of the surgeon. The pathological examination of the tumour requires special attention, as carcinomas might be difficult to recognize. Rating systems as the Weiss-score and the Van Slooten score should be applied to all adrenal tumours. Close follow-up using medical imaging is strongly recommended as the risk of recurrence is high, even after complete resection. The debate regarding adjuvant therapy with mitotane is still ongoing, but it is the opinion of the authors that this is

A much discussed matter in the management of patients with an non-functioning adrenal adenoma is the frequency and duration of follow-up evaluation. Recommendations regarding follow-up are aimed at identifying changes in size or functionality of the adrenal adenoma and to recognize lesions with malignant potential that have escaped detection on primary analysis. Research suggests that approximately 8% of non-functional adrenal incidentalomas increase in size by at least 1 cm during follow-up, whereas 3-4% decrease in size (Singh and Buch 2008, Young, Jr. 2000). The majority of adrenal adenomas remain stable. In contrast, adrenocortical carcinomas usually display rapid growth. It is recommended to repeat adrenal imaging by CTscan in patients with nonfunctioning adenomas smaller than 4 cm within 6-12 months after the

Approximately 20% of adrenal adenomas which displayed no excess hormone secretion at time of discovery, become autonomous during subsequent period of 4 years. Lesions of at least 3 cm in diameter are more likely to develop subclinical hyperfunction in contrast to smaller tumors (Androulakis et al. 2011). It is reported that the risk seems to disappear after 3-4 years follow-up. Hyperaldosteronism or catecholamine hypersecretion occurs rarely during follow-up (Grumbach et al. 2003). Cortisol overproduction is more likely to occur. Hence, annual repetition of hormonal work-up, including late-night salivary cortisol and/or overnight dexamethasone (1 mg) suppression test is recommended during 4 years of follow-

recommended if the tumor has a ki-67 index >10% (Terzolo et al. 2007).

**5. Follow-up of nonfunctioning adenoma** 

initial discovery to detect size changes (Grumbach et al. 2003).

performing a laparotomy.

The occurrence of metastatic disease in patients with adrenocortical carcinoma is not rare, as 35% of patients present with stage 4 disease. 50% of patients who initially have had a curative resection, ultimately suffer a recurrence (Pommier & Brennan 1992; Stojadinovic et al. 2002). Even in advanced stages, a surgical debulking should be considered as our own observations indicate this might give a survival benefit. The backbone of treatment in advanced stages is formed by drug therapy with mitotane. Cytotoxic chemotherapy may be added, but response percentages vary. The role of radiation therapy remains disputed. Current experimental treatments include IGF-R blockers (OSI-906) and sunitinib.

Adrenal Incidentaloma and Adrenocortical Carcinoma:

(Hahner & Fassnacht 2005; Igaz et al. 2008).

ACT). Results of this trial are expected in 2011.

able to manage them.

**6.5 Radiation therapy** 

adjuvant setting.

**7. Limitations** 

**6.6 Future therapeutic agents** 

2010).

**6.4 Cytotoxic chemotherapy** 

A Clinical Guideline on Treating the Unexpected and a Plea for Specialized Care 305

hormone and thyroid stimulating hormone levels, as mitotane can decrease thyroid hormone as well. A third and possibly favorable interaction is the supposedly increased efficacy of cytotoxic chemotherapy when combined with mitotane. However, evidence on this topic is not conclusive. The proposed mechanism for this synergistic effect is the possible negative effect of mitotane on multidrug resistance proteins, as investigated in vitro, which could decrease the resistance of adrenocortical cancer cells to cytotoxic agents

Given the rarity of the indication and use of mitotane, it is recommended to leave treatment with mitotane to experienced doctors who are familiar with possible adverse events and are

Regarding cytotoxic chemotherapy, several combinations of agents have been tried so far. The highest response rates have been found in a trial with a treatment regimen combining mitotane with etoposide, doxorubicine and cisplatin (response rate 49%) and another trial with a treatment regimen combining mitotane and streptozotocine (response rate 36%) (Berruti et al. 2005), (Khan et al. 2000). Recently, these two regimens were compared in the First International Trial in Locally Advanced and Metastatic Adrenocortical Cancer (FIRM-

Whether there is a place for radiation therapy in the treatment of adrenocortical carcinoma, is not yet clear according to the literature. Some authors claim to have accomplished favorable results, like prevention of local recurrence and adequate pain relief in metastatic disease, whereas toxicity was low (Fassnacht et al. 2006; Polat et al. 2009; Hermsen et al.

Other investigators recommend a more conservative approach, seeing that re-operations in a post-radiation tumor bed would be more difficult and that the favorable results are not all too convincing, given the retrospective character of research so far (Veytsman et al. 2009). One could argue that radiation therapy can be of use in a palliative setting, especially in alleviating pain or neurologic complaints caused by metastatic disease in bone or brain and that a prospective trial is needed to determine the efficacy in an

The insulin-like growth factor receptor (IGF-R) in adrenocortical carcinoma is regarded as a possible target for treatment. Both antibody and tyrosine kinase inhibitor trials targeted against IGF-R are in progress. A trial using sunitinib as therapeutic agent produced disappointing results, but a better understanding of the metabolic complexity of the disease might lead to better trials in the future. Other areas of interest are VEGFR inhibitors and

Due to limited evidence and guidelines, there are still multiple unresolved issues regarding management of incidentalomas, mainly concerning the duration of follow-up. The most important health risk in patients with an incidentaloma is related to several

FGFR inhibitors, but these have not been translated into clinical trials yet.

## **6.2 Surgery**

In their recent review article, Fassnacht and Allolio provide a flowchart for management of ACC, which advocates at least consideration of surgery in every stage of disease (Fassnacht & Allolio 2009). Surgery including metastasectomy should at least be considered in stage IV patients and should be pursued if technically feasible and if the patient is motivated and in appropriate physical condition. On the other hand, the absolute survival gain might not weigh up against morbidity after surgery in certain (older) patients. This implies that the decision to perform surgery should be tailored to individual cases and should be discussed in a multidisciplinary team including an experienced surgeon. An additional benefit in cases of hormonal overproduction is that surgery might help controlling hormonal excess (Fassnacht & Allolio 2009).

Repeat surgery should be considered individually, results indicate that this could be beneficial with regard to survival, especially if the interval between the two operations is more than 6 months (Allolio & Fassnacht 2006; Veytsman et al. 2009).

## **6.3 Mitotane**

Mitotane is the only adrenal-specific agent available for the treatment of ACC (Haak et al. 1994). The exact mechanism of action is not known, but it is proposed and generally accepted that mitotane is metabolized in adrenal mitochondria and causes cytotoxicity by oxidative damage through the production of free radicals (Veytsman et al. 2009). Whatever the exact pathway may be, the main effect is focal degeneration of the fascicular and (particularly) the reticular zone, which clinically leads to adrenal insufficiency for which glucocorticoid substitution is needed. (Hahner & Fassnacht 2005).

When describing results of mitotane, one should differentiate between antitumor- and antihormonal effects. Regarding antitumor activity, mitotane has been assessed in several clinical studies, with variable results. Most studies were retrospective and comprised only small numbers of patients. Results show that mitotane does have activity against ACC. Percentages vary, but most investigators report total or partial tumor responses in about 25% to 30% of cases.

Concerning hormone excess, therapy with mitotane is sufficient in the majority of patients. However, the onset of mitotane is slow due to its lipophilic properties and the resulting accumulation in adipose tissues. It can take up to three months before therapeutic levels are established, so in patients with severe hypercortisolism another agent must be used concurrently to treat this condition while mitotane levels are being built up. The recommended treatment in this situation would be ketoconazol, which is generally well tolerated. Other options, dependent on the case at hand, could be etomidate, mifeprestone or metyrapone (Igaz et al. 2008; Veytsman et al. 2009).

Mitotane treatment with a plasma concentration >14mg/L is associated with prolonged survival (Haak et al. 1994). Adverse effects occur in over 80% of patients and involve mainly the gastro-intestinal tract: anorexia, nausea, vomiting and diarrhea are frequently observed (Hahner & Fassnacht 2005). Reported symptoms caused by effects on the central nervous system are ataxia, speed disturbances, confusion and somnolence. Typically, all adverse effects are reversible after mitotane withdrawal (Lanser et al. 1992).

It is important to bear in mind that mitotane not only has adrenolytic effects, impairing adrenal steroidogenesis and thus inducing a need for replacement hydrocortisone, but also stimulates peripheral cortisol metabolism, so that hydrocortisone should be administered in higher doses. A second issue in managing patients on mitotane is monitoring thyroid hormone and thyroid stimulating hormone levels, as mitotane can decrease thyroid hormone as well. A third and possibly favorable interaction is the supposedly increased efficacy of cytotoxic chemotherapy when combined with mitotane. However, evidence on this topic is not conclusive. The proposed mechanism for this synergistic effect is the possible negative effect of mitotane on multidrug resistance proteins, as investigated in vitro, which could decrease the resistance of adrenocortical cancer cells to cytotoxic agents (Hahner & Fassnacht 2005; Igaz et al. 2008).

Given the rarity of the indication and use of mitotane, it is recommended to leave treatment with mitotane to experienced doctors who are familiar with possible adverse events and are able to manage them.

## **6.4 Cytotoxic chemotherapy**

304 Contemporary Aspects of Endocrinology

In their recent review article, Fassnacht and Allolio provide a flowchart for management of ACC, which advocates at least consideration of surgery in every stage of disease (Fassnacht & Allolio 2009). Surgery including metastasectomy should at least be considered in stage IV patients and should be pursued if technically feasible and if the patient is motivated and in appropriate physical condition. On the other hand, the absolute survival gain might not weigh up against morbidity after surgery in certain (older) patients. This implies that the decision to perform surgery should be tailored to individual cases and should be discussed in a multidisciplinary team including an experienced surgeon. An additional benefit in cases of hormonal overproduction is that surgery might help controlling hormonal excess

Repeat surgery should be considered individually, results indicate that this could be beneficial with regard to survival, especially if the interval between the two operations is

Mitotane is the only adrenal-specific agent available for the treatment of ACC (Haak et al. 1994). The exact mechanism of action is not known, but it is proposed and generally accepted that mitotane is metabolized in adrenal mitochondria and causes cytotoxicity by oxidative damage through the production of free radicals (Veytsman et al. 2009). Whatever the exact pathway may be, the main effect is focal degeneration of the fascicular and (particularly) the reticular zone, which clinically leads to adrenal insufficiency for which

When describing results of mitotane, one should differentiate between antitumor- and antihormonal effects. Regarding antitumor activity, mitotane has been assessed in several clinical studies, with variable results. Most studies were retrospective and comprised only small numbers of patients. Results show that mitotane does have activity against ACC. Percentages vary, but most investigators report total or partial tumor responses in about

Concerning hormone excess, therapy with mitotane is sufficient in the majority of patients. However, the onset of mitotane is slow due to its lipophilic properties and the resulting accumulation in adipose tissues. It can take up to three months before therapeutic levels are established, so in patients with severe hypercortisolism another agent must be used concurrently to treat this condition while mitotane levels are being built up. The recommended treatment in this situation would be ketoconazol, which is generally well tolerated. Other options, dependent on the case at hand, could be etomidate, mifeprestone

Mitotane treatment with a plasma concentration >14mg/L is associated with prolonged survival (Haak et al. 1994). Adverse effects occur in over 80% of patients and involve mainly the gastro-intestinal tract: anorexia, nausea, vomiting and diarrhea are frequently observed (Hahner & Fassnacht 2005). Reported symptoms caused by effects on the central nervous system are ataxia, speed disturbances, confusion and somnolence. Typically, all adverse

It is important to bear in mind that mitotane not only has adrenolytic effects, impairing adrenal steroidogenesis and thus inducing a need for replacement hydrocortisone, but also stimulates peripheral cortisol metabolism, so that hydrocortisone should be administered in higher doses. A second issue in managing patients on mitotane is monitoring thyroid

more than 6 months (Allolio & Fassnacht 2006; Veytsman et al. 2009).

glucocorticoid substitution is needed. (Hahner & Fassnacht 2005).

or metyrapone (Igaz et al. 2008; Veytsman et al. 2009).

effects are reversible after mitotane withdrawal (Lanser et al. 1992).

**6.2 Surgery** 

**6.3 Mitotane** 

25% to 30% of cases.

(Fassnacht & Allolio 2009).

Regarding cytotoxic chemotherapy, several combinations of agents have been tried so far. The highest response rates have been found in a trial with a treatment regimen combining mitotane with etoposide, doxorubicine and cisplatin (response rate 49%) and another trial with a treatment regimen combining mitotane and streptozotocine (response rate 36%) (Berruti et al. 2005), (Khan et al. 2000). Recently, these two regimens were compared in the First International Trial in Locally Advanced and Metastatic Adrenocortical Cancer (FIRM-ACT). Results of this trial are expected in 2011.

## **6.5 Radiation therapy**

Whether there is a place for radiation therapy in the treatment of adrenocortical carcinoma, is not yet clear according to the literature. Some authors claim to have accomplished favorable results, like prevention of local recurrence and adequate pain relief in metastatic disease, whereas toxicity was low (Fassnacht et al. 2006; Polat et al. 2009; Hermsen et al. 2010).

Other investigators recommend a more conservative approach, seeing that re-operations in a post-radiation tumor bed would be more difficult and that the favorable results are not all too convincing, given the retrospective character of research so far (Veytsman et al. 2009). One could argue that radiation therapy can be of use in a palliative setting, especially in alleviating pain or neurologic complaints caused by metastatic disease in bone or brain and that a prospective trial is needed to determine the efficacy in an adjuvant setting.

## **6.6 Future therapeutic agents**

The insulin-like growth factor receptor (IGF-R) in adrenocortical carcinoma is regarded as a possible target for treatment. Both antibody and tyrosine kinase inhibitor trials targeted against IGF-R are in progress. A trial using sunitinib as therapeutic agent produced disappointing results, but a better understanding of the metabolic complexity of the disease might lead to better trials in the future. Other areas of interest are VEGFR inhibitors and FGFR inhibitors, but these have not been translated into clinical trials yet.

## **7. Limitations**

Due to limited evidence and guidelines, there are still multiple unresolved issues regarding management of incidentalomas, mainly concerning the duration of follow-up. The most important health risk in patients with an incidentaloma is related to several

Adrenal Incidentaloma and Adrenocortical Carcinoma:

**9. Conclusion** 

research and trial participation.

12, 657-666.

Surg, 25, 914-926.

Clin Endocrinol. Metab, 91, 2027-2037.

Roentgenol., 196, W109-W111.

note. Surgery, 138, 1078-1085.

adrenal incidentalomas. Eur J Clin Invest, 41, 552-560.

Pract. Res. Clin Endocrinol. Metab, 23, 273-289.

**10. References** 

A Clinical Guideline on Treating the Unexpected and a Plea for Specialized Care 307

Due to the increasing discovery of adrenal incidentalomas, the diagnostic work-up as well as the management of incidentalomas is a growing public health challenge. Hormonal functionality and malignant potential of the lesion need to be evaluated. Incidentalomas are mostly benign nonhypersecretory adrenal adenomas, however important diagnoses to exclude are (subclinical) Cushing's Syndrome, primary aldosteronism, sex hormone overproduction, pheochromocytoma or malignancy (e.g. adrenocortical carcinoma, metastasis). Surgical treatment is recommended in all patients with a hormonally active tumor or a tumor larger than 6 cm. Furthermore, surgery may be indicated in individual cases depending on radiological characteristics. In patients with nonfunctioning adrenal adenomas smaller than 4 cm follow-up with CT-scan after 6-12 months and annual hormonal work-up for 4 years is recommended. An adrenocortical carcinoma is rare, but often lethal. Surgery is the cornerstone of initial treatment, whereas drug therapy with mitotane is inevitable in advanced stages. It is recommended that patients with adrenal disorders are treated in a multidisciplinary setting by experienced physicians. Centralization of care is strongly encouraged in order to improve patient outcome and to stimulate

Allolio,B. & Fassnacht,M. 2006. Clinical review: Adrenocortical carcinoma: clinical update. J

Androulakis,I.I., Kaltsas,G., Piaditis,G. & Grossman,A.B. 2011. The clinical significance of

Berruti,A., Terzolo,M., Sperone,P., Pia,A., Casa,S.D., Gross,D.J., Carnaghi,C., Casali,P.,

Boland,G.W. 2011. Adrenal imaging: why, when, what, and how? Part 3. The algorithmic

Cheah,W.K., Clark,O.H., Horn,J.K., Siperstein,A.E. & Duh,Q.Y. 2002. Laparoscopic adrenalectomy for pheochromocytoma. World J Surg, 26, 1048-1051. Dackiw,A.P., Lee,J.E., Gagel,R.F. & Evans,D.B. 2001. Adrenal cortical carcinoma. World J

Fassnacht,M. & Allolio,B. 2009. Clinical management of adrenocortical carcinoma. Best.

Fassnacht,M., Hahner,S., Polat,B., Koschker,A.C., Kenn,W., Flentje,M. & Allolio,B. 2006.

Gonzalez,R.J., Shapiro,S., Sarlis,N., Vassilopoulou-Sellin,R., Perrier,N.D., Evans,D.B. &

adrenocortical carcinoma. J Clin Endocrinol. Metab, 91, 4501-4504.

Gill,I.S. 2001. The case for laparoscopic adrenalectomy. J Urol., 166, 429-436.

Efficacy of adjuvant radiotherapy of the tumor bed on local recurrence of

Lee,J.E. 2005. Laparoscopic resection of adrenal cortical carcinoma: a cautionary

Porpiglia,F., Mantero,F., Reimondo,G., Angeli,A. & Dogliotti,L. 2005. Etoposide, doxorubicin and cisplatin plus mitotane in the treatment of advanced adrenocortical carcinoma: a large prospective phase II trial. Endocr. Relat Cancer,

approach to definitive characterization of the adrenal incidentaloma. AJR Am J

characteristics of the adrenal mass associated with a malignant mass or pheochromocytoma (Kievit & Haak 2000). The rate of growth of a benign adrenal lesion remains unclear. Besides this, the percentage of patients that will develop hormonal overproduction when initial analysis was negative is uncertain as well. Furthermore, there is some concern regarding the side effects of repeated CT imaging. One report estimated the risk of fatal cancer due to exposure to ionising radiation during CT-imaging to be one in 430-2170 (Androulakis et al. 2011). This is comparable to the chance of developing an adrenocortical carcinoma during 3-year follow-up of an incidentaloma. Additionally, a long follow-up period with repeated extensive hormonal work-up and radiological imaging is associated with high costs. Since the frequency of discovered adrenal incidentalomas is expected to increase and the use of abdominal imaging is also increasing, the cost-effectiveness of repeated hormonal work-up and imaging becomes an important issue in health care. However, in practice, choices of follow-up or treatment are also based on psychological or social mechanisms, such as anxiety, doubt and risk aversion as well as cost-effectiveness. To elucidate these uncertainties prospective trials are warranted to evaluate the optimal diagnostic approach and management of an incidentaloma and provide an answer for unresolved questions.

## **8. Organization of care**

The rarity of a number of adrenal disorders, such as ACC or pheochromocytoma, and the dismal prognosis associated with an adrenal malignancy, requires a multidisciplinary approach of each patient. In the event of an ACC, physicians often are not familiar with the disorder and its few available treatment options, resulting in inferior patient care. Given that a large part of diagnostics and management is based on pragmatism and expert opinion instead of prospective trials, additional studies concerning treatment and follow-up of adrenal tumors are necessary. In order to improve care in patients with adrenal disorders and stimulate scientific research, national and international collaboration is vital. In a number of European countries (France, Germany, Italy, The Netherlands), national networks have been set up to coordinate adrenal diseases-research and - patient care. (Koschker et al. 2006; van Ditzhuijsen et al. 2007)

In the southern region of The Netherlands, our hospital acts as a tertiary referral center for patients with adrenal tumors. We have provided local hospitals with a guideline for diagnostics and patient referral similar to the procedure described in this chapter. The subsequent centralization of these patients facilitates reliable pre-operative diagnostics and specialized surgery, of which the importance cannot be overemphasized. Too many patients each year see their chance of survival be ruined because an adrenal malignancy is not recognized before, during or even after surgery. Irradical resection and/or rupture of the tumor capsule in adrenocortical carcinoma is fatal without exception, but can often be prevented if treated by experienced doctors.

Therefore, we strongly support initiatives of centralization being deployed in other regions and countries, as the beneficial effects of specialization have been proven multiple times in other rare diseases (Sosa et al. 1998; Kumar et al. 2001). Centralization and multidisciplinary approach is associated with more complete resections, improved survival and enhanced patient care. A secondary benefit is the facilitation of scientific research and participation in clinical trials in centralized populations of patients with a rare disease.

## **9. Conclusion**

306 Contemporary Aspects of Endocrinology

characteristics of the adrenal mass associated with a malignant mass or pheochromocytoma (Kievit & Haak 2000). The rate of growth of a benign adrenal lesion remains unclear. Besides this, the percentage of patients that will develop hormonal overproduction when initial analysis was negative is uncertain as well. Furthermore, there is some concern regarding the side effects of repeated CT imaging. One report estimated the risk of fatal cancer due to exposure to ionising radiation during CT-imaging to be one in 430-2170 (Androulakis et al. 2011). This is comparable to the chance of developing an adrenocortical carcinoma during 3-year follow-up of an incidentaloma. Additionally, a long follow-up period with repeated extensive hormonal work-up and radiological imaging is associated with high costs. Since the frequency of discovered adrenal incidentalomas is expected to increase and the use of abdominal imaging is also increasing, the cost-effectiveness of repeated hormonal work-up and imaging becomes an important issue in health care. However, in practice, choices of follow-up or treatment are also based on psychological or social mechanisms, such as anxiety, doubt and risk aversion as well as cost-effectiveness. To elucidate these uncertainties prospective trials are warranted to evaluate the optimal diagnostic approach and management of an

The rarity of a number of adrenal disorders, such as ACC or pheochromocytoma, and the dismal prognosis associated with an adrenal malignancy, requires a multidisciplinary approach of each patient. In the event of an ACC, physicians often are not familiar with the disorder and its few available treatment options, resulting in inferior patient care. Given that a large part of diagnostics and management is based on pragmatism and expert opinion instead of prospective trials, additional studies concerning treatment and follow-up of adrenal tumors are necessary. In order to improve care in patients with adrenal disorders and stimulate scientific research, national and international collaboration is vital. In a number of European countries (France, Germany, Italy, The Netherlands), national networks have been set up to coordinate adrenal diseases-research and - patient care.

In the southern region of The Netherlands, our hospital acts as a tertiary referral center for patients with adrenal tumors. We have provided local hospitals with a guideline for diagnostics and patient referral similar to the procedure described in this chapter. The subsequent centralization of these patients facilitates reliable pre-operative diagnostics and specialized surgery, of which the importance cannot be overemphasized. Too many patients each year see their chance of survival be ruined because an adrenal malignancy is not recognized before, during or even after surgery. Irradical resection and/or rupture of the tumor capsule in adrenocortical carcinoma is fatal without exception, but can often be

Therefore, we strongly support initiatives of centralization being deployed in other regions and countries, as the beneficial effects of specialization have been proven multiple times in other rare diseases (Sosa et al. 1998; Kumar et al. 2001). Centralization and multidisciplinary approach is associated with more complete resections, improved survival and enhanced patient care. A secondary benefit is the facilitation of scientific research and participation in

clinical trials in centralized populations of patients with a rare disease.

incidentaloma and provide an answer for unresolved questions.

(Koschker et al. 2006; van Ditzhuijsen et al. 2007)

prevented if treated by experienced doctors.

**8. Organization of care** 

Due to the increasing discovery of adrenal incidentalomas, the diagnostic work-up as well as the management of incidentalomas is a growing public health challenge. Hormonal functionality and malignant potential of the lesion need to be evaluated. Incidentalomas are mostly benign nonhypersecretory adrenal adenomas, however important diagnoses to exclude are (subclinical) Cushing's Syndrome, primary aldosteronism, sex hormone overproduction, pheochromocytoma or malignancy (e.g. adrenocortical carcinoma, metastasis). Surgical treatment is recommended in all patients with a hormonally active tumor or a tumor larger than 6 cm. Furthermore, surgery may be indicated in individual cases depending on radiological characteristics. In patients with nonfunctioning adrenal adenomas smaller than 4 cm follow-up with CT-scan after 6-12 months and annual hormonal work-up for 4 years is recommended. An adrenocortical carcinoma is rare, but often lethal. Surgery is the cornerstone of initial treatment, whereas drug therapy with mitotane is inevitable in advanced stages. It is recommended that patients with adrenal disorders are treated in a multidisciplinary setting by experienced physicians. Centralization of care is strongly encouraged in order to improve patient outcome and to stimulate research and trial participation.

## **10. References**


Adrenal Incidentaloma and Adrenocortical Carcinoma:

Adrenocortical Carcinoma. World J Surg.

Endocrinol. Metab, 95, 4106-4113.

carcinoma. Cancer, 115, 2816-2823.

carcinoma. Surgery, 112, 963-970.

Cancer, 12, 667-680.

Pathol, 61, 1168-1173.

2372-2380.

65, 55-60.

Oncol.

potentially hazardous. Surgery, 142, 497-502.

thyroidectomy. Ann Surg, 228, 320-330.

Endocrinology BES 2010 Abstract, 3-72. 2010.

A Clinical Guideline on Treating the Unexpected and a Plea for Specialized Care 309

Miller,B.S., Ammori,J.B., Gauger,P.G., Broome,J.T., Hammer,G.D. & Doherty,G.M. 2010.

Nieman,L.K. 2010. Approach to the patient with an adrenal incidentaloma. J Clin

Polat,B., Fassnacht,M., Pfreundner,L., Guckenberger,M., Bratengeier,K., Johanssen,S.,

Pommier,R.F. & Brennan,M.F. 1992. An eleven-year experience with adrenocortical

Quayle,F.J., Spitler,J.A., Pierce,R.A., Lairmore,T.C., Moley,J.F. & Brunt,L.M. 2007. Needle

Schteingart,D.E., Doherty,G.M., Gauger,P.G., Giordano,T.J., Hammer,G.D., Korobkin,M.

Singh,P.K. & Buch,H.N. 2008. Adrenal incidentaloma: evaluation and management. J Clin

Sosa,J.A., Bowman,H.M., Tielsch,J.M., Powe,N.R., Gordon,T.A. & Udelsman,R. 1998. The

Stojadinovic,A., Ghossein,R.A., Hoos,A., Nissan,A., Marshall,D., Dudas,M., Cordon-

Terzolo,M., Angeli,A., Fassnacht,M., Daffara,F., Tauchmanova,L., Conton,P.A., Rossetto,R.,

Terzolo,M., Bovio,S., Pia,A., Reimondo,G. & Angeli,A. 2009. Management of adrenal

van Ditzhuijsen,C.I., van de,W.R. & Haak,H.R. 2007. Adrenocortical carcinoma. Neth. J Med,

Veytsman,I., Nieman,L. & Fojo,T. 2009. Management of Endocrine Manifestations and the

Young,W.F., Jr. 2000. Management approaches to adrenal incidentalomas. A view from Rochester, Minnesota. Endocrinol. Metab Clin North Am., 29, 159-85, x.

Use of Mitotane as a Chemotherapeutic Agent for Adrenocortical Carcinoma. J Clin

incidentaloma. Best. Pract. Res Clin Endocrinol. Metab, 23, 233-243.

morphologic, and molecular characterization. J Clin Oncol, 20, 941-950. Taylor A & Arlt,W. Urinary Steroid Profiling as a High-Throughput Screening Tool for the

Laparoscopic Resection is Inappropriate in Patients with Known or Suspected

Kenn,W., Hahner,S., Allolio,B. & Flentje,M. 2009. Radiotherapy in adrenocortical

biopsy of incidentally discovered adrenal masses is rarely informative and

& Worden,F.P. 2005. Management of patients with adrenal cancer: recommendations of an international consensus conference. Endocr. Relat

importance of surgeon experience for clinical and economic outcomes from

Cardo,C., Jaques,D.P. & Brennan,M.F. 2002. Adrenocortical carcinoma: clinical,

Detection of Malignancy in Patients with Adrenal Tumors. Society for

Buci,L., Sperone,P., Grossrubatscher,E., Reimondo,G., Bollito,E., Papotti,M., Saeger,W., Hahner,S., Koschker,A.C., Arvat,E., Ambrosi,B., Loli,P., Lombardi,G., Mannelli,M., Bruzzi,P., Mantero,F., Allolio,B., Dogliotti,L. & Berruti,A. 2007. Adjuvant mitotane treatment for adrenocortical carcinoma. N Engl J Med, 356,


Grumbach,M.M., Biller,B.M., Braunstein,G.D., Campbell,K.K., Carney,J.A., Godley,P.A.,

Haak,H.R., Hermans,J., van de Velde,C.J., Lentjes,E.G., Goslings,B.M., Fleuren,G.J. &

Hahner,S. & Fassnacht,M. 2005. Mitotane for adrenocortical carcinoma treatment. Curr.

Hamrahian,A.H., Ioachimescu,A.G., Remer,E.M., Motta-Ramirez,G., Bogabathina,H.,

Hermsen,I.G., Groenen,Y.E., Dercksen,M.W., Theuws,J. & Haak,H.R. 2010. Response to Radiation Therapy in Adrenocortical Carcinoma. J Endocrinol. Invest. Ichikawa,T., Mikami,K., Suzuki,H., Imamoto,T., Yamazaki,T., Naya,Y., Ueda,T., Igarashi,T.

Igaz,P., Tombol,Z., Szabo,P.M., Liko,I. & Racz,K. 2008. Steroid biosynthesis inhibitors in the therapy of hypercortisolism: theory and practice. Curr Med Chem., 15, 2734-2747. Khan,T.S., Imam,H., Juhlin,C., Skogseid,B., Grondal,S., Tibblin,S., Wilander,E., Oberg,K. &

Koschker,A.C., Fassnacht,M., Hahner,S., Weismann,D. & Allolio,B. 2006. Adrenocortical

Kumar,H., Daykin,J., Holder,R., Watkinson,J.C., Sheppard,M.C. & Franklyn,J.A. 2001. An

Lanser,J.B., van Seters,A.P., Moolenaar,A.J., Haak,H.R. & Bollen,E.L. 1992.

Leboulleux,S., Deandreis,D., Al,G.A., Auperin,A., Goere,D., Dromain,C., Elias,D., Caillou,B.,

Matsuda,T., Murota,T., Oguchi,N., Kawa,G. & Muguruma,K. 2002. Laparoscopic

effectiveness analysis. Endocrinol. Metab Clin North Am, 29, 69-ix.

specialist clinic settings. Clin Endocrinol. (Oxf), 54, 719-723.

Intern Med, 138, 424-429.

Opin. Investig. Drugs, 6, 386-394.

Pharmacother., 56 Suppl 1, 149s-153s.

Endocrinol. Diabetes, 114, 45-51.

symptoms. J Clin Oncol, 10, 1504.

carcinomatosis? Eur J Endocrinol..

56 Suppl 1, 132s-138s.

experience. J Clin Endocrinol. Metab, 90, 871-877.

Harris,E.L., Lee,J.K., Oertel,Y.C., Posner,M.C., Schlechte,J.A. & Wieand,H.S. 2003. Management of the clinically inapparent adrenal mass ("incidentaloma"). Ann

Krans,H.M. 1994. Optimal treatment of adrenocortical carcinoma with mitotane: results in a consecutive series of 96 patients. Br J Cancer, 69, 947-951.

Levin,H.S., Reddy,S., Gill,I.S., Siperstein,A. & Bravo,E.L. 2005. Clinical utility of noncontrast computed tomography attenuation value (hounsfield units) to differentiate adrenal adenomas/hyperplasias from nonadenomas: Cleveland Clinic

& Ito,H. 2002. Laparoscopic adrenalectomy for pheochromocytoma. Biomed.

Eriksson,B. 2000. Streptozocin and o,p'DDD in the treatment of adrenocortical cancer patients: long-term survival in its adjuvant use. Ann Oncol, 11, 1281-1287. Kievit,J. & Haak,H.R. 2000. Diagnosis and treatment of adrenal incidentaloma. A cost-

carcinoma -- improving patient care by establishing new structures. Exp. Clin

audit of management of differentiated thyroid cancer in specialist and non-

Neuropsychologic and neurologic side effects of mitotane and reversibility of

Travagli,J.P., De,B.T., Lumbroso,J., Young,J., Schlumberger,M. & Baudin,E. 2010. Adrenocortical carcinoma: is the surgical approach a risk factor of peritoneal

adrenalectomy for pheochromocytoma: a literature review. Biomed. Pharmacother.,


**14** 

*Portugal* 

Duarte Pignatelli1,2,3

*1Endocrinology, Hospital S. João, Porto* 

*3IPATIMUP, University of Porto* 

*2Faculty of Medicine of the University of Porto* 

**Adrenal Cortex Tumors and Hyperplasias** 

The adrenal cortex tumors include both malignant adrenal cortex cancers (ACC) and benign masses (ACT) that can be either secreting, of one of the hormones normally produced in the adrenal cortex (Cushing's syndrome if the hypersecretion is of cortisol or Conn's syndrome

The outer part of the adrenal glands, the adrenal cortex, is responsible for regulating important body functions including blood sugar levels, body water and salt levels, and consequently blood pressure and kidney functions, the immune system, the inflammatory response, the

The three different parts of the adrenal cortex, *zona glomerulosa*, *zona fasciculata* and *zona reticularis*, are responsible for producing different hormones namely mineralocorticoids, glucocorticoids, and androgens (and eventually also estrogens). The *glomerulosa* secretes aldosterone, and gives rise to Primary Aldosteronism (PA)/Hyperaldosteronism that can result either from an adenoma (Conn's syndrome) or from bilateral hyperplasia (BAH). The *zona fasciculata* secretes cortisol and adenomas that produce this hormone are associated to a distinct syndrome called Cushing's syndrome. Finally the adrenal cortex *reticularis* zone is supposed to produce adrenal androgens (namely dehydroepiandrosterone – DHEA and dehydroepiandrosterone sulfate – DHEA-s) that can in turn be either converted into testosterone or aromatized to estrogen in peripheral organs like the adipose tissue. In spite of the fact that normally this peripheral conversion is more important than the local production, there are adrenal cortex tumors that can produce testosterone directly, the Androgen-secreting tumors as well as adrenocortical carcinomas expressing aromatase and

The majority of adrenocortical tumors (ACT) are benign and silent (non-secreting adenomas or incidentalomas) since they do not ever result in hormone secretion. Its true incidence is still unknown because it is probable that many of these cases still go undiagnosed. However, it is estimated that they are present in at least 3% of the adult population (especially over 50 years of age) (National Institutes of Health, 2002; Grumbach et al., 2003). Most of these tumors are discovered incidentally due to the widespread availability of imaging studies for intra-abdominal diseases. This is the reason why they are designated as

physiological response to stress, and, finally, sexual and reproductive functions.

**1. Introduction** 

Incidentalomas.

if it is aldosterone) or non-secretory (Incidentalomas).

producing estrogens, the Estrogen-secreting tumors.


## **Adrenal Cortex Tumors and Hyperplasias**

## Duarte Pignatelli1,2,3

*1Endocrinology, Hospital S. João, Porto 2Faculty of Medicine of the University of Porto 3IPATIMUP, University of Porto Portugal* 

## **1. Introduction**

310 Contemporary Aspects of Endocrinology

Young,W.F., Jr. 2007. Clinical practice. The incidentally discovered adrenal mass. N. Engl. J

Zografos,G.N., Vasiliadis,G., Farfaras,A.N., Aggeli,C. & Digalakis,M. 2009. Laparoscopic

surgery for malignant adrenal tumors. JSLS., 13, 196-202.

Med, 356, 601-610.

The adrenal cortex tumors include both malignant adrenal cortex cancers (ACC) and benign masses (ACT) that can be either secreting, of one of the hormones normally produced in the adrenal cortex (Cushing's syndrome if the hypersecretion is of cortisol or Conn's syndrome if it is aldosterone) or non-secretory (Incidentalomas).

The outer part of the adrenal glands, the adrenal cortex, is responsible for regulating important body functions including blood sugar levels, body water and salt levels, and consequently blood pressure and kidney functions, the immune system, the inflammatory response, the physiological response to stress, and, finally, sexual and reproductive functions.

The three different parts of the adrenal cortex, *zona glomerulosa*, *zona fasciculata* and *zona reticularis*, are responsible for producing different hormones namely mineralocorticoids, glucocorticoids, and androgens (and eventually also estrogens). The *glomerulosa* secretes aldosterone, and gives rise to Primary Aldosteronism (PA)/Hyperaldosteronism that can result either from an adenoma (Conn's syndrome) or from bilateral hyperplasia (BAH). The *zona fasciculata* secretes cortisol and adenomas that produce this hormone are associated to a distinct syndrome called Cushing's syndrome. Finally the adrenal cortex *reticularis* zone is supposed to produce adrenal androgens (namely dehydroepiandrosterone – DHEA and dehydroepiandrosterone sulfate – DHEA-s) that can in turn be either converted into testosterone or aromatized to estrogen in peripheral organs like the adipose tissue. In spite of the fact that normally this peripheral conversion is more important than the local production, there are adrenal cortex tumors that can produce testosterone directly, the Androgen-secreting tumors as well as adrenocortical carcinomas expressing aromatase and producing estrogens, the Estrogen-secreting tumors.

The majority of adrenocortical tumors (ACT) are benign and silent (non-secreting adenomas or incidentalomas) since they do not ever result in hormone secretion. Its true incidence is still unknown because it is probable that many of these cases still go undiagnosed. However, it is estimated that they are present in at least 3% of the adult population (especially over 50 years of age) (National Institutes of Health, 2002; Grumbach et al., 2003). Most of these tumors are discovered incidentally due to the widespread availability of imaging studies for intra-abdominal diseases. This is the reason why they are designated as Incidentalomas.

Adrenal Cortex Tumors and Hyperplasias 313

 High nuclear grade (grades 3 or 4) (High Nuclear/Cytoplasm ratio; marked variation of nuclear characteristics; giant cells with hyperchromatic nuclei; visible

2. Larger nuclei, more irregular in shape and with visible nucleoli (at 400x

Diffuse architecture (>33% vs. ≤33% of the area) (cells unorganized in trabecular or

1. Nuclear grade: nuclear grade III and IV based on criteria of Fuhrman (Fuhrman et al., 1982). 2. Mitotic rate: greater than 5/50 HPF (x400 objective). According to Weiss, "mitosis was evaluated by counting 10 random high-power-fields in the area of the greatest numbers of mitotic figures on the five slides with greatest number of mitoses. If less than five slides were available for a case, a correspondingly greater number of fields per slide were used to make fifty high power-

distribution of chromosomes or an excessive number of mitotic spindles."

3. Atypical mitotic figures: "mitosis was regarded as atypical when it definitely showed an abnormal

4. Cytoplasm: presence of ≤25% "clear or vacuolated cells resembling the normal *zona fasciculata*." 5. Diffuse architecture: diffuse architecture was present "if greater than one-third of the tumor formed patternless sheets of cells." Trabecular, columnar, alveolar or nesting organizations were

6. Necrosis: necrosis was "regarded as present when occurring in at least confluent nests of cells." 7. Venous invasion: Weiss defined a vein as an "endothelial-lined vessel with smooth muscle as a

little supportive tissues." Only sinusoids located within the tumor were considered.

tumor extended into or through the capsule, with a corresponding stroma reaction."

8. Sinusoid invasion: a sinusoid was defined as "endothelial-lined vessel in the adrenal gland with

9. Invasion of tumor capsule: "invasion of the capsule was accepted as present when nests or cords of

3. Irregular nuclei, with larger size, with visible nucleoli (at 100x)

nucleoli)

magnification)

Mitoses (>5 per 50 HPF vs. <6)

Clear cells (≤25% vs. >25%)

alveolar structures) Necrosis (present vs. absent)

fields."

Abnormal mitoses (absent vs. present)

 Venous invasion (present vs. absent) Sinusoidal invasion (present vs. absent) Capsular invasion (present vs. absent)

regarded as non-diffuse patterns.

component of the wall."

Fig. 1. Weiss classification

1. Small roundish nuclei; without nucleoli

4. enormous cells with polylobulated nuclei

In summary, only a minority of the adrenocortical benign tumors (about 15%) are hormonesecreting adenomas, responsible for Cushing's syndrome, primary aldosteronism (Conn's syndrome) or even sometimes virilization.

Adrenocortical carcinoma is a rare, highly malignant tumor usually associated with a poor prognosis which may occur either in children or adults. This is a malignancy with an heterogeneous presentation and despite probably still underestimated it has an expected incidence of about 1-2 cases per 1 million population per year (Wajchenberg et al., 2000; Dackiw et al., 2001; Kebebew et al., 2006). Although the adrenocortical carcinomas may occur and develop at any age, two different disease peaks were identified, one before the age of five and the other in the fifth decade of life (Wajchenberg et al., 2000; Ng & Libertino, 2003).

## **2. Adrenal cortex cancer**

The evaluation and categorization of adrenocortical neoplasms remain among the most challenging areas in adrenal pathology (Lau & Weiss, 2009), since the pathological diagnosis of ACC, which is based on gross and microscopic criteria, is still full of areas of subjectivity. Moreover, in the absence of the gold standards that constitute the appearance of metastases, local invasion or recurrence, the diagnosis of malignancy may represent a great difficulty for both clinicians and pathologists.

Several multiparametric systems have been developed to assess this malignancy (Aubert, 2005). Among them, the Weiss system (Weiss, 1984), first introduced 25 years ago, and based on nine microscopic criteria, appears to be the most employed scoring methodology, because of its simplicity and reliability.

This system provides specific guidelines for differentiating adrenocortical adenoma from adrenocortical carcinoma and is considered the standard for determining malignancy in tumors of the adrenal cortex. However, considerable advances in the understanding of the pathology of adrenocortical neoplasias have occurred since delineation of the Weiss system, offering alternative approaches in the contemporary assessment of adrenocortical tumors (Lau & Weiss, 2009). In a recent study based on whole genome gene analysis the authors proposed a molecular assay for the classification and prognosis of adrenocortical tumors (Giordano et al., 2009). There were many genetic expression differences between ACC and ACT and normal adrenals. There were in fact 879 genes over expressed and 1011 under expressed in ACC that could differentiate ACC from ACT and normal adrenals. The most significant ones were related to cell proliferation, as would be expected. But the reality is that such systems are still very expensive and add very little to the diagnostic power of the morphological analyses. Therefore, in most adrenocortical tumors, the morphological approach considering the probability of malignancy in adrenal masses > 6 cm and that of being benign in tumors < 4 cm, together with the postoperative assessment by the Weiss system, brings sufficient elements to establish the differential diagnosis between a benign and a malignant tumor (Tissier, 2010).

The Weiss system, which, as previously was said, is currently the most popular scoring system, combines nine morphological parameters, of which three are structural ("dark" cytoplasm, diffuse architecture, necrosis), three are cytological (atypia, mitotic count, atypical mitotic figures) and three are related to invasion (of sinusoids, veins and tumor capsule) (Volante et al., 2008). The nine histological criteria are:

In summary, only a minority of the adrenocortical benign tumors (about 15%) are hormonesecreting adenomas, responsible for Cushing's syndrome, primary aldosteronism (Conn's

Adrenocortical carcinoma is a rare, highly malignant tumor usually associated with a poor prognosis which may occur either in children or adults. This is a malignancy with an heterogeneous presentation and despite probably still underestimated it has an expected incidence of about 1-2 cases per 1 million population per year (Wajchenberg et al., 2000; Dackiw et al., 2001; Kebebew et al., 2006). Although the adrenocortical carcinomas may occur and develop at any age, two different disease peaks were identified, one before the age of five and the other in the fifth decade of life (Wajchenberg et al., 2000; Ng & Libertino,

The evaluation and categorization of adrenocortical neoplasms remain among the most challenging areas in adrenal pathology (Lau & Weiss, 2009), since the pathological diagnosis of ACC, which is based on gross and microscopic criteria, is still full of areas of subjectivity. Moreover, in the absence of the gold standards that constitute the appearance of metastases, local invasion or recurrence, the diagnosis of malignancy may represent a great difficulty for

Several multiparametric systems have been developed to assess this malignancy (Aubert, 2005). Among them, the Weiss system (Weiss, 1984), first introduced 25 years ago, and based on nine microscopic criteria, appears to be the most employed scoring methodology,

This system provides specific guidelines for differentiating adrenocortical adenoma from adrenocortical carcinoma and is considered the standard for determining malignancy in tumors of the adrenal cortex. However, considerable advances in the understanding of the pathology of adrenocortical neoplasias have occurred since delineation of the Weiss system, offering alternative approaches in the contemporary assessment of adrenocortical tumors (Lau & Weiss, 2009). In a recent study based on whole genome gene analysis the authors proposed a molecular assay for the classification and prognosis of adrenocortical tumors (Giordano et al., 2009). There were many genetic expression differences between ACC and ACT and normal adrenals. There were in fact 879 genes over expressed and 1011 under expressed in ACC that could differentiate ACC from ACT and normal adrenals. The most significant ones were related to cell proliferation, as would be expected. But the reality is that such systems are still very expensive and add very little to the diagnostic power of the morphological analyses. Therefore, in most adrenocortical tumors, the morphological approach considering the probability of malignancy in adrenal masses > 6 cm and that of being benign in tumors < 4 cm, together with the postoperative assessment by the Weiss system, brings sufficient elements to establish the differential diagnosis between a benign

The Weiss system, which, as previously was said, is currently the most popular scoring system, combines nine morphological parameters, of which three are structural ("dark" cytoplasm, diffuse architecture, necrosis), three are cytological (atypia, mitotic count, atypical mitotic figures) and three are related to invasion (of sinusoids, veins and tumor

syndrome) or even sometimes virilization.

**2. Adrenal cortex cancer** 

both clinicians and pathologists.

because of its simplicity and reliability.

and a malignant tumor (Tissier, 2010).

capsule) (Volante et al., 2008). The nine histological criteria are:

2003).

	- 1. Small roundish nuclei; without nucleoli
	- 2. Larger nuclei, more irregular in shape and with visible nucleoli (at 400x magnification)
	- 3. Irregular nuclei, with larger size, with visible nucleoli (at 100x)
	- 4. enormous cells with polylobulated nuclei

Fig. 1. Weiss classification

Adrenal Cortex Tumors and Hyperplasias 315

**syndrome Gene (***locus***) Prevalence of ACT** 

*hCHK2* (22q12.1) ACC 3%-4%

*KCNQ1* (11p15) ACC 5%

*Menin gene* (11q13) ACT 25-50%;

ACC rare

(usual)

ACT in up to 82%;

ACC (rare) vs Hyperplasia

*TP53* (17p13), HIC-1 (17p13),

*IGF-II*, *H19*, *CDKN1C (p57kip2)*,

*Mostly CYP21B* (6p21.3)

 In LFS there is a germline mutation of the tumor suppressor gene TP53 in more than 70% of the families. Tumors associated with this syndrome include breast carcinoma; soft tissue sarcoma; brain tumors; osteosarcoma; leukemia and ACC. Mutations in Checkpoint Kinase 2 gene (hCHK2) encoding a kinase that phosphorylates TP53 were identified in some of these tumors but not in

 In BWS there is, on the contrary, deregulation of the imprinted IGF-II locus at 11p15. The IGF-II gene is maternally imprinted and so it's expressed only from the paternal allele. H19 and p57kip2 are paternally imprinted. In cases of paternal isodisomy, IGF-II is over-expressed and H19 and p57kip2 are under-expressed! BWS is a syndrome of "overgrowth" that includes many tumors like the renal' Wilms tumor, ACC, neuroblastoma and hepatoblastoma (Libé &

 In MEN-1 the germline mutation is in the Menin gene (90% of the families). This gene is also a tumor suppressor gene and it is located in chromosome 11 (11q13). LOH at 11q13 exist in more

Adapted from Soon P. et al., (2008). Molecular markers and the pathogenesis of adrenocortical cancer.

Table 1. Hereditary tumor syndromes, responsible genes and associated ACT prevalence

proliferation, through the IGF-I receptor (Fottner et al., 2001 and Logié et al., 1999).

In **sporadic ACC** it has been reported that hyper-expression of the insulin-like growth factor II (**IGF-II)** is observed in the vast majority of cases (Boulle et al., 1998; Gicquel et al., 1994; Gicquel et al., 1997; Gicquel et al., 2001; Ilvesmaki et al., 1993). Together with the increase of this growth factor there is also an increased expression of its receptor (IGF-IR) in most ACC (Weber et al., 1997). The over-expression of IGF-II is probably related to adrenal cancer cell

The IGF-II overexpression is the result of changes at the 11p15 locus (Gicquel et al., 1994; Gicquel et al., 1997). LOH at 11p15 is much more frequent in ACC (78,5%) than in ACT (9,5%) (Gicquel et al., 2001). It is associated with a higher risk of tumor recurrence, and correlates with Weiss score. Thus, according to Gicquel and colleagues, 11p15 alterations could be used as a biological marker for confirming ACC malignancy after surgical removal

than 90% of ACC (Kjellman et al., 1999; Schulte et al., 2000; Heppner et al., 1999)

**Hereditary tumor** 

**Li-Fraumeni syndrome** 

**Beckwith-Wiedemann** 

**Multiple Endocrine** 

**Congenital Adrenal** 

Bertherat, 2005).

The Oncologist 13: 548-561

of the tumor (Gicquel et al., 2001).

ACC (Libé & Bertherat, 2005).

**(LFS)** 

**syndrome (BWS)** 

**Neoplasia 1 (MEN-1)** 

**Hyperplasia (CAH)** 

Tumors are classified as malignant when they meet 4 or more of these histological criteria. However, it must be stated that there are still some difficulties and subjectivity in the application of this system. Also, whether the presence of 3 criteria represents malignancy, is still controversial (Aubert et al., 2005). But, despite the referred limitations and subjectivity the Weiss classification is still the most reliable and most used criteria system.

Other markers not included in the Weiss scores are now perfectly identified as being associated with the risk of recurrence and lower survival. Ki67 expression ≥ 10% for instance is associated with much less chances of survival at 5 years. The same can be said about a high expression of SF-1. The immuno-histochemistry of these two factors is now routine in most pathology labs. (Fassnacht et al., 2011; Sbiera et al., 2010; Terzolo et al., 2001)

## **2.1 Adrenal cortex cancer pathogenesis**

Molecular studies support the fact that uncontrolled cell proliferation is probably the most important factor in the development of cancers and ACC is no exception. ACC consist of monoclonal populations of cells (Beuschlein et al., 1994) while for instance adrenocortical macronodular hyperplasias are usually polyclonal. It is a basic rule that the mutations that give rise to cancer development are deletions of tumor suppressor genes or amplifications of oncogenes. The increase in cell proliferation induced by growth factors like the IGFs, bFGF or TGF β1 (Feige et al., 1991; Mesiano et al., 1991; Mesiano et al., 1993) leads to the development of polyclonal tumors but also renders the cells more susceptible to mutations in tumor suppressor genes or in oncogenes and if these mutations give those cells a genetic advantage, cancer development may ensue. Genomic instability is the basis of gross chromosomal alterations and aneuploidy (Giordano et al., 2009).

Most cases of adrenocortical cancers appear to be sporadic and only a small percentage of patients present ACC as a component of one of the known hereditary cancer syndromes, such as the Li-Fraumeni's syndrome, the Beckwith-Wiedemann syndrome or the Multiple Endocrine Neoplasia type 1 (Koch et al., 2002; Sidhu et al., 2004; Libé & Bertherat, 2005; Kjellman et al., 1999; Schulte et al., 2000; Heppner et al., 1999).

One important difference between these two forms of adrenocortical carcinomas (either sporadic or part of an hereditary syndrome) is the current degree of knowledge about its tumorigenesis (Soon et al., 2008). For sporadic adrenocortical malignant tumors the molecular mechanisms underlying its development are still far from completely understood (Sidhu et al, 2002). One hypothesis refers the possible evolution of adrenocortical cancers from adrenal adenomas (Bernard et al., 2003); however long-term follow-up data of incidentally discovered adrenal neoplasms do not support that hypothesis (Barzon et al., 2003; Bernini et al., 2005).

The study and investigation of the pathophysiology of ACC is not only crucial for the understanding of these malignant tumors but also for the development of more sensitive means of diagnosis and better ways of treatment. And despite the fact that knowledge of these tumors has greatly evolved in the last decades, the understanding of the genes and pathways underlying the development of adrenal cortex cancers has been slow. Many genes and pathways are thought to play an important role in their development but frequently their biological plausibility is still missing.

Tumors are classified as malignant when they meet 4 or more of these histological criteria. However, it must be stated that there are still some difficulties and subjectivity in the application of this system. Also, whether the presence of 3 criteria represents malignancy, is still controversial (Aubert et al., 2005). But, despite the referred limitations and subjectivity the Weiss classification is still the most reliable and most used criteria

Other markers not included in the Weiss scores are now perfectly identified as being associated with the risk of recurrence and lower survival. Ki67 expression ≥ 10% for instance is associated with much less chances of survival at 5 years. The same can be said about a high expression of SF-1. The immuno-histochemistry of these two factors is now routine in most pathology labs. (Fassnacht et al., 2011; Sbiera et al., 2010; Terzolo et al.,

Molecular studies support the fact that uncontrolled cell proliferation is probably the most important factor in the development of cancers and ACC is no exception. ACC consist of monoclonal populations of cells (Beuschlein et al., 1994) while for instance adrenocortical macronodular hyperplasias are usually polyclonal. It is a basic rule that the mutations that give rise to cancer development are deletions of tumor suppressor genes or amplifications of oncogenes. The increase in cell proliferation induced by growth factors like the IGFs, bFGF or TGF β1 (Feige et al., 1991; Mesiano et al., 1991; Mesiano et al., 1993) leads to the development of polyclonal tumors but also renders the cells more susceptible to mutations in tumor suppressor genes or in oncogenes and if these mutations give those cells a genetic advantage, cancer development may ensue. Genomic instability is the basis of gross chromosomal alterations and aneuploidy

Most cases of adrenocortical cancers appear to be sporadic and only a small percentage of patients present ACC as a component of one of the known hereditary cancer syndromes, such as the Li-Fraumeni's syndrome, the Beckwith-Wiedemann syndrome or the Multiple Endocrine Neoplasia type 1 (Koch et al., 2002; Sidhu et al., 2004; Libé & Bertherat, 2005;

One important difference between these two forms of adrenocortical carcinomas (either sporadic or part of an hereditary syndrome) is the current degree of knowledge about its tumorigenesis (Soon et al., 2008). For sporadic adrenocortical malignant tumors the molecular mechanisms underlying its development are still far from completely understood (Sidhu et al, 2002). One hypothesis refers the possible evolution of adrenocortical cancers from adrenal adenomas (Bernard et al., 2003); however long-term follow-up data of incidentally discovered adrenal neoplasms do not support that hypothesis (Barzon et al.,

The study and investigation of the pathophysiology of ACC is not only crucial for the understanding of these malignant tumors but also for the development of more sensitive means of diagnosis and better ways of treatment. And despite the fact that knowledge of these tumors has greatly evolved in the last decades, the understanding of the genes and pathways underlying the development of adrenal cortex cancers has been slow. Many genes and pathways are thought to play an important role in their development but frequently

Kjellman et al., 1999; Schulte et al., 2000; Heppner et al., 1999).

system.

2001)

**2.1 Adrenal cortex cancer pathogenesis** 

(Giordano et al., 2009).

2003; Bernini et al., 2005).

their biological plausibility is still missing.



Adapted from Soon P. et al., (2008). Molecular markers and the pathogenesis of adrenocortical cancer. The Oncologist 13: 548-561

Table 1. Hereditary tumor syndromes, responsible genes and associated ACT prevalence

In **sporadic ACC** it has been reported that hyper-expression of the insulin-like growth factor II (**IGF-II)** is observed in the vast majority of cases (Boulle et al., 1998; Gicquel et al., 1994; Gicquel et al., 1997; Gicquel et al., 2001; Ilvesmaki et al., 1993). Together with the increase of this growth factor there is also an increased expression of its receptor (IGF-IR) in most ACC (Weber et al., 1997). The over-expression of IGF-II is probably related to adrenal cancer cell proliferation, through the IGF-I receptor (Fottner et al., 2001 and Logié et al., 1999).

The IGF-II overexpression is the result of changes at the 11p15 locus (Gicquel et al., 1994; Gicquel et al., 1997). LOH at 11p15 is much more frequent in ACC (78,5%) than in ACT (9,5%) (Gicquel et al., 2001). It is associated with a higher risk of tumor recurrence, and correlates with Weiss score. Thus, according to Gicquel and colleagues, 11p15 alterations could be used as a biological marker for confirming ACC malignancy after surgical removal of the tumor (Gicquel et al., 2001).

Adrenal Cortex Tumors and Hyperplasias 317

(Gordon & Nusse, 2006). Curiously, in adrenocortical tumors, the accumulation of βcatenin has been found in both benign and malignant situations although with a slightly higher prevalence in adrenal cortex cancer (Tissier et al., 2005). It is a fact that β-catenin mutations are the most frequent genetic defects reported in adrenocortical adenomas and in these benign ACT it is mostly the non-secretory adenomas that have these mutations (Tissier et al., 2005). According to that study, abnormal cytoplasmic and/or nuclear accumulation of β-catenin was found in 38% of the adrenocortical adenomas (ACA) and in 77% of the ACC, but mutations in the β-catenin gene were found with similar frequencies of in both ACA and ACC (27% *vs.* 31%) (Tissier et al., 2005). These somewhat opposite results suggest that other components of the Wnt signaling pathway, such as the adenomatous polyposis coli (APC) or axin, may be contributing to the pathogenesis of

Adrenocortical tumors can be classified as functional, when their hormonal secretions result in clinical consequences, or nonfunctional tumors, when they do not secrete hormones in a sufficient level to produce clinical consequences. About 50 to 60% of the adrenocortical carcinomas are functional, therefore, associated with hormonal secretion (Ng & Libertino, 2003; Allolio & Fassnacht, 2006). The most frequent presentation among adults is the Cushing's syndrome alone (45%) or the association of Cushing's syndrome with a virilization syndrome, with over-production of both glucocorticoids and androgens (25%) (Ng & Libertino, 2003; Wajchenberg et al., 2000). Other forms of functional tumors include the virilization syndrome alone and the feminization syndrome. Thus, signs and symptoms of adrenocortical tumors may vary significantly according to their origin and depending on the type of hormones that are released. Cortisol excess can be associated to symptoms such as centripetal obesity, protein wasting with skin thinning and striae, muscle atrophy (myopathy), osteoporosis, psychiatric disturbances, impaired defense against infections, diabetes, hypertension and gonadal dysfunction in men and women. In the case of aggressive malignant ACC weight loss may be observed. Androgen over-secretion is associated with various manifestations in women like hirsutism, menstrual abnormalities, infertility and eventually virilization, while excess of estrogen, although not so common, can present as gynecomastia in men. It is most important to characterize the adrenocortical carcinoma's secretory profile in order to establish its origin and better guide its treatment and follow-

Due to the elevated possibility of non-specific symptoms, both symptomatic and

According to the European Network for the Study of Adrenal Tumors (ENSAT), both should be studied with the following laboratory tests to determine the secretory activity of

adrenal androgens (DHEA-s, androstenedione, testosterone, 17-OH progesterone);

cortisol and adrenocorticotropic hormone (ACTH) both fasting and around midnight

apparently asymptomatic patients should be evaluated.

serum estradiol in men and postmenopausal women;

**2.2 Adrenal cortex cancer – Diagnosis and clinical presentation** 

ACC (Tissier et al., 2005).

up (Libé et al., 2007).

serum potassium;

the tumor (Fassnacht & Allolio, 2009): fasting blood glucose and HbA1c;

(in the serum or in the saliva);

The 11p15 region is organized in a telomeric domain containing the IGF-II gene and H19 and a centromeric domain including the CDKN1C (p57kip2) (DeChiara et al., 1991; Hao et al., 1993; Lee et al., 1995; Matsuoka et al., 1995). Genetic and epigenetic changes in the imprinted 11p15 region resulting in low p57kip2 and H19 and elevated IGF2 mRNA expression levels have been reported in sporadic ACCs (Gicquel et al., 1994; Gicquel et al., 1997). The IGF-II system, in the adrenal gland, is responsible for growth-promoting and differentiating functions during the fetal period (Mesiano et al., 1993), but its role has been largely documented in adrenocortical malignant tumors, also in adult patients (Gicquel et al., 2001). In fact, several studies have been successful in showing the strong overexpression of IGF-II in malignant adrenocortical tumors (in approximately 90%of the cases) (Boulle et al., 1998; Gicquel et al., 1994; Gicquel et al., 1997; Gicquel et al., 2001; Ilvesmaki et al., 1993a).

Inactivating mutations of the **TP53 gene** located at the 17p13 locus are another genetic alteration that is frequently encountered in ACC. TP53 is one of the most relevant tumor suppressor genes, frequently mutated in human cancers. The TP53 mutations are thought to happen late in the evolution of sporadic malignant adrenocortical tumors. Mutations in the exons 5-8 are found more frequently in ACC than in ACT (Hollstein et al., 1991; Reincke et al., 1994). The germline mutations in TP53 have been observed in 50- 80% of children diagnosed with sporadic ACC (Libé & Bertherat, 2005; Wagner et al., 1994; Varley et al., 1999). In southern Brazil where the prevalence of ACC in children is 10 times greater than in the rest of the world, there is a particular mutation at exon 10 of TP53 (Arginine 337 Histidine) in most of the cases (Ribeiro et al., 2001; Latronico et al., 2001).

Considering TP 53 gene mutations in sporadic ACC in adults, its frequency has been reported in different proportions in diverse studies ranging from 25% to 70%. (Ohgaki et al., 1993; Reincke et al., 1994; Barzon et al., 2001; Lin et al., 1994) Loss of Heterozigoty (LOH) at 17p13 was reported in 95% of ACC and only in 30% of ACT (Gicquel et al., 2001) and therefore this can also be used as a marker of malignancy.

Other reported molecular studies have suggested that genetic alterations of the **Wnt signaling pathway** may also be associated with the development of adrenocortical tumors. In fact the activation of the Wnt signaling pathway is the most prevalent defect in adrenocortical tumorigenesis particularly due to the fact that it is not only present in malignant lesions but in benign adrenocortical adenomas as well (Tissier et al., 2005).

The Wnt family includes a group of growth factors involved in developmental and homeostatic processes. Some regulatory genes in this pathway (including the down regulators of β-catenin, GSK3, Axin and APC, and β-catenin itself) can be mutated in primary human cancers (Polakis et al., 2000). In all of them the common denominator is the activation of gene transcription by β-catenin (via the transcription factors TCF and LEF).

β-catenin has a dual function in the cell: cell-adhesion (conjugated with E-cadherin) and transcriptional regulation. When the regulators of β-catenin are down-regulated the transcriptional function is increased and the adhesion is reduced and both of these alterations lead to the progression of malignancies (Brembeck et al., 2006).

Genetic alterations in the Wnt pathway conducting to β-catenin accumulation in the cytoplasm have been correlated with the pathogenesis of different types of cancer

The 11p15 region is organized in a telomeric domain containing the IGF-II gene and H19 and a centromeric domain including the CDKN1C (p57kip2) (DeChiara et al., 1991; Hao et al., 1993; Lee et al., 1995; Matsuoka et al., 1995). Genetic and epigenetic changes in the imprinted 11p15 region resulting in low p57kip2 and H19 and elevated IGF2 mRNA expression levels have been reported in sporadic ACCs (Gicquel et al., 1994; Gicquel et al., 1997). The IGF-II system, in the adrenal gland, is responsible for growth-promoting and differentiating functions during the fetal period (Mesiano et al., 1993), but its role has been largely documented in adrenocortical malignant tumors, also in adult patients (Gicquel et al., 2001). In fact, several studies have been successful in showing the strong overexpression of IGF-II in malignant adrenocortical tumors (in approximately 90%of the cases) (Boulle et al., 1998; Gicquel et al., 1994; Gicquel et al., 1997; Gicquel et al., 2001;

Inactivating mutations of the **TP53 gene** located at the 17p13 locus are another genetic alteration that is frequently encountered in ACC. TP53 is one of the most relevant tumor suppressor genes, frequently mutated in human cancers. The TP53 mutations are thought to happen late in the evolution of sporadic malignant adrenocortical tumors. Mutations in the exons 5-8 are found more frequently in ACC than in ACT (Hollstein et al., 1991; Reincke et al., 1994). The germline mutations in TP53 have been observed in 50- 80% of children diagnosed with sporadic ACC (Libé & Bertherat, 2005; Wagner et al., 1994; Varley et al., 1999). In southern Brazil where the prevalence of ACC in children is 10 times greater than in the rest of the world, there is a particular mutation at exon 10 of TP53 (Arginine 337 Histidine) in most of the cases (Ribeiro et al., 2001; Latronico et al.,

Considering TP 53 gene mutations in sporadic ACC in adults, its frequency has been reported in different proportions in diverse studies ranging from 25% to 70%. (Ohgaki et al., 1993; Reincke et al., 1994; Barzon et al., 2001; Lin et al., 1994) Loss of Heterozigoty (LOH) at 17p13 was reported in 95% of ACC and only in 30% of ACT (Gicquel et al., 2001) and

Other reported molecular studies have suggested that genetic alterations of the **Wnt signaling pathway** may also be associated with the development of adrenocortical tumors. In fact the activation of the Wnt signaling pathway is the most prevalent defect in adrenocortical tumorigenesis particularly due to the fact that it is not only present in malignant lesions but in benign adrenocortical adenomas as well (Tissier et al., 2005). The Wnt family includes a group of growth factors involved in developmental and homeostatic processes. Some regulatory genes in this pathway (including the down regulators of β-catenin, GSK3, Axin and APC, and β-catenin itself) can be mutated in primary human cancers (Polakis et al., 2000). In all of them the common denominator is the activation of gene transcription by β-catenin (via the transcription factors TCF and

β-catenin has a dual function in the cell: cell-adhesion (conjugated with E-cadherin) and transcriptional regulation. When the regulators of β-catenin are down-regulated the transcriptional function is increased and the adhesion is reduced and both of these

Genetic alterations in the Wnt pathway conducting to β-catenin accumulation in the cytoplasm have been correlated with the pathogenesis of different types of cancer

alterations lead to the progression of malignancies (Brembeck et al., 2006).

therefore this can also be used as a marker of malignancy.

Ilvesmaki et al., 1993a).

2001).

LEF).

(Gordon & Nusse, 2006). Curiously, in adrenocortical tumors, the accumulation of βcatenin has been found in both benign and malignant situations although with a slightly higher prevalence in adrenal cortex cancer (Tissier et al., 2005). It is a fact that β-catenin mutations are the most frequent genetic defects reported in adrenocortical adenomas and in these benign ACT it is mostly the non-secretory adenomas that have these mutations (Tissier et al., 2005). According to that study, abnormal cytoplasmic and/or nuclear accumulation of β-catenin was found in 38% of the adrenocortical adenomas (ACA) and in 77% of the ACC, but mutations in the β-catenin gene were found with similar frequencies of in both ACA and ACC (27% *vs.* 31%) (Tissier et al., 2005). These somewhat opposite results suggest that other components of the Wnt signaling pathway, such as the adenomatous polyposis coli (APC) or axin, may be contributing to the pathogenesis of ACC (Tissier et al., 2005).

## **2.2 Adrenal cortex cancer – Diagnosis and clinical presentation**

Adrenocortical tumors can be classified as functional, when their hormonal secretions result in clinical consequences, or nonfunctional tumors, when they do not secrete hormones in a sufficient level to produce clinical consequences. About 50 to 60% of the adrenocortical carcinomas are functional, therefore, associated with hormonal secretion (Ng & Libertino, 2003; Allolio & Fassnacht, 2006). The most frequent presentation among adults is the Cushing's syndrome alone (45%) or the association of Cushing's syndrome with a virilization syndrome, with over-production of both glucocorticoids and androgens (25%) (Ng & Libertino, 2003; Wajchenberg et al., 2000). Other forms of functional tumors include the virilization syndrome alone and the feminization syndrome. Thus, signs and symptoms of adrenocortical tumors may vary significantly according to their origin and depending on the type of hormones that are released. Cortisol excess can be associated to symptoms such as centripetal obesity, protein wasting with skin thinning and striae, muscle atrophy (myopathy), osteoporosis, psychiatric disturbances, impaired defense against infections, diabetes, hypertension and gonadal dysfunction in men and women. In the case of aggressive malignant ACC weight loss may be observed. Androgen over-secretion is associated with various manifestations in women like hirsutism, menstrual abnormalities, infertility and eventually virilization, while excess of estrogen, although not so common, can present as gynecomastia in men. It is most important to characterize the adrenocortical carcinoma's secretory profile in order to establish its origin and better guide its treatment and followup (Libé et al., 2007).

Due to the elevated possibility of non-specific symptoms, both symptomatic and apparently asymptomatic patients should be evaluated.

According to the European Network for the Study of Adrenal Tumors (ENSAT), both should be studied with the following laboratory tests to determine the secretory activity of the tumor (Fassnacht & Allolio, 2009):


Adrenal Cortex Tumors and Hyperplasias 319

cut-off for distinguishing adrenocortical carcinomas from benign adrenal tumors, according to several studies (Boland et al., 1998; Hamrahian et al., 2005). However, in those cases of benign tumors with poor intracytoplasmatic lipid concentration a better discrimination can be obtained by searching for a delayed contrast clearance in contrastenhanced CT. In this case, tumors measuring > 10HU in a unenhanced CT, that show a contrast washout of less than 50% after 10- to 15-min of contrast-enhanced CT and also a delayed attenuation of more than 35HU, are suspicious for malignancy (Szolar et al., 2005;

The use of MRI for differentiating benign and malignant adrenocortical tumors is equally effective to CT scan. But since MRI is more expensive and less standardized, CT scan

The utilization of the PET scanning with fluorodeoxyglucose (FDG) has been successful in identifying unilateral adrenal tumors with higher suspicion for malignancy, due to the greater reported uptake of FDG by malignant tumors compared to the benign adrenocortical tumors (Groussin et al., 2009; Maurea et al. 2001; Minn et al., 2004). The use of integrated PET-CT can further improve the capacity to distinguish between malignant and benign tumors by increasing the quality of the image. This improvement is also due to the combination of CT attenuation measurements with the intensity of FDG uptake, as described by the standardized uptake value (SUV) for the adrenal lesion (Metser et al., 2006;

In what concerns **fine-needle aspiration biopsy** (FNA) one must stress that usually it is not successful in distinguishing between malignant and benign tumors and there are doubts about the risk of disseminating a carcinoma through the abdominal cavity; it can however be of some utility in differentiating an adrenal tumor from a metastasis to the adrenal and in evaluating staging for a known cancer (Jhala et al., 2004; Kocijancic et al.,

The first staging system published by the World Health Organization (WHO) dates from in 2004 (DeLellis, 2004), and was based on different staging systems, such as the Sullivan modification of the Macfarlane system (Sullivan, 1978). The AJCC (American Joint Committee on Cancer)/UICC (International Union Against Cancer) developed a TNM staging system with the same definitions for the first time in 2009, being published on the AJCC/UICC Cancer Staging Manual, Seventh Edition. A simplified classification system was recently proposed by the European network ENSAT in which stage III includes cases with lymph nodes metastasis, infiltration of surrounding tissues and venous tumor thrombosis and stage IV only cases with distant metastases (Fassnacht et

Tumor clinical staging is most dependent of clinical examination and radiographic imaging in order to evaluate the size of the primary tumor and the extent of local and distant disease. Since disease-free and overall survival rates seem to be strongly related with tumor staging, resection of the primary tumor and examination of local extension of the disease and regional lymph nodes involvement should be performed for a better pathologic tumor

The following table describes the AJCC/UICC anatomic stages and prognostic groups:

Caoili et al., 2002).

Caoili et al., 2007).

**2.3 Adrenal cortex cancer staging** 

2004).

al., 2009).

staging.

remains the primary adrenal imaging procedure,


After careful hormonal assessment, imaging studies, by means of computerized tomography (CT), magnetic resonance imaging (MRI) or 18 F-fluorodeoxyglucose positron emission tomography (FDG-PET), are the next essential exams both to localize and delimitate the tumor and to distinguish benign adenomas from adrenocortical carcinomas (Boland et al., 1998; Hamrahian et al., 2005; Szolaret al., 2005; Caoili et al., 2002; Groussin et al., 2009; Minn et al., 2004; Metser et al., 2006 Wajchenberg et al., 2000). Despite sometimes being considered a controversial position, several studies have shown that the size and the appearance of the tumor remains one of the best indicators of malignancy (most molecular studies add only a little to the accuracy of malignancy identification by the mere determination of tumor size). In a study from the National Italian Study Group on Adrenal Tumors including 887 patients with adrenal incidentalomas, adrenocortical carcinomas were significantly associated with mass size, with 90% being more than 4 cm in diameter when discovered (Angeli et al., 1997). According, to a study by Sturgeon and colleagues at the University of California (San Francisco) including 457 ACC cases, a size of ≥4 cm makes the likelihood of malignancy double (to 10%) while in tumors ≥8 cm it gets more than ninefold higher (47%) (Sturgeon et al., 2006).

However, because of the growing evidence of adrenocortical cancers diagnosed with a diameter between 4 and 6 cm (Sturgeon et al., 2006; Grumbach et al., 2003; Herrera et al., 1991; Mantero et al., 2000) and since it seems evident that during their early stages of development, carcinomas have to be small, it becomes clear that surgical intervention would be most beneficial the smaller and more localized the tumor would be.

Overall, prognosis does improve for patients with smaller adrenocortical tumors at the time of diagnosis. In a retrospective review of 62 ACC cases (Henley et al., 1983) patients with stages I to III lesions who underwent curative resections had significantly longer survival rates. In another study done by Fassnacht and colleagues, the five year survival significantly improved (82% *vs* 18%) for patients with smaller tumors (stages I and II, confined to the adrenal gland) vs. metastatic disease, stage IV (Fassnacht et al., 2009).

As general rules, one could say that the prognosis is better in the case of young children, in smaller and localized tumors specially if nonfunctioning and in which a complete resection can be achieved.

Despite the importance of evaluating an adrenal mass size and appearance, this should not be the only parameter guiding diagnosis and posterior treatment, since radiographic features are often of strong predictive value (Dunnick et al., 1996). MRI and CT images may in fact be useful in helping to define what will be the histological type of the adrenal tumor:

On unenhanced CT scanning, the measurements of Hounsfield units (HU) are of great value in differentiating malignant from benign adrenocortical tumors. The Hounsfield scale is a semi-quantitative method of measuring x-ray attenuation. Despite the fact that around 30% of adenomas do not contain large amounts of lipid, being indistinguishable from non-adenomas, adrenal masses with < 10 HU on unenhanced CT are almost certainly benign tumors (Grumbach et al., 2003). Therefore, this seems to be the consensus

fasting serum cortisol at 8 AM following a 1 mg dose of dexamethasone on the previous

After careful hormonal assessment, imaging studies, by means of computerized tomography (CT), magnetic resonance imaging (MRI) or 18 F-fluorodeoxyglucose positron emission tomography (FDG-PET), are the next essential exams both to localize and delimitate the tumor and to distinguish benign adenomas from adrenocortical carcinomas (Boland et al., 1998; Hamrahian et al., 2005; Szolaret al., 2005; Caoili et al., 2002; Groussin et al., 2009; Minn et al., 2004; Metser et al., 2006 Wajchenberg et al., 2000). Despite sometimes being considered a controversial position, several studies have shown that the size and the appearance of the tumor remains one of the best indicators of malignancy (most molecular studies add only a little to the accuracy of malignancy identification by the mere determination of tumor size). In a study from the National Italian Study Group on Adrenal Tumors including 887 patients with adrenal incidentalomas, adrenocortical carcinomas were significantly associated with mass size, with 90% being more than 4 cm in diameter when discovered (Angeli et al., 1997). According, to a study by Sturgeon and colleagues at the University of California (San Francisco) including 457 ACC cases, a size of ≥4 cm makes the likelihood of malignancy double (to 10%) while in tumors ≥8 cm it gets more than ninefold higher (47%) (Sturgeon et

However, because of the growing evidence of adrenocortical cancers diagnosed with a diameter between 4 and 6 cm (Sturgeon et al., 2006; Grumbach et al., 2003; Herrera et al., 1991; Mantero et al., 2000) and since it seems evident that during their early stages of development, carcinomas have to be small, it becomes clear that surgical intervention would

Overall, prognosis does improve for patients with smaller adrenocortical tumors at the time of diagnosis. In a retrospective review of 62 ACC cases (Henley et al., 1983) patients with stages I to III lesions who underwent curative resections had significantly longer survival rates. In another study done by Fassnacht and colleagues, the five year survival significantly improved (82% *vs* 18%) for patients with smaller tumors (stages I and II, confined to the adrenal gland) vs. metastatic disease, stage IV (Fassnacht et al.,

As general rules, one could say that the prognosis is better in the case of young children, in smaller and localized tumors specially if nonfunctioning and in which a complete

Despite the importance of evaluating an adrenal mass size and appearance, this should not be the only parameter guiding diagnosis and posterior treatment, since radiographic features are often of strong predictive value (Dunnick et al., 1996). MRI and CT images may in fact be useful in helping to define what will be the histological type of the adrenal

On unenhanced CT scanning, the measurements of Hounsfield units (HU) are of great value in differentiating malignant from benign adrenocortical tumors. The Hounsfield scale is a semi-quantitative method of measuring x-ray attenuation. Despite the fact that around 30% of adenomas do not contain large amounts of lipid, being indistinguishable from non-adenomas, adrenal masses with < 10 HU on unenhanced CT are almost certainly benign tumors (Grumbach et al., 2003). Therefore, this seems to be the consensus

be most beneficial the smaller and more localized the tumor would be.

day at bedtime;

al., 2006).

2009).

tumor:

resection can be achieved.

24-hour urinary free cortisol.

cut-off for distinguishing adrenocortical carcinomas from benign adrenal tumors, according to several studies (Boland et al., 1998; Hamrahian et al., 2005). However, in those cases of benign tumors with poor intracytoplasmatic lipid concentration a better discrimination can be obtained by searching for a delayed contrast clearance in contrastenhanced CT. In this case, tumors measuring > 10HU in a unenhanced CT, that show a contrast washout of less than 50% after 10- to 15-min of contrast-enhanced CT and also a delayed attenuation of more than 35HU, are suspicious for malignancy (Szolar et al., 2005; Caoili et al., 2002).

The use of MRI for differentiating benign and malignant adrenocortical tumors is equally effective to CT scan. But since MRI is more expensive and less standardized, CT scan remains the primary adrenal imaging procedure,

The utilization of the PET scanning with fluorodeoxyglucose (FDG) has been successful in identifying unilateral adrenal tumors with higher suspicion for malignancy, due to the greater reported uptake of FDG by malignant tumors compared to the benign adrenocortical tumors (Groussin et al., 2009; Maurea et al. 2001; Minn et al., 2004). The use of integrated PET-CT can further improve the capacity to distinguish between malignant and benign tumors by increasing the quality of the image. This improvement is also due to the combination of CT attenuation measurements with the intensity of FDG uptake, as described by the standardized uptake value (SUV) for the adrenal lesion (Metser et al., 2006; Caoili et al., 2007).

In what concerns **fine-needle aspiration biopsy** (FNA) one must stress that usually it is not successful in distinguishing between malignant and benign tumors and there are doubts about the risk of disseminating a carcinoma through the abdominal cavity; it can however be of some utility in differentiating an adrenal tumor from a metastasis to the adrenal and in evaluating staging for a known cancer (Jhala et al., 2004; Kocijancic et al., 2004).

## **2.3 Adrenal cortex cancer staging**

The first staging system published by the World Health Organization (WHO) dates from in 2004 (DeLellis, 2004), and was based on different staging systems, such as the Sullivan modification of the Macfarlane system (Sullivan, 1978). The AJCC (American Joint Committee on Cancer)/UICC (International Union Against Cancer) developed a TNM staging system with the same definitions for the first time in 2009, being published on the AJCC/UICC Cancer Staging Manual, Seventh Edition. A simplified classification system was recently proposed by the European network ENSAT in which stage III includes cases with lymph nodes metastasis, infiltration of surrounding tissues and venous tumor thrombosis and stage IV only cases with distant metastases (Fassnacht et al., 2009).

Tumor clinical staging is most dependent of clinical examination and radiographic imaging in order to evaluate the size of the primary tumor and the extent of local and distant disease. Since disease-free and overall survival rates seem to be strongly related with tumor staging, resection of the primary tumor and examination of local extension of the disease and regional lymph nodes involvement should be performed for a better pathologic tumor staging.

The following table describes the AJCC/UICC anatomic stages and prognostic groups:

Adrenal Cortex Tumors and Hyperplasias 321

Therefore, surgery in these patients must be as extensive as possible, with lymphadenectomy associated. One should be very careful to avoid capsular damage and the spill of malignant cells that may result in the development of metastasis (Terzolo et al., 2007; van Ditzhuijsen et al., 2007). Nowadays, open adrenalectomy is the most consensual operation type, since laparoscopy is associated with greater risk of malignant cells spread and therefore higher risk of recurrence or dissemination (Schteingart et al., 2005; Gonzalez et al., 2005; Cobb et al., 2005). Studies have also shown that whenever total resection is not possible, maximal debulking is associated with a decrease in excess of hormone production and with better overall survival when compared with non-surgical treatments (Ng & Libertino, 2003; Luton, et al., 1990). Whenever surgery is not feasible or is unable to completely remove the tumor, mitotane (Lysodren), an adrenocorticolytic drug, was shown to be effective, either as a primary therapy or as an adjuvant therapy (Henley et al., 1983; Dackiw et al., 2001; Berruti et al.,

Mitotane has a

2005; Terzolo et al., 2007; Luton et al 1990; Hahner & Fassnacht, 2005).

1983; Baudin et al., 2001).

agents has to be utilized (Allolio & Fassnacht, 2006).

Quinkler et al., 2008; Khan et al., 2004).

specific effect on adrenal cells resulting in their lysis (Hahner & Fassnacht, 2005).

As a primary treatment for unresectable tumors, mitotane is especially beneficial in improvement of symptoms associated with hypercortisolism. However this benefit tends to last for short periods of time, and is associated to inconsistent survival rates (Henley et al.,

In what concerns the adjuvant use of mitotane therapy, its benefits have been questioned mainly due to the lack of data from controlled clinical trials and even from large prospective studies with consistent assessments of dosing and tumor variability (Kendrick et al., 2001; Kopf et al., 2001). Despite the lack of robust data, several retrospective analyses have reported higher recurrence-free survival when compared to control groups and tumor regression rates of around 30% also being associated with a better control of hormone excess (Allolio & Fassnacht, 2006; Terzolo et al., 2007). Treatment with mitotane has especially good results in patients previously submitted to tumor resection, who begun therapy right after surgery and who are submitted to regular monitoring of mitotane plasma levels (Daffara et al., 2008). When considering recurrent or advanced adrenocortical cancer, aggressive resection of local or distant disease is still considered to be an effective therapy method capable of increasing overall survival (Schteingart et al., 1982; Meyer et al., 2004). However, in these cases the use of cytotoxic drugs such as mitotane alone or in combination with other chemotherapeutic

Mitotane is recommended even in patients with unresectable advanced disease, since several studies have reported the effectiveness of this drug in producing objective improvements in the majority of treated patients, despite its low impact on survival. Moreover, it has been demonstrated that cytotoxic activity of chemotherapeutic agents is increased when combined with mitotane in human adrenal carcinoma cells in vitro (Bukowski et al., 1993; Abraham et al., 2002). Despite the modest results found in the few prospective trials published until now, the combination of mitotane with different chemotherapeutic regimens resulted in overall response rates varying between 14 to 49%

Other regimens of chemotherapy without mitotane have been also evaluated in a few clinical trials but showed modest response rates, revealing the need for the development of more and better drugs and well-designed prospective trials (Schlumberger et al., 1988;

(Berruti et al., 2005; Khan et al., 2000; Abraham et al., 2002; Bonacci et al., 1998).


Adapted from Edge, SB., Byrd, DR., Compton, CC., Fritz, AG., Greene, FL., Trotti, A. (Eds.). (2010). AJCC Cancer Staging Manual, 7th Ed. Springer, Chicago.

\*Adjacent organs include kidney, diaphragm, great vessels, pancreas, spleen and liver.

Table 2. AJCC/UICC anatomic stages and prognostic groups

## **2.4 Adrenal cortex cancer treatment**

For being a very rare and aggressive carcinoma the prognosis for patients with adrenocortical cancer is poor, also due to usually not being diagnosed in the early stages of the disease (Ng & Libertino, 2003; Harrison et al., 1999). Its rarity is one of the main reasons for the lack of robust clinical studies on the most efficacious treatments (Decker et al., 1991; Bukowski et al., 1993; Khan et al., 2000). Several studies and clinical trials, however, have shown that this trend in prognosis is changing and in fact patients with this type of carcinoma are living longer as progresses are being made in its treatment (Berruti et al., 2005; Adam et al., 2006; Allolio et al., 2004; Terzolo et al., 2007; van Ditzhuijsen et al, 2007; Fassnacht et al., 2011).

Currently, the only potentially curative treatment for adrenal cortex carcinomas is total resection of the tumor at the time of initial evaluation (Allolio et al., 2006; Dackiw et al., 2001). However, in a study of Haak and colleagues with 96 patients, the overall five-year survival rate after total resection was only 49% (Haak et al., 1994). This happens probably due to the presence of hidden micrometastases that will only become apparent some months to years later (Allolio & Fassnacht, 2006; Stojadinovic et al., 2002). In fact, many patients may develop distant metastases two or more years after the diagnosis date (Abiven et al., 2006).

**Stage I** T1 N0 M0 Tumor 5 cm or less in greatest dimension, no

**Stage II** T2 N0 M0 Tumor greater than 5 cm, no extra-adrenal

invasion.

extra-adrenal invasion.

regional lymph node(s).

not invading adjacent organs\*.

metastasis in regional lymph node(s).

nodes, but with distant metastases.

lymph node(s). T3 N0 M0 Tumor of any size with local invasion, but

T4 N0 M0 Tumor of any size with invasion of adjacent

T4 N1 M0 Tumor of any size with invasion of adjacent

organs\*.

Adapted from Edge, SB., Byrd, DR., Compton, CC., Fritz, AG., Greene, FL., Trotti, A. (Eds.). (2010).

For being a very rare and aggressive carcinoma the prognosis for patients with adrenocortical cancer is poor, also due to usually not being diagnosed in the early stages of the disease (Ng & Libertino, 2003; Harrison et al., 1999). Its rarity is one of the main reasons for the lack of robust clinical studies on the most efficacious treatments (Decker et al., 1991; Bukowski et al., 1993; Khan et al., 2000). Several studies and clinical trials, however, have shown that this trend in prognosis is changing and in fact patients with this type of carcinoma are living longer as progresses are being made in its treatment (Berruti et al., 2005; Adam et al., 2006; Allolio et al.,

Currently, the only potentially curative treatment for adrenal cortex carcinomas is total resection of the tumor at the time of initial evaluation (Allolio et al., 2006; Dackiw et al., 2001). However, in a study of Haak and colleagues with 96 patients, the overall five-year survival rate after total resection was only 49% (Haak et al., 1994). This happens probably due to the presence of hidden micrometastases that will only become apparent some months to years later (Allolio & Fassnacht, 2006; Stojadinovic et al., 2002). In fact, many patients may develop distant metastases two or more years after the diagnosis date (Abiven et al., 2006).

\*Adjacent organs include kidney, diaphragm, great vessels, pancreas, spleen and liver.

2004; Terzolo et al., 2007; van Ditzhuijsen et al, 2007; Fassnacht et al., 2011).

Tumor 5 cm or less in greatest dimension, no extra-adrenal invasion but with metastasis in

Tumor greater than 5 cm, no extra-adrenal invasion but with metastasis in regional

Tumor of any size with local invasion, but not invading adjacent organs\* plus

organs\* plus metastasis in regional lymph node(s).

Tumor of any size and with or without invasion of adjacent organs and lymph

**Stage T N M Description** 

T1 N1 M0

T2 N1 M0

T3 N1 M0

Any T Any N M1

Table 2. AJCC/UICC anatomic stages and prognostic groups

AJCC Cancer Staging Manual, 7th Ed. Springer, Chicago.

**2.4 Adrenal cortex cancer treatment** 

**Stage III** 

**Stage IV** 

Therefore, surgery in these patients must be as extensive as possible, with lymphadenectomy associated. One should be very careful to avoid capsular damage and the spill of malignant cells that may result in the development of metastasis (Terzolo et al., 2007; van Ditzhuijsen et al., 2007). Nowadays, open adrenalectomy is the most consensual operation type, since laparoscopy is associated with greater risk of malignant cells spread and therefore higher risk of recurrence or dissemination (Schteingart et al., 2005; Gonzalez et al., 2005; Cobb et al., 2005). Studies have also shown that whenever total resection is not possible, maximal debulking is associated with a decrease in excess of hormone production and with better overall survival

when compared with non-surgical treatments (Ng & Libertino, 2003; Luton, et al., 1990). Whenever surgery is not feasible or is unable to completely remove the tumor, mitotane (Lysodren), an adrenocorticolytic drug, was shown to be effective, either as a primary therapy or as an adjuvant therapy (Henley et al., 1983; Dackiw et al., 2001; Berruti et al., 2005; Terzolo et al., 2007; Luton et al 1990; Hahner & Fassnacht, 2005). Mitotane has a specific effect on adrenal cells resulting in their lysis (Hahner & Fassnacht, 2005).

As a primary treatment for unresectable tumors, mitotane is especially beneficial in improvement of symptoms associated with hypercortisolism. However this benefit tends to last for short periods of time, and is associated to inconsistent survival rates (Henley et al., 1983; Baudin et al., 2001).

In what concerns the adjuvant use of mitotane therapy, its benefits have been questioned mainly due to the lack of data from controlled clinical trials and even from large prospective studies with consistent assessments of dosing and tumor variability (Kendrick et al., 2001; Kopf et al., 2001). Despite the lack of robust data, several retrospective analyses have reported higher recurrence-free survival when compared to control groups and tumor regression rates of around 30% also being associated with a better control of hormone excess (Allolio & Fassnacht, 2006; Terzolo et al., 2007). Treatment with mitotane has especially good results in patients previously submitted to tumor resection, who begun therapy right after surgery and who are submitted to regular monitoring of mitotane plasma levels (Daffara et al., 2008).

When considering recurrent or advanced adrenocortical cancer, aggressive resection of local or distant disease is still considered to be an effective therapy method capable of increasing overall survival (Schteingart et al., 1982; Meyer et al., 2004). However, in these cases the use of cytotoxic drugs such as mitotane alone or in combination with other chemotherapeutic agents has to be utilized (Allolio & Fassnacht, 2006).

Mitotane is recommended even in patients with unresectable advanced disease, since several studies have reported the effectiveness of this drug in producing objective improvements in the majority of treated patients, despite its low impact on survival. Moreover, it has been demonstrated that cytotoxic activity of chemotherapeutic agents is increased when combined with mitotane in human adrenal carcinoma cells in vitro (Bukowski et al., 1993; Abraham et al., 2002). Despite the modest results found in the few prospective trials published until now, the combination of mitotane with different chemotherapeutic regimens resulted in overall response rates varying between 14 to 49% (Berruti et al., 2005; Khan et al., 2000; Abraham et al., 2002; Bonacci et al., 1998).

Other regimens of chemotherapy without mitotane have been also evaluated in a few clinical trials but showed modest response rates, revealing the need for the development of more and better drugs and well-designed prospective trials (Schlumberger et al., 1988; Quinkler et al., 2008; Khan et al., 2004).

Adrenal Cortex Tumors and Hyperplasias 323

increased Aldosterone (*in ng/dl*)/PRA (*in ng/ml/h*) ratio above 20 or 40 (accordingly to the

Since these tumors are generally very small, CT scan has a low sensitivity to localize them, and the fact that in people above 40 to 50 years of age, the prevalence of incidentalomas is high makes its specificity also decrease. Therefore the gold standard for a correct diagnosis of APA is Adrenal Venous Sampling in spite of the fact that it is an invasive method with a

During the past two decades it has become increasingly recognized that primary aldosteronism is much more common than previously thought. It is currently acknowledged that primary aldosteronism accounts for up to 5–10% of hypertensive patients, correlating with the severity of hypertension and going up to 20% in cases of resistant hypertension (i.e

The clinical features of PA are mostly determined by the renal actions of aldosterone. Its diagnosis is more frequently made in patients who are in the third to sixth decades of life, with resistant hypertension, accompanied by marked hypokalemia, possibly muscle weakness and cramping, headaches, palpitations, polydipsia, polyuria, nocturia, or a

Hypokalemia, once the most important "screening" method for PA is observed less and less frequently both due to the sodium restriction that most doctors recommend to their patients with high blood pressure and also to the higher prevalence of BAH *vs* APA observed in the

Patients' elevated blood pressure is a major clinical finding in PA (Mattsson & Young, 2006; Young, 2007a). However, PA is rarely associated with malignant hypertension (Zarifis et al., 1996). In a study of Blumenfeld and colleagues, the mean blood pressure was 184/112 mmHg in patients with an adrenal adenoma and 161/105 mmHg in patients diagnosed with bilateral hyperplasia (Blumenfeld et al., 1994). One important and special feature associated with PA hypertension is the failure to achieve the goal blood pressure (BP) despite a

It was also clearly demonstrated that aldosterone excess has direct adverse cardiovascular consequences that go well beyond the risks associated with this type of hypertension (Stowasser, 2009). Aldosterone is responsible for the development of myocardial fibrosis aggravating the prognosis post myocardial infarct (MI) and in congestive heart failure (CHF). Cardiovascular risk factors seem to be more severe with PA, since when matched for age, blood pressure and the duration of hypertension, these patients have greater left ventricular mass measurements when compared to patients with other types of hypertension, including essential hypertension, pheochromocytoma, and Cushing's syndrome (Milliez et al., 2005; Tanabe et al., 1997). Also, in a case–control study of 124 patients with PA and 465 patients with essential hypertension, matched for age, sex, and systolic and diastolic blood pressure, it was found that patients presenting with either APA or bilateral hyperplasia had a significantly higher rate of cardiovascular events (e.g. stroke, atrial fibrillation and myocardial infarction) than the matched essential hypertension patients (Milliez et al., 2005).

combination of these. There is, however, generally a characteristic lack of edema!

Then a confirmatory test is needed and this can be done by one of the following tests:

good success rate only in the hands of experienced radiologists.

complete adherence to a multi-drug regimen of treatment.

one that does not respond to 3-drug-regimen).

desired sensitivity).

 oral salt load saline infusion test Captopril test

more recent series.

fludrocortisone suppression test

One must be conscious that progresses in this cancer treatment are limited and slow. More clinical trials and large prospective studies are necessary to better support physicians' choices of treatment. An example of those trials was the recently concluded "First International Randomized trial in locally advanced and Metastatic Adrenocortical Carcinoma Treatment" (FIRM-ACT), an international clinical study comparing the efficacy of etoposide, doxorubicin and cisplatin (EDP) plus mitotane versus streptozotocin plus mitotane in patients with metastatic adrenocortical cancer. This sufficiently large prospective study gave support to the use of the first therapeutic combination (EDP+mitotane) in these conditions (Fassnacht et al., 2011).

The use of radiation therapy or radiofrequency ablation are the least studied hypothesis. They are mainly beneficial in patients with unresectable local tumors with local symptoms or symptomatic metastasis (Schteingart et al., 2005; Polat et al., 2009; Magee et al., 1987). Their impact in patients' survival is still unknown and needs further investigation (Wood et al., 2003; Mayo-Smith et al., 2004).

In the future one may expect that the understanding of the specific molecular alterations in these malignant cells can identify suitable therapeutical targets that may significantly improve the prognosis for these patients.

## **3. Primary hyperaldosteronism/Conn's syndrome**

The synthesis of aldosterone by the adrenal glands occurs in the *zona glomerulosa*. The major conditions for the production of this hormone such as the low concentration of 17-alphahydroxylase and the ability to add an hydroxyl group at the 18-carbon position and its subsequent oxidation to an aldehyde, only occur in the *zona glomerulosa* and this processing is mediated by a single multifunctional cytochrome P450 - CYP11B2 or Aldo Synthase (White et al., 1987; White, 1994; Ulick et al., 1992; Holland & Carr, 1993).

The aldosterone-producing adenoma was first described by Conn in 1954 (Conn, 1955; Young, 2007a), who also established for the first time the relationship between adrenal aldosterone-producing tumors, hypertension, and hypokalemia (Gittler & Fajans, 1995). In addition to the aldosterone-producing adenoma (APA), other subtypes of primary aldosteronism (PA) have been described over the subsequent four decades (Conn, 1955; Conn, 1964; Gitler & Fajans, 1995; Young, 2007a; Stowasser, 2009). The most common is the bilateral idiopathic hyperaldosteronism (IHA) which represent approximately 70% of all PA cases (while APA, approximately 30%). Other forms include unilateral hyperplasia or primary adrenal hyperplasia (caused by hyperplasia of the *zona glomerulosa* of only one adrenal gland), familial hyperaldosteronism type I (glucocorticoid-remediable aldosteronism - GRA) caused by the existence of an hybrid gene composed of the CYP11B1 promoter and CYP11B2 gene in which aldosterone is produced in response to ACTH and hence responds to glucocorticoid mediated suppression of ACTH, familial hyperaldosteronism type II (the familial occurrence of aldosterone-producing adenoma or bilateral idiopathic hyperplasia or both), and also the familial or sporadic occurrence of APA due to a mutation in the gene of the K+ channel (KCNJ5) (Choi et al., 2011).

Finally, in spite of being very rare, pure aldosterone-producing adrenocortical carcinomas and ectopic aldosterone-secreting tumors (e.g. neoplasms in the ovary or kidney) may also occur.

The screening of PA is done by the demonstration of an elevated aldosterone level (> 15 ng/dl) together with the suppression of Plasma Renin Activity (PRA), translated in an increased Aldosterone (*in ng/dl*)/PRA (*in ng/ml/h*) ratio above 20 or 40 (accordingly to the desired sensitivity).

Then a confirmatory test is needed and this can be done by one of the following tests:


322 Contemporary Aspects of Endocrinology

One must be conscious that progresses in this cancer treatment are limited and slow. More clinical trials and large prospective studies are necessary to better support physicians' choices of treatment. An example of those trials was the recently concluded "First International Randomized trial in locally advanced and Metastatic Adrenocortical Carcinoma Treatment" (FIRM-ACT), an international clinical study comparing the efficacy of etoposide, doxorubicin and cisplatin (EDP) plus mitotane versus streptozotocin plus mitotane in patients with metastatic adrenocortical cancer. This sufficiently large prospective study gave support to the use of the first therapeutic combination

The use of radiation therapy or radiofrequency ablation are the least studied hypothesis. They are mainly beneficial in patients with unresectable local tumors with local symptoms or symptomatic metastasis (Schteingart et al., 2005; Polat et al., 2009; Magee et al., 1987). Their impact in patients' survival is still unknown and needs further investigation (Wood et

In the future one may expect that the understanding of the specific molecular alterations in these malignant cells can identify suitable therapeutical targets that may significantly

The synthesis of aldosterone by the adrenal glands occurs in the *zona glomerulosa*. The major conditions for the production of this hormone such as the low concentration of 17-alphahydroxylase and the ability to add an hydroxyl group at the 18-carbon position and its subsequent oxidation to an aldehyde, only occur in the *zona glomerulosa* and this processing is mediated by a single multifunctional cytochrome P450 - CYP11B2 or Aldo Synthase

The aldosterone-producing adenoma was first described by Conn in 1954 (Conn, 1955; Young, 2007a), who also established for the first time the relationship between adrenal aldosterone-producing tumors, hypertension, and hypokalemia (Gittler & Fajans, 1995). In addition to the aldosterone-producing adenoma (APA), other subtypes of primary aldosteronism (PA) have been described over the subsequent four decades (Conn, 1955; Conn, 1964; Gitler & Fajans, 1995; Young, 2007a; Stowasser, 2009). The most common is the bilateral idiopathic hyperaldosteronism (IHA) which represent approximately 70% of all PA cases (while APA, approximately 30%). Other forms include unilateral hyperplasia or primary adrenal hyperplasia (caused by hyperplasia of the *zona glomerulosa* of only one adrenal gland), familial hyperaldosteronism type I (glucocorticoid-remediable aldosteronism - GRA) caused by the existence of an hybrid gene composed of the CYP11B1 promoter and CYP11B2 gene in which aldosterone is produced in response to ACTH and hence responds to glucocorticoid mediated suppression of ACTH, familial hyperaldosteronism type II (the familial occurrence of aldosterone-producing adenoma or bilateral idiopathic hyperplasia or both), and also the familial or sporadic occurrence of APA

Finally, in spite of being very rare, pure aldosterone-producing adrenocortical carcinomas and ectopic aldosterone-secreting tumors (e.g. neoplasms in the ovary or kidney) may also

The screening of PA is done by the demonstration of an elevated aldosterone level (> 15 ng/dl) together with the suppression of Plasma Renin Activity (PRA), translated in an

(EDP+mitotane) in these conditions (Fassnacht et al., 2011).

**3. Primary hyperaldosteronism/Conn's syndrome** 

(White et al., 1987; White, 1994; Ulick et al., 1992; Holland & Carr, 1993).

due to a mutation in the gene of the K+ channel (KCNJ5) (Choi et al., 2011).

al., 2003; Mayo-Smith et al., 2004).

occur.

improve the prognosis for these patients.


Since these tumors are generally very small, CT scan has a low sensitivity to localize them, and the fact that in people above 40 to 50 years of age, the prevalence of incidentalomas is high makes its specificity also decrease. Therefore the gold standard for a correct diagnosis of APA is Adrenal Venous Sampling in spite of the fact that it is an invasive method with a good success rate only in the hands of experienced radiologists.

During the past two decades it has become increasingly recognized that primary aldosteronism is much more common than previously thought. It is currently acknowledged that primary aldosteronism accounts for up to 5–10% of hypertensive patients, correlating with the severity of hypertension and going up to 20% in cases of resistant hypertension (i.e one that does not respond to 3-drug-regimen).

The clinical features of PA are mostly determined by the renal actions of aldosterone. Its diagnosis is more frequently made in patients who are in the third to sixth decades of life, with resistant hypertension, accompanied by marked hypokalemia, possibly muscle weakness and cramping, headaches, palpitations, polydipsia, polyuria, nocturia, or a combination of these. There is, however, generally a characteristic lack of edema!

Hypokalemia, once the most important "screening" method for PA is observed less and less frequently both due to the sodium restriction that most doctors recommend to their patients with high blood pressure and also to the higher prevalence of BAH *vs* APA observed in the more recent series.

Patients' elevated blood pressure is a major clinical finding in PA (Mattsson & Young, 2006; Young, 2007a). However, PA is rarely associated with malignant hypertension (Zarifis et al., 1996). In a study of Blumenfeld and colleagues, the mean blood pressure was 184/112 mmHg in patients with an adrenal adenoma and 161/105 mmHg in patients diagnosed with bilateral hyperplasia (Blumenfeld et al., 1994). One important and special feature associated with PA hypertension is the failure to achieve the goal blood pressure (BP) despite a complete adherence to a multi-drug regimen of treatment.

It was also clearly demonstrated that aldosterone excess has direct adverse cardiovascular consequences that go well beyond the risks associated with this type of hypertension (Stowasser, 2009). Aldosterone is responsible for the development of myocardial fibrosis aggravating the prognosis post myocardial infarct (MI) and in congestive heart failure (CHF).

Cardiovascular risk factors seem to be more severe with PA, since when matched for age, blood pressure and the duration of hypertension, these patients have greater left ventricular mass measurements when compared to patients with other types of hypertension, including essential hypertension, pheochromocytoma, and Cushing's syndrome (Milliez et al., 2005; Tanabe et al., 1997). Also, in a case–control study of 124 patients with PA and 465 patients with essential hypertension, matched for age, sex, and systolic and diastolic blood pressure, it was found that patients presenting with either APA or bilateral hyperplasia had a significantly higher rate of cardiovascular events (e.g. stroke, atrial fibrillation and myocardial infarction) than the matched essential hypertension patients (Milliez et al., 2005).

Adrenal Cortex Tumors and Hyperplasias 325

Estrogen-secreting adrenal cortex tumors correspond to a very rare type of tumors characterized by the over-production of estrogens (estrone or estradiol). The over- secretion of these hormones may cause precocious puberty with very early menarche in girls and more often sex-reversal characteristics in men (feminizing symptoms) (Advani et al., 2010). The feminizing symptoms, such as the characteristic gynecomastia, are associated with the expression of the cytochrome P450 aromatase (aromatase) in adrenocortical cells. Normally, aromatase catalyses the conversion of C19 steroids into estrogens in tissues such as the ovarian follicles' granulosa layer and the adipose tissue, whereas normal adrenal tissues

The Cushing's syndrome was first described by Harvey Cushing in 1932, and can be caused by several mechanisms associated with increased levels of cortisol in the blood. The diagnosis of Cushing's syndrome is determined through biochemical tests, since the presence of suggestive symptoms and signs are not enough to sustain it. In fact none of its symptoms is pathognomonic and most of them are non-specific such as obesity, hypertension and increased cardiovascular risk, menstrual irregularity and infertility, osteoporosis and glucose intolerance. It can also cause some form of psychological distress, going from impaired quality of life to depression and even psychosis. It should always be borne in mind, however, that if left untreated, Cushing's syndrome has a 5 fold excess

The high levels of cortisol in the blood can be caused not only by adrenocortical tumors but also by adrenocorticotropic hormone (ACTH) or corticotropin-releasing hormone (CRH) hyperproduction, as well as by the excessive intake of glucocorticoid drugs. This is even one of the most frequent causes of Cushing's syndrome (Iatrogenic Cushing's). In the study of a Cushing's syndrome case these situations need to be excluded (Weber SL., 1997; Hughes et al., 1996; Quddusi et al., 1998). Moreover, special attention is also required for other disorders causing hypercortisolism-related symptoms and sometimes also exhibiting mild to moderate elevations of plasma cortisol, known as pseudo-Cushing's syndrome. The

 Patients who are physically stressed (e.g. severe bacterial infections) (Liddle , 1960); Patients with severe obesity, especially visceral obesity or polycystic ovary syndrome

Rarely, also patients with chronic alcoholism (Kirkman & Nelson, 1988).

Patients with psychological stress (major depressive disorder and severe melancholic

The difficulties normally met in Cushing's syndrome diagnostic process are well translated by the fact that patients normally express some signs and symptoms of the syndrome, 2 years before a confirmation of diagnosis can be reached. After raising the suspicion by the observation of a patient with central (truncal) obesity plus hypertension, in many cases accompanied by a typical cushingoid facies (round, plethoric face), the most specific signs are the presence of thin skin, easy bruising and proximal myopathy. However, to avoid mistakes in diagnosing Cushing's syndrome due to all of the different conditions that might imitate its signs and symptoms, initial diagnostic tests for hypercortisolism must be highly

**5. Estrogen-secreting adrenal cortex tumors** 

**6. Cushing's syndrome** 

pseudo-Cushing's syndromes may include:

syndromes) (Gold et al ., 1986);

(Liddle, 1960);

mortality.

have no detectable aromatase activity (Watanabe & Nakajin, 2004).

Furthermore, some particular renal effects may be also experienced by PA patients, independently of their systemic hypertension. Several reports have shown that glomerular filtration rate (GFR) and urinary albumin excretion may be increased in these patients; however these changes appear to be largely reversible after appropriate treatment. Adrenalectomy increased the serum creatinine and decreased the mean GFR. Treatment with spironolactone resulted in a similar decline in GFR. Thus, surgical cure or mineralocorticoid receptor blockade reverse the hyperfiltration state and unmask the underlying renal insufficiency (Stowasser, 2009).

One final point to be stressed in relation to PA is that generally APA should be treated surgically while bilateral adrenal hyperplasias are better treated medically with mineralocorticoid inhibition by means of spironolactone, eplerenone or amiloride. Nevertheless, even APAs, specially the small ones, may also be treated appropriately with these drugs and hence, the choice should always be given to the patients.

## **4. Androgen-secreting adrenal cortex tumors**

Androgen-secreting adrenal cortex tumors are rare tumors, accounting for only 0.2% of the causes of androgen excess (Azziz et al., 2004; Carmina et al., 2006). Androgen over-secretion results in the development of androgenic features in affected women, with the development of hirsutism, androgenic alopecia, acne, ovulatory dysfunction, and, if the oversecretion is extreme or prolonged, even virilization may ensue (Wajchenberg et al., 2000; Azziz et al., 2004).

Despite the fact that benign androgen-secreting adrenal tumors have been described, the finding of androgen secretion by an ACT is considered to be highly suggestive of malignancy. The presence of a virilizing adrenocortical carcinoma can be suggested by very high testosterone levels and the failure of androgen suppression in response to glucocorticoid administration (Kaltsas et al., 2003; Waggoner et al., 1999; Derksen et al., 1994). In a report of 21 women with androgen-secreting tumors, serum testosterone levels were 2.6-fold higher in the women with malignant tumors (n=10) than in women with benign tumors (n=11) (Moreno et al., 2004).

Benign cortisol-secreting adenomas can also produce small amounts of androgens, but the serum androgen levels are usually not elevated (Kamenicky et al., 2007).

Considering its elevated probability of malignancy it is of great importance to identify patients with this type of rare carcinomas among women with androgen excess, due to its life-threatening potential (Wajchenberg et al., 2000). Despite several authors having considered that a clinical presentation with rapidly progressive virilization was sufficient to identify patients requiring a more extensive investigation (Kettel, 1989), it is consensual that some androgen-secreting adrenocortical tumors may produce only moderate levels of androgens and have a rather indolent presentation (Rosenfield , 2005; Kaltsas et al., 2003).

It should also be noticed that androgen-secreting tumors in men same as estrogen secreting tumors in women, may not result in clinically significant syndromes, and both can be erroneously considered as non-functioning, delaying their treatment. If one doesn't apply an extensive analytical protocol to nonfunctioning adrenocortical tumors, only the development of mass effects or the occurrence of metastases would lead to their recognition as malignant.

Furthermore, some particular renal effects may be also experienced by PA patients, independently of their systemic hypertension. Several reports have shown that glomerular filtration rate (GFR) and urinary albumin excretion may be increased in these patients; however these changes appear to be largely reversible after appropriate treatment. Adrenalectomy increased the serum creatinine and decreased the mean GFR. Treatment with spironolactone resulted in a similar decline in GFR. Thus, surgical cure or mineralocorticoid receptor blockade reverse the hyperfiltration state and unmask the

One final point to be stressed in relation to PA is that generally APA should be treated surgically while bilateral adrenal hyperplasias are better treated medically with mineralocorticoid inhibition by means of spironolactone, eplerenone or amiloride. Nevertheless, even APAs, specially the small ones, may also be treated appropriately with

Androgen-secreting adrenal cortex tumors are rare tumors, accounting for only 0.2% of the causes of androgen excess (Azziz et al., 2004; Carmina et al., 2006). Androgen over-secretion results in the development of androgenic features in affected women, with the development of hirsutism, androgenic alopecia, acne, ovulatory dysfunction, and, if the oversecretion is extreme or prolonged, even virilization may ensue (Wajchenberg et al., 2000; Azziz et al.,

Despite the fact that benign androgen-secreting adrenal tumors have been described, the finding of androgen secretion by an ACT is considered to be highly suggestive of malignancy. The presence of a virilizing adrenocortical carcinoma can be suggested by very high testosterone levels and the failure of androgen suppression in response to glucocorticoid administration (Kaltsas et al., 2003; Waggoner et al., 1999; Derksen et al., 1994). In a report of 21 women with androgen-secreting tumors, serum testosterone levels were 2.6-fold higher in the women with malignant tumors (n=10) than in women with

Benign cortisol-secreting adenomas can also produce small amounts of androgens, but the

Considering its elevated probability of malignancy it is of great importance to identify patients with this type of rare carcinomas among women with androgen excess, due to its life-threatening potential (Wajchenberg et al., 2000). Despite several authors having considered that a clinical presentation with rapidly progressive virilization was sufficient to identify patients requiring a more extensive investigation (Kettel, 1989), it is consensual that some androgen-secreting adrenocortical tumors may produce only moderate levels of androgens and have a rather indolent presentation (Rosenfield , 2005;

It should also be noticed that androgen-secreting tumors in men same as estrogen secreting tumors in women, may not result in clinically significant syndromes, and both can be erroneously considered as non-functioning, delaying their treatment. If one doesn't apply an extensive analytical protocol to nonfunctioning adrenocortical tumors, only the development of mass effects or the occurrence of metastases would lead to their recognition

serum androgen levels are usually not elevated (Kamenicky et al., 2007).

these drugs and hence, the choice should always be given to the patients.

underlying renal insufficiency (Stowasser, 2009).

**4. Androgen-secreting adrenal cortex tumors** 

benign tumors (n=11) (Moreno et al., 2004).

Kaltsas et al., 2003).

as malignant.

2004).

## **5. Estrogen-secreting adrenal cortex tumors**

Estrogen-secreting adrenal cortex tumors correspond to a very rare type of tumors characterized by the over-production of estrogens (estrone or estradiol). The over- secretion of these hormones may cause precocious puberty with very early menarche in girls and more often sex-reversal characteristics in men (feminizing symptoms) (Advani et al., 2010). The feminizing symptoms, such as the characteristic gynecomastia, are associated with the expression of the cytochrome P450 aromatase (aromatase) in adrenocortical cells. Normally, aromatase catalyses the conversion of C19 steroids into estrogens in tissues such as the ovarian follicles' granulosa layer and the adipose tissue, whereas normal adrenal tissues have no detectable aromatase activity (Watanabe & Nakajin, 2004).

## **6. Cushing's syndrome**

The Cushing's syndrome was first described by Harvey Cushing in 1932, and can be caused by several mechanisms associated with increased levels of cortisol in the blood. The diagnosis of Cushing's syndrome is determined through biochemical tests, since the presence of suggestive symptoms and signs are not enough to sustain it. In fact none of its symptoms is pathognomonic and most of them are non-specific such as obesity, hypertension and increased cardiovascular risk, menstrual irregularity and infertility, osteoporosis and glucose intolerance. It can also cause some form of psychological distress, going from impaired quality of life to depression and even psychosis. It should always be borne in mind, however, that if left untreated, Cushing's syndrome has a 5 fold excess mortality.

The high levels of cortisol in the blood can be caused not only by adrenocortical tumors but also by adrenocorticotropic hormone (ACTH) or corticotropin-releasing hormone (CRH) hyperproduction, as well as by the excessive intake of glucocorticoid drugs. This is even one of the most frequent causes of Cushing's syndrome (Iatrogenic Cushing's). In the study of a Cushing's syndrome case these situations need to be excluded (Weber SL., 1997; Hughes et al., 1996; Quddusi et al., 1998). Moreover, special attention is also required for other disorders causing hypercortisolism-related symptoms and sometimes also exhibiting mild to moderate elevations of plasma cortisol, known as pseudo-Cushing's syndrome. The pseudo-Cushing's syndromes may include:


The difficulties normally met in Cushing's syndrome diagnostic process are well translated by the fact that patients normally express some signs and symptoms of the syndrome, 2 years before a confirmation of diagnosis can be reached. After raising the suspicion by the observation of a patient with central (truncal) obesity plus hypertension, in many cases accompanied by a typical cushingoid facies (round, plethoric face), the most specific signs are the presence of thin skin, easy bruising and proximal myopathy. However, to avoid mistakes in diagnosing Cushing's syndrome due to all of the different conditions that might imitate its signs and symptoms, initial diagnostic tests for hypercortisolism must be highly

Adrenal Cortex Tumors and Hyperplasias 327

One of the most important, and therefore the initial, phase of determining Cushing's syndrome's etiology is to determine if the hypercortisolism is ACTH-dependent or ACTH independent. The ACTH-dependent hypercortisolism is normally due to a pituitary (or less frequently non-pituitary) ACTH secreting tumor, while ACTH-independent hypercortisolism is usually due to an adrenal tumor or hyperplasia. The preferred test is naturally the measurement of plasma ACTH. Usually a low plasma ACTH concentration of <5 pg/mL (1.1 pmol/L) in a hypercortisolemic patient is evidence of ACTHindependent disease (Invitti et al., 1999), while if the plasma ACTH concentration is above 15 pg/mL (3.3 pmol/L) it can be assumed that cortisol secretion is ACTH-dependent. Despite values between 5 and 15 pg/mL (1.1 to 3.3 pmol/L) being less definitive they normally indicate the hypercortisolism is ACTH-dependent. However, it is recommendable to perform a CRH stimulation test in these patients to confirm that

In the presence of an ACTH-independent Cushing's syndrome, it is important to proceed with a thin-section CT imaging of the adrenal glands, to determine its cause. When CT imaging suggests a suspicious lesion (for instance with large size) further investigation will be required to distinguish between the malignant ACC and benign ACT. The presence of bilateral disease on the other hand implies the distinction between, for instance, a bilateral

Unilateral adenomas causing Cushing's syndrome should be surgically removed as they imply a very significant increase in morbidity and mortality, which is due to cardiovascular

For the great majority of ACTH-dependent Cushing's syndrome patients, the cause of the hypercortisolism is a pituitary corticotroph adenoma (Cushing's disease). Even so,

tumor and bilateral macronodular adrenal hyperplasia.

hypothesis.

Fig. 2. Cushing syndrome

diseases or infections.

sensitive. According to the evidence-based 2008 Endocrine Society Clinical Guidelines the *first-line tests* for this syndrome should be the late night salivary cortisol, the 24h urinary cortisol, or the low-dose dexamethasone suppression test (either the 1 mg, overnight or the 2mg/day, 48h dexamethasone suppression tests). To establish the diagnosis of Cushing's syndrome the following criteria should be met (Nieman et al., 2008):


Cushing's syndrome is rare (it has an incidence of up to 3:1.000.000 persons per year) (Lindholm et al., 2001). It's also an intriguing condition both because of its complex diagnostic protocol and the demand for a correct treatment to avoid its devastating complications that can even conduct to death if left untreated. After diagnosing the hypercortisolism, it is important to determine its cause (Table 3) to better chose the appropriate treatment. It is a disease whose patients should be sent to a major hospital where multidisciplinary and well experienced teams will be available.


Table 3. Frequency of causes of Cushing's syndrome

sensitive. According to the evidence-based 2008 Endocrine Society Clinical Guidelines the *first-line tests* for this syndrome should be the late night salivary cortisol, the 24h urinary cortisol, or the low-dose dexamethasone suppression test (either the 1 mg, overnight or the 2mg/day, 48h dexamethasone suppression tests). To establish the diagnosis of Cushing's

 At least two of the first-line tests must be abnormal and conservative criteria should be used to interpret it to maximize sensitivity; for instance, in a patient with a symptomatic Cushing's syndrome, the cortisol cutoff level to be considered as un-suppressed after the Dexamethasone test should be >1.8 µg/dl (while in the case of incidentalomas studied to exclude subclinical Cushing's syndrome, specificity should be the main

 The urinary cortisol excretion should be unequivocally increased (threefold above the upper limit of normal for the assay), or the diagnosis of Cushing's syndrome is

The patient should undergo additional evaluation if the test results are discordant or

 If test results are normal, the patient does not have Cushing's syndrome unless it is extremely mild or cyclic. Additional evaluations are not suggested unless symptoms

Cushing's syndrome is rare (it has an incidence of up to 3:1.000.000 persons per year) (Lindholm et al., 2001). It's also an intriguing condition both because of its complex diagnostic protocol and the demand for a correct treatment to avoid its devastating complications that can even conduct to death if left untreated. After diagnosing the hypercortisolism, it is important to determine its cause (Table 3) to better chose the appropriate treatment. It is a disease whose patients should be sent to a major hospital

**Diagnosis Percentage of Patients (%)** 

Urinary and salivary cortisol measurements should be obtained at least twice;

syndrome the following criteria should be met (Nieman et al., 2008):

criterion and so the cutoff level should be >5 µg /dl).

uncertain and other tests should be performed;

progress or cyclic Cushing's syndrome is suspected.

where multidisciplinary and well experienced teams will be available.

Cushing's disease 68 Ectopic ACTH syndrome 12 Ectopic CRH syndrome < 1

Adrenal adenoma 10 Adrenal carcinoma 8 Micronodular hyperplasia 1 Macronodular hyperplasia < 1

Major depressive disorder 1 Alcoholism < 1

only slightly abnormal;

**ACTH-dependent Cushing's syndrome** 

**ACTH-independent Cushing's syndrome** 

Table 3. Frequency of causes of Cushing's syndrome

**Pseudo-Cushing's syndrome** 

One of the most important, and therefore the initial, phase of determining Cushing's syndrome's etiology is to determine if the hypercortisolism is ACTH-dependent or ACTH independent. The ACTH-dependent hypercortisolism is normally due to a pituitary (or less frequently non-pituitary) ACTH secreting tumor, while ACTH-independent hypercortisolism is usually due to an adrenal tumor or hyperplasia. The preferred test is naturally the measurement of plasma ACTH. Usually a low plasma ACTH concentration of <5 pg/mL (1.1 pmol/L) in a hypercortisolemic patient is evidence of ACTHindependent disease (Invitti et al., 1999), while if the plasma ACTH concentration is above 15 pg/mL (3.3 pmol/L) it can be assumed that cortisol secretion is ACTH-dependent. Despite values between 5 and 15 pg/mL (1.1 to 3.3 pmol/L) being less definitive they normally indicate the hypercortisolism is ACTH-dependent. However, it is recommendable to perform a CRH stimulation test in these patients to confirm that hypothesis.

In the presence of an ACTH-independent Cushing's syndrome, it is important to proceed with a thin-section CT imaging of the adrenal glands, to determine its cause. When CT imaging suggests a suspicious lesion (for instance with large size) further investigation will be required to distinguish between the malignant ACC and benign ACT. The presence of bilateral disease on the other hand implies the distinction between, for instance, a bilateral tumor and bilateral macronodular adrenal hyperplasia.

Fig. 2. Cushing syndrome

Unilateral adenomas causing Cushing's syndrome should be surgically removed as they imply a very significant increase in morbidity and mortality, which is due to cardiovascular diseases or infections.

For the great majority of ACTH-dependent Cushing's syndrome patients, the cause of the hypercortisolism is a pituitary corticotroph adenoma (Cushing's disease). Even so,

Adrenal Cortex Tumors and Hyperplasias 329

Despite the fact that the majority of adrenal incidentalomas are clinically non-hypersecreting and benign adrenocortical adenomas (Mansmann et al., 2004), frequently, incidentalomas' series include cases that are cortisol secreting adrenocortical adenomas (5 to 9%) (Mantero et al., 2000; Young 2007) or pheochromocytomas (3 to 5%) (Young, 2007; Cawood et al., 2009). Of these pheochromocytomas, 50% are normotensive (Motta Ramirez et al., 2005). Incidentalomas can also be adrenocortical carcinomas and metastatic carcinomas. In a group of 2005 patients with adrenal incidentalomas, almost 5% were adrenocortical carcinomas

The approach to the evaluation and management of adrenal incidentalomas usually begins with taking patients' clinical history and performing a physical examination, testing for signs or symptoms of adrenal hyperfunction or malignant disease, and performing a

The probability to find a primary adrenal carcinoma in these cases has to be considered as rare, in spite of being dependant on the size of the tumor (above 4 cm the probability of an incidentaloma being malignant is 24% (Angeli et al., 1997); however, due to the importance of such a situation the initial major concern in evaluating an adrenal incidentaloma is the possibility of malignancy, followed by the evaluation of the possibility of metastatic cancer. In fact, one should also remember that several types of carcinomas may metastasize to the

Adrenal incidentalomas are bilateral in 10-to 15% of the cases. In these cases the etiology will be one of the following: metastases; congenital adrenal hyperplasia; bilateral adenomas, bilateral adrenocortical macronodular hyperplasia; bilateral pheochromocytomas;

As a main conclusion we would like to stress that it is of crucial importance to evaluate all patients with adrenal incidentalomas for the possibility of either subclinical hormonal hyper-function, including SCS and pheochromocytoma, as well as cancer. Table 4 describes major evaluations and clinical features for differential diagnosis of adrenal

The presence and diagnosis of adrenal cortex tumors in children is rare and may occur sporadically or as a component of certain hereditary tumour syndromes, such as the Li-Fraumeni syndrome, the multiple endocrine neoplasia-1 (MEN1), the Beckwith-Wiedemann syndrome, the Carney complex, and even in some rare cases of congenital adrenal hyperplasia. Its incidence is around 1 to 3 in 10.000.000 except in the southern regions of Brazil where it reaches 1 to 3 :1.000.000 (Agrons et al., 1999; Ribeiro et al., 2000, Wasserman et al., 2011).). In southern Brazil, these carcinomas are frequently associated with a particular mutation of

Clinical and biological characteristics of adrenocortical tumours are different from those observed in other paediatric carcinomas. About 65% of them are diagnosed in children younger than 5 years of age (Ribeiro et al., 1990). This age distribution has been demonstrated in several reports, including a study of Zerbini and colleagues, with 32 pediatric patients with adrenocortical neoplasms, in which the age at diagnosis ranged from 6 months to 19 years (median age, 5 years), with a predominant number of patients being 5 years of age and younger (Zerbini et al., 1992). In another study of Lefebvre and colleagues, with 42 children with adrenocortical neoplasms, two-thirds were younger than 5 years of age (Lefevre et al., 1983).

and 2.5% corresponded to other primary carcinomas'metastases (Young, 2000).

adrenal glands (e.g. lung, kidney, colon, breast, pancreas, liver and stomach).

hemorrhage, lymphoma; infectious or infiltrative diseases.

**9. Pediatric adrenal cortex tumors** 

TP53 (namely Arg337His) (Ribeiro et al., 1990).

incidentalomas.

complete hormonal evaluation (Young, 2007; Kudva et al., 2003; Terzolo et al., 2005).

patients with ACTH-dependent disease should undergo non-invasive tests such as the high-dose dexamethasone suppression test and the CRH stimulation test, to confirm the presence of Cushing's disease. It is also important to exclude extrapituitary (ectopic) sources of ACTH.

## **7. Subclinical Cushing's syndrome**

The "subclinical" Cushing's syndrome (SCS) refers to autonomous cortisol production that is insufficient to generate the typical, clinically recognizable, combination of symptoms. The prevalence of overt Cushing's syndrome caused by an adrenal adenoma in the general population is lower than the prevalence of subclinical Cushing's syndrome in patients with clinically non-functioning adrenal adenoma (Ross, 1994).

Patients with SCS have an adrenal mass usually detected incidentally (an incidentaloma) and normally do not show any of the clinical manifestation of the Cushing's syndrome (Terzolo et al., 2005a). Still, they have some endocrine alterations that allows their recognition (Urinary free cortisol > 70 µg /24h; serum cortisol levels after a dexamethasone suppression test >5 µg/dl; morning ACTH levels < 10 pg/ml). According to the Italian National survey on 1,004 adrenal incidentalomas (Mantero et al., 2000), of which 92 were classified as SCS, the hormonal evaluation showed low baseline secretion of ACTH in 79% of the SCS patients, lack of suppressibility of cortisol secretion after 1 mg dexamethasone in 73%, supra-normal 24-hour urinary cortisol excretion in 75% or disturbed cortisol circadian rhythm in 43%. Subclinical Cushing's syndrome is the most commonly detected abnormality in patients with adrenal incidentalomas.

Most patients with SCS may show one or more of the clinical manifestation of cortisol over-secretion, such as arterial hypertension, obesity or diabetes (Terzolo et al., 2000; Angeli & Terzolo, 2002). The association between a clinically silent adrenal adenoma and some of clinical manifestations of the metabolic syndrome has been studied and is considered well proven. In a retrospective study done by Terzolo and colleagues (Terzolo et al., 2005b), of 210 such patients, 53.8% had hypertension, 21.4% were obese and 22.4% had hyperglycemia.

## **8. Incidentalomas**

An adrenal incidentaloma is a mass lesion, usually with 1cm or more in diameter, discovered incidentally by radiologic examination (Young, 2007b). In recent years these incidentally discovered adrenal masses have been found with increasing frequency due to the widespread use of imaging techniques of the abdomen and their prevalence is estimated to be around 4% in the general population (Bovio et al., 2006). Several studies have been published concerning the prevalence of adrenal incidentalomas. In a series of 739 autopsies, Hedeland and colleagues (Hedeland et al., 1968) reported the presence of adrenal masses in 9% of normotensive patients versus 12% in patients with hypertension. In another review including 25 studies (Kloos et al., 1995), the calculated prevalence of adrenal incidentaloma was of 6%. The prevalence of adrenal adenomas increases with age from 0.2%in a patient between 20 and 29 years of age to 7% in a patient over 70 years of age (Young, 2007; Kloos et al., 1995). It is noteworthy that they are rare under the age of 40.

patients with ACTH-dependent disease should undergo non-invasive tests such as the high-dose dexamethasone suppression test and the CRH stimulation test, to confirm the presence of Cushing's disease. It is also important to exclude extrapituitary (ectopic)

The "subclinical" Cushing's syndrome (SCS) refers to autonomous cortisol production that is insufficient to generate the typical, clinically recognizable, combination of symptoms. The prevalence of overt Cushing's syndrome caused by an adrenal adenoma in the general population is lower than the prevalence of subclinical Cushing's syndrome in patients with

Patients with SCS have an adrenal mass usually detected incidentally (an incidentaloma) and normally do not show any of the clinical manifestation of the Cushing's syndrome (Terzolo et al., 2005a). Still, they have some endocrine alterations that allows their recognition (Urinary free cortisol > 70 µg /24h; serum cortisol levels after a dexamethasone suppression test >5 µg/dl; morning ACTH levels < 10 pg/ml). According to the Italian National survey on 1,004 adrenal incidentalomas (Mantero et al., 2000), of which 92 were classified as SCS, the hormonal evaluation showed low baseline secretion of ACTH in 79% of the SCS patients, lack of suppressibility of cortisol secretion after 1 mg dexamethasone in 73%, supra-normal 24-hour urinary cortisol excretion in 75% or disturbed cortisol circadian rhythm in 43%. Subclinical Cushing's syndrome is the most commonly detected

Most patients with SCS may show one or more of the clinical manifestation of cortisol over-secretion, such as arterial hypertension, obesity or diabetes (Terzolo et al., 2000; Angeli & Terzolo, 2002). The association between a clinically silent adrenal adenoma and some of clinical manifestations of the metabolic syndrome has been studied and is considered well proven. In a retrospective study done by Terzolo and colleagues (Terzolo et al., 2005b), of 210 such patients, 53.8% had hypertension, 21.4% were obese and 22.4%

An adrenal incidentaloma is a mass lesion, usually with 1cm or more in diameter, discovered incidentally by radiologic examination (Young, 2007b). In recent years these incidentally discovered adrenal masses have been found with increasing frequency due to the widespread use of imaging techniques of the abdomen and their prevalence is estimated to be around 4% in the general population (Bovio et al., 2006). Several studies have been published concerning the prevalence of adrenal incidentalomas. In a series of 739 autopsies, Hedeland and colleagues (Hedeland et al., 1968) reported the presence of adrenal masses in 9% of normotensive patients versus 12% in patients with hypertension. In another review including 25 studies (Kloos et al., 1995), the calculated prevalence of adrenal incidentaloma was of 6%. The prevalence of adrenal adenomas increases with age from 0.2%in a patient between 20 and 29 years of age to 7% in a patient over 70 years of age (Young, 2007; Kloos et al., 1995). It is noteworthy that they are rare under the age

sources of ACTH.

had hyperglycemia.

**8. Incidentalomas** 

of 40.

**7. Subclinical Cushing's syndrome** 

clinically non-functioning adrenal adenoma (Ross, 1994).

abnormality in patients with adrenal incidentalomas.

Despite the fact that the majority of adrenal incidentalomas are clinically non-hypersecreting and benign adrenocortical adenomas (Mansmann et al., 2004), frequently, incidentalomas' series include cases that are cortisol secreting adrenocortical adenomas (5 to 9%) (Mantero et al., 2000; Young 2007) or pheochromocytomas (3 to 5%) (Young, 2007; Cawood et al., 2009). Of these pheochromocytomas, 50% are normotensive (Motta Ramirez et al., 2005). Incidentalomas can also be adrenocortical carcinomas and metastatic carcinomas. In a group of 2005 patients with adrenal incidentalomas, almost 5% were adrenocortical carcinomas and 2.5% corresponded to other primary carcinomas'metastases (Young, 2000).

The approach to the evaluation and management of adrenal incidentalomas usually begins with taking patients' clinical history and performing a physical examination, testing for signs or symptoms of adrenal hyperfunction or malignant disease, and performing a complete hormonal evaluation (Young, 2007; Kudva et al., 2003; Terzolo et al., 2005).

The probability to find a primary adrenal carcinoma in these cases has to be considered as rare, in spite of being dependant on the size of the tumor (above 4 cm the probability of an incidentaloma being malignant is 24% (Angeli et al., 1997); however, due to the importance of such a situation the initial major concern in evaluating an adrenal incidentaloma is the possibility of malignancy, followed by the evaluation of the possibility of metastatic cancer. In fact, one should also remember that several types of carcinomas may metastasize to the adrenal glands (e.g. lung, kidney, colon, breast, pancreas, liver and stomach).

Adrenal incidentalomas are bilateral in 10-to 15% of the cases. In these cases the etiology will be one of the following: metastases; congenital adrenal hyperplasia; bilateral adenomas, bilateral adrenocortical macronodular hyperplasia; bilateral pheochromocytomas; hemorrhage, lymphoma; infectious or infiltrative diseases.

As a main conclusion we would like to stress that it is of crucial importance to evaluate all patients with adrenal incidentalomas for the possibility of either subclinical hormonal hyper-function, including SCS and pheochromocytoma, as well as cancer. Table 4 describes major evaluations and clinical features for differential diagnosis of adrenal incidentalomas.

## **9. Pediatric adrenal cortex tumors**

The presence and diagnosis of adrenal cortex tumors in children is rare and may occur sporadically or as a component of certain hereditary tumour syndromes, such as the Li-Fraumeni syndrome, the multiple endocrine neoplasia-1 (MEN1), the Beckwith-Wiedemann syndrome, the Carney complex, and even in some rare cases of congenital adrenal hyperplasia. Its incidence is around 1 to 3 in 10.000.000 except in the southern regions of Brazil where it reaches 1 to 3 :1.000.000 (Agrons et al., 1999; Ribeiro et al., 2000, Wasserman et al., 2011).).

In southern Brazil, these carcinomas are frequently associated with a particular mutation of TP53 (namely Arg337His) (Ribeiro et al., 1990).

Clinical and biological characteristics of adrenocortical tumours are different from those observed in other paediatric carcinomas. About 65% of them are diagnosed in children younger than 5 years of age (Ribeiro et al., 1990). This age distribution has been demonstrated in several reports, including a study of Zerbini and colleagues, with 32 pediatric patients with adrenocortical neoplasms, in which the age at diagnosis ranged from 6 months to 19 years (median age, 5 years), with a predominant number of patients being 5 years of age and younger (Zerbini et al., 1992). In another study of Lefebvre and colleagues, with 42 children with adrenocortical neoplasms, two-thirds were younger than 5 years of age (Lefevre et al., 1983).

Adrenal Cortex Tumors and Hyperplasias 331

**Features Imaging Characteristics** 

Usually large

Usually vascular

adenomas

adenomas do

common

nature

MRI

 Round or oval, with clear margins Heterogeneous, with cystic areas

 Delay in contrast medium washout (ten minutes after administration of contrast, an absolute contrast medium washout of less than 50 percent) but may be normal, mimicking the

 Markedly hyper intense in relation to the liver on T2-weighted images, in

 Chemical-shift imaging: Pheos and ACC don't loose signal intensity on out-of phase images in comparison with in-phase ones, whereas

Hemorrhage and cystic areas

Tendency to be bilateral

increased water content)

Irregular shape and inhomogeneous

 High unenhanced CT attenuation values (>20 HU) and enhancement with intravenous contrast on CT Delay in contrast medium washout (ten minutes after administration of contrast, an absolute contrast medium washout of less than 50 percent) Isointense or slightly less intense than the liver on T-1 weighted MRI and high to intermediate signal intensity on T-2 weighted MRI (representing an

 Usually solitary, unilateral High unenhanced CT attenuation values (>10 HU) (usually >25)

**Diagnosis Suggestive Clinical** 

Hypertension, Paroxysmal

palpitation, diaphoresis, headache, pallor, tremor). Half of the cases will remain undiagnosed! Plasma metanephrines

metanephrines are the initial screening tests

Cancer-specific signs. The identification of a primary extra-adrenal cancer favors this possibility

Adapted from Young WF, Jr. Clinical practice. The incidentally discovered adrenal mass. N Engl J Med

Table 4. Clinical features and imaging characteristics of adrenal incidentalomas

Symptoms (e.g.

and 24h urine

**Pheochromocytoma**

**Metastatic Cancer** 

2007a; 356: 601-10


**Features Imaging Characteristics** 

Homogeneous

hemorrhage

values >10%) Not highly vascular

50 % or more)

Irregular shape

tumor necrosis

values (>20 HU)

weighted MRI

metastases.

Round or oval, with smooth margins

Rare tumor calcification, necrosis or

 Small, usually ≤ 3 cm in diameter Usually solitary, unilateral

 CT unenhanced attenuation values ≤10 HU (25% may have low lipid content and hence have attenuation

 Isointense in relation to liver onT1 and T2-weighted images in MRI No delay in contrast medium washout (ten minutes after administration of contrast, an

absolute contrast medium washout of

 Inhomogeneous density because of central areas of low attenuation due to

 Common tumor calcification Diameter usually >4 cm Unilateral location

with intravenous contrast Delay in contrast medium washout (ten minutes after administration of contrast, an absolute contrast medium

washout of less than 50 %) Hypo-intensity compared with liver on T-1 weighted MRI and high to intermediate signal intensity on T-2

 High standardized uptake value (SUV) on FDG-PET-CT study Evidence of local invasion or

High unenhanced CT attenuation

Inhomogeneous enhancement on CT

**Diagnosis Suggestive Clinical** 

May have symptoms related to excess glucocorticoid, mineralocorticoid, androgen, or estrogen

Mass effect symptoms, symptoms related to excess glucocorticoid, mineralocorticoid, androgen, or estrogen secretion. The size (>4/6 cm) and the evolution are the most important signs to raise the suspicion

secretion

**Adrenocortical Adenoma** 

**Adrenocortical carcinoma** 


Adapted from Young WF, Jr. Clinical practice. The incidentally discovered adrenal mass. N Engl J Med 2007a; 356: 601-10

Table 4. Clinical features and imaging characteristics of adrenal incidentalomas

Adrenal Cortex Tumors and Hyperplasias 333

(Swords et al., 2002). The same occurred with GNAS activating mutations resulting in constitutive activation of the cAMP pathway that were shown to cause ACTH-independent macronodular adrenocortical hyperplasia (AIMAH) in McCune-Albright syndrome (Weinstein, 1991). On the other hand PRKAR1A-inactivating mutations resulting in a permanent activation of PKA may be associated to the development of PPNAD either isolated or as part of the Carney complex (Kirschner et al., 2000; Groussin et al., 2002b). More recently, inactivating mutations of the phosphodiesterase 11A gene, a gene coding for an enzyme that normally regulates cyclic nucleotide levels was reported both in cases of

The ACTH-independent macronodular adrenocortical hyperplasias (AIMAH) constitute a rare condition that consists of multiple bilateral adrenocortical macronodules causing a striking enlargement of the adrenal glands (Doppman et al., 1991; Malchoff et al., 1989; Swain et al., 1998). The great majority of AIMAH cases is sporadic. AIMAH is responsible for less than 1% of all the endogenous cases of Cushing's syndrome (Christopoulos et al., 2005). Usually patients present in the fifth and sixth decades of life, a significantly latter age

Increased cortisol levels in AIMAH result from the fact that hormones other than ACTH become able to activate cortisol secretion through receptors aberrantly located in the adrenal cortex cells and coupled to cAMP activation. Hormones like GIP, catecholamines, vasopressin, serotonin, LH among others can activate PKA signaling, via cAMP production,

In fact a great number of patients with AIMAH have that ectopic expression of and/or increased responsiveness to one of several possible receptors like the gastric inhibitory polypeptide (GIP) receptors (food-dependent hypercortisolism) (Resnik et al., 1992; N'diaye et al., 1998), vasopressin receptors (Horiba et al., 1995), the β-adrenergic receptors (Lacroix et al., 1997), the LH receptors, the serotonin receptors, the leptin receptors and angiotensin II

In the example of GIP-activated-cortisol-production, k cells from the duodenum and small intestine release, after food ingestion, a gastro-intestinal hormone named GIP (Gastric Inhibiting Peptide or Glucose-dependent Insulinotropic Peptide) in physiological concentrations (Lacroix et al., 2001). The expression of GIP receptors in the cells of the *zona fasciculata*, where they normally don't exist, can then be activated by the GIP secreted in response to meals, causing what is known as "food-dependent" cortisol production. The presence of this receptor can be confirmed *in vivo* by clinical testing or by adrenal imaging

To date, more than 30 cases were reported where the adrenal hormonal hypersecretion was associated to GIP stimulation. In the majority of cases patients presented with AIMAH (Lacroix et al., 2004; Groussin et al., 2002c). Besides that, other receptors were identified, some ectopically expressed and some being eutopic but showing an over-expression in the adrenocortical cells, as being the cause of cases of AIMAH and recently also demonstrated

The majority of cases of AIMAH is sporadic. Some cases however are familial and in most an autosomal dominant hereditarity has been described (Lacroix, 2009). Nevertheless, the

PPNAD and other bilateral hyperplasias (e.g. macronodular) (Libé et al., 2008).

of onset compared to other cortisol producing adenomas (Swain et al., 1998).

receptors (Lacroix et al., 1997; Lacroix et al., 2001; Lacroix et al., 1992).

following the injection of [123I]-GIP (Lacroix et al., 1992).

in cases of unilateral adenomas (Lacroix, 2009).

**11. ACTH-independent macronodular hyperplasias** 

**11.1 AIMAH pathogenesis** 

leading to a situation of Cushing's syndrome.

About half of the adrenocortical tumours in children have predisposing constitutional genetic factors, and are usually associated with the Li-Fraumeni syndrome or the Beckwith-Wiedemann syndrome (Li & Fraumeni, 1969a; Wiedemann, 1983; Lynch et al., 1978).

The Li-Fraumeni syndrome is a cancer-predisposing syndrome that includes breast cancer, brain carcinoma, sarcomas, leukaemia and adrenocortical carcinoma (Li & Fraumeni, 1969a; Lynch et al., 1978). This syndrome is a rare autosomal dominant condition associated with germline mutations of the tumour suppressor gene TP53 on the chromosome 17 (17p13) (Li & Fraumeni, 1969b; Li et al., 1998; ). The patient and the affected family members may develop different types of tumours (Birch, 1994; Srivastava et al., 1990; Sandrini et al., 1997; Hisada et al., 1998).

On the other side the Beckwith-Wiedemann syndrome, associated with abnormalities involving chromosome 11p15, and defined as a growth disorder is sometimes referred to as the EMG [exomphalos-macroglossia-gigantism] syndrome. This syndrome is associated with an increased risk of benign and malignant tumors of multiple organs (Fraumeni & Miller et al., 1967; Wiedemann, 1983), particularly the Wilms tumor of the kidneys and adrenocortical carcinoma (Lack, 1997).

The incidence of adrenocortical carcinomas in children is higher in girls. These pediatric carcinomas are hormone secreting tumors more frequently than in adults (90% vs 50%) (Michalkiewicz et al., 2004; Patil et al., 2002; Bonfig et al., 2003). The classic endocrine syndromes (namely the virilising and the Cushing's syndromes) represent the most common presentations of adrenocortical carcinomas in this age group (Wilkins, 1948 and Ribeiro et al., 2000).

However in spite of being pathologically malignant these carcinomas have a much better prognosis, with many of them becoming cured by the first surgical intervention (Michalkiewicz et al., 2004; Sutter et al., 2006; Wieneke et al., 2003; 27: Sabbaga et al., 1993)

## **10. ACTH-independent adrenal cortex hyperplasias**

ACTH-independent hypercortisolism is always of adrenocortical origin and an adrenocortical adenoma or carcinoma are by far its most common aetiologies (in up to 95% of patients). The remaining cases will be adrenocortical hyperplasias.

Even in these cases it's important to distinguish adrenocorticotropin (ACTH)–dependent forms like Cushing's disease or CAH (due to 21-hydroxylase deficiency) from ACTHindependent ones as a primary step in the differential diagnosis of Cushing's syndrome due to adrenocortical bilateral hyperplasias (Doppman et al., 2000).

Among the adrenal causes of Cushing's syndrome about 10-15% are due to bilateral adrenal lesions that include micronodular (particularly its most common variant the *Primary Pigmented Nodular Adrenocortical Disease – PPNAD*) and macronodular adrenal hyperplasias (*ACTH-Independent Macronodular Adrenocortical Hyperplasia - AIMAH*) and, more rarely, bilateral adenomas or carcinomas (Christopoulos et al., 2005; Stratakis & Boikos, 2007).

The hyperplasias can be sporadic or familial as is the case of PPNAD that can occur isolated or as part of an autosomal dominant disease including other tumors, endocrine and nonendocrine, called the Carney Complex.

Many adrenal cortex hyperplasia cases are thought to be the consequence of genetic changes in several key components of the cyclic AMP (cAMP) pathway (Libé & Betherat, 2005; Groussin et al., 2002a; Stratakis et al., 2007). Activating germline mutations of the ACTH receptor (MC2R) gene, making it display high levels of basal activity, have been reported

About half of the adrenocortical tumours in children have predisposing constitutional genetic factors, and are usually associated with the Li-Fraumeni syndrome or the Beckwith-

The Li-Fraumeni syndrome is a cancer-predisposing syndrome that includes breast cancer, brain carcinoma, sarcomas, leukaemia and adrenocortical carcinoma (Li & Fraumeni, 1969a; Lynch et al., 1978). This syndrome is a rare autosomal dominant condition associated with germline mutations of the tumour suppressor gene TP53 on the chromosome 17 (17p13) (Li & Fraumeni, 1969b; Li et al., 1998; ). The patient and the affected family members may develop different types of tumours (Birch, 1994; Srivastava et al., 1990; Sandrini et al., 1997; Hisada et

On the other side the Beckwith-Wiedemann syndrome, associated with abnormalities involving chromosome 11p15, and defined as a growth disorder is sometimes referred to as the EMG [exomphalos-macroglossia-gigantism] syndrome. This syndrome is associated with an increased risk of benign and malignant tumors of multiple organs (Fraumeni & Miller et al., 1967; Wiedemann, 1983), particularly the Wilms tumor of the kidneys and

The incidence of adrenocortical carcinomas in children is higher in girls. These pediatric carcinomas are hormone secreting tumors more frequently than in adults (90% vs 50%) (Michalkiewicz et al., 2004; Patil et al., 2002; Bonfig et al., 2003). The classic endocrine syndromes (namely the virilising and the Cushing's syndromes) represent the most common presentations of adrenocortical carcinomas in this age group (Wilkins, 1948 and

However in spite of being pathologically malignant these carcinomas have a much better prognosis, with many of them becoming cured by the first surgical intervention (Michalkiewicz et al., 2004; Sutter et al., 2006; Wieneke et al., 2003; 27: Sabbaga et al., 1993)

ACTH-independent hypercortisolism is always of adrenocortical origin and an adrenocortical adenoma or carcinoma are by far its most common aetiologies (in up to 95%

Even in these cases it's important to distinguish adrenocorticotropin (ACTH)–dependent forms like Cushing's disease or CAH (due to 21-hydroxylase deficiency) from ACTHindependent ones as a primary step in the differential diagnosis of Cushing's syndrome due

Among the adrenal causes of Cushing's syndrome about 10-15% are due to bilateral adrenal lesions that include micronodular (particularly its most common variant the *Primary Pigmented Nodular Adrenocortical Disease – PPNAD*) and macronodular adrenal hyperplasias (*ACTH-Independent Macronodular Adrenocortical Hyperplasia - AIMAH*) and, more rarely, bilateral adenomas or carcinomas (Christopoulos et al., 2005; Stratakis & Boikos, 2007). The hyperplasias can be sporadic or familial as is the case of PPNAD that can occur isolated or as part of an autosomal dominant disease including other tumors, endocrine and non-

Many adrenal cortex hyperplasia cases are thought to be the consequence of genetic changes in several key components of the cyclic AMP (cAMP) pathway (Libé & Betherat, 2005; Groussin et al., 2002a; Stratakis et al., 2007). Activating germline mutations of the ACTH receptor (MC2R) gene, making it display high levels of basal activity, have been reported

Wiedemann syndrome (Li & Fraumeni, 1969a; Wiedemann, 1983; Lynch et al., 1978).

al., 1998).

Ribeiro et al., 2000).

adrenocortical carcinoma (Lack, 1997).

endocrine, called the Carney Complex.

**10. ACTH-independent adrenal cortex hyperplasias** 

to adrenocortical bilateral hyperplasias (Doppman et al., 2000).

of patients). The remaining cases will be adrenocortical hyperplasias.

(Swords et al., 2002). The same occurred with GNAS activating mutations resulting in constitutive activation of the cAMP pathway that were shown to cause ACTH-independent macronodular adrenocortical hyperplasia (AIMAH) in McCune-Albright syndrome (Weinstein, 1991). On the other hand PRKAR1A-inactivating mutations resulting in a permanent activation of PKA may be associated to the development of PPNAD either isolated or as part of the Carney complex (Kirschner et al., 2000; Groussin et al., 2002b). More recently, inactivating mutations of the phosphodiesterase 11A gene, a gene coding for an enzyme that normally regulates cyclic nucleotide levels was reported both in cases of PPNAD and other bilateral hyperplasias (e.g. macronodular) (Libé et al., 2008).

## **11. ACTH-independent macronodular hyperplasias**

The ACTH-independent macronodular adrenocortical hyperplasias (AIMAH) constitute a rare condition that consists of multiple bilateral adrenocortical macronodules causing a striking enlargement of the adrenal glands (Doppman et al., 1991; Malchoff et al., 1989; Swain et al., 1998). The great majority of AIMAH cases is sporadic. AIMAH is responsible for less than 1% of all the endogenous cases of Cushing's syndrome (Christopoulos et al., 2005). Usually patients present in the fifth and sixth decades of life, a significantly latter age of onset compared to other cortisol producing adenomas (Swain et al., 1998).

## **11.1 AIMAH pathogenesis**

Increased cortisol levels in AIMAH result from the fact that hormones other than ACTH become able to activate cortisol secretion through receptors aberrantly located in the adrenal cortex cells and coupled to cAMP activation. Hormones like GIP, catecholamines, vasopressin, serotonin, LH among others can activate PKA signaling, via cAMP production, leading to a situation of Cushing's syndrome.

In fact a great number of patients with AIMAH have that ectopic expression of and/or increased responsiveness to one of several possible receptors like the gastric inhibitory polypeptide (GIP) receptors (food-dependent hypercortisolism) (Resnik et al., 1992; N'diaye et al., 1998), vasopressin receptors (Horiba et al., 1995), the β-adrenergic receptors (Lacroix et al., 1997), the LH receptors, the serotonin receptors, the leptin receptors and angiotensin II receptors (Lacroix et al., 1997; Lacroix et al., 2001; Lacroix et al., 1992).

In the example of GIP-activated-cortisol-production, k cells from the duodenum and small intestine release, after food ingestion, a gastro-intestinal hormone named GIP (Gastric Inhibiting Peptide or Glucose-dependent Insulinotropic Peptide) in physiological concentrations (Lacroix et al., 2001). The expression of GIP receptors in the cells of the *zona fasciculata*, where they normally don't exist, can then be activated by the GIP secreted in response to meals, causing what is known as "food-dependent" cortisol production. The presence of this receptor can be confirmed *in vivo* by clinical testing or by adrenal imaging following the injection of [123I]-GIP (Lacroix et al., 1992).

To date, more than 30 cases were reported where the adrenal hormonal hypersecretion was associated to GIP stimulation. In the majority of cases patients presented with AIMAH (Lacroix et al., 2004; Groussin et al., 2002c). Besides that, other receptors were identified, some ectopically expressed and some being eutopic but showing an over-expression in the adrenocortical cells, as being the cause of cases of AIMAH and recently also demonstrated in cases of unilateral adenomas (Lacroix, 2009).

The majority of cases of AIMAH is sporadic. Some cases however are familial and in most an autosomal dominant hereditarity has been described (Lacroix, 2009). Nevertheless, the

Adrenal Cortex Tumors and Hyperplasias 335

The asymmetric appearance of the adrenal macronodules in AIMAH has been described (Liebermann et al., 1994; Lacroix et al., 2001) and also, according to a study including patients with surgically proven AIMAH, adrenal masses measuring up to 5 cm of soft tissue density can distort and obscure the adrenal glands (Doppman et al., 1991). This may

One important suggestion consist of evaluating **all** patients with AIMAH and clinical and sub-clinical Cushing's syndrome for the presence of aberrant receptors, that are very

In this scenario, tests that modulate the levels of ligands for those receptors may be useful determining cortisol and other steroid changes. These tests include physiological tests, such as upright posture and mixed meals, and pharmacological tests including gonadotropinreleasing hormone, thyrotropin-releasing hormone, vasopressin, glucagon and metoclopramide (Lacroix et al., 2001; Mircescu et al., 2000). Cortisol increases ≥25% are considered as significant, provided there is no increase in ACTH. If necessary, these tests should be carried out under Dexamethasone suppression. Responses between 25% and 49% are considered partial responses and if ≥50% complete responses. Any positive change should prompt the continuation of the study to identify all the receptors that may be

The importance of identifying these aberrant receptors is the possibility to have specific

**RECEPTOR IN VIVO SCREENING MEDICAL TREATMENT** 

Octreotide GIPR antagonist

antagonist

Vasopressin receptor

DDAVP antagonist (V2)

Β-blocker (Propranolol)

Long acting GnRH agonist

GnRH antagonist

Angiotensin receptor

antagonist

Therefore, other clinical and molecular features must be used in diagnosing AIMAH.

frequently present in AIMAH (Lacroix et al., 2001; Mircescu et al., 2000).

therapeutical weapons that may permit avoiding bilateral adrenalectomy:

Administration of Arginine Vasopressin Administration of DDAVP (- =V1R; + =V2R)

Stimulation by insulin-induced hypoglycemia

Pregnancy or Menopausal related cortisol

(Adapted from Lacroix et al., 2009 ACTH independent macronodular hyperplasia. Best Practice and

Table 5. Receptors involved in AIMAH, in vivo screening tests and possible medical treatments

Metoclopramide/Cisapride/Tegaserod test 5HT-4 receptor antagonist

Sometimes also androgen secreting

Stimulation by GIP infusion

**GIP** Mixed meal (Food-dependent Cushing)

Upright posture Inhibition by water load Stimulation by saline infusion

Upright posture

Recombinant LH

Upright posture Angiotensin infusion (?) Angiotensin antagonist

Research Clinical Endocrinology and Metabolism. Vol 23. Pp 245-259)

GnRH test hCG

elevation

**5HT-4** Administration of 5HT-4 agonists

Isoproterenol infusion Propranolol suppression

conduct to the erroneous diagnosis of a unilateral adenoma.

involved (Lacroix et al., 2001)

**Vasopressin** 

**Β-adrenergic** 

**LH / βHCG** 

**Angiotensin** 

genetic cause for these cases hasn't yet been identified. In addition to those familiar reports, AIMAH has been described in MEN-1 with a frequency between 6% (Burgess et al., 1996) and 21% (Skogseid et al., 1992), and in rare cases of Gs alpha subunit mutations (Weinstein et al., 1991; Fragoso et al., 2003) or activating mutations of the ACTH receptor (MC2R) (Swords et al., 2002):


## **11.2 AIMAH diagnosis and clinical presentation**

Usually AIMAH cases can be discovered after an incidental radiological finding or following the investigation of an adrenal hypersecretion syndrome and can be distinguished from ACTH-dependent macronodular hyperplasia by a suppressed plasma ACTH (<5 pg/mL *vs.* ≥15 pg/mL).

The most common laboratory findings associated with AIMAH are the following:


An exception to this general pattern occurs in patients with GIP-dependent Cushing's syndrome in whom cortisol hypersecretion occurs in response to meals and serum cortisol may be low in the fasting state (Resnik et al., 1992; Lacroix et al., 1992).


The diagnosis of AIMAH is usually suspected after typical imaging studies, which can be variable. At the computed tomography (CT) the adrenal glands in patients with AIMAH are greatly enlarged with multiple macronodules up to 5 cm in diameter. These adrenals' weight may vary between 24 to 500g (Doppman et al., 2000; Malchoff et al., 1989).

genetic cause for these cases hasn't yet been identified. In addition to those familiar reports, AIMAH has been described in MEN-1 with a frequency between 6% (Burgess et al., 1996) and 21% (Skogseid et al., 1992), and in rare cases of Gs alpha subunit mutations (Weinstein et al., 1991; Fragoso et al., 2003) or activating mutations of the ACTH receptor (MC2R)

 **Gs alpha-subunit mutations** — an activating mutation in the gene of the Gsa subunit of G-protein coupled receptors (stimulatory guanine nucleotide-binding protein, Gs) leads to constitutive activation of cAMP. These mutations may be responsible not only for increased production of cortisol but also for increased proliferation and consequently the formation of adrenal nodules (Weinstein et al., 1991; Fragoso et al.,

 **MEN1** – In patients with multiple endocrine neoplasia syndrome type 1 (MEN1) caused by mutations in the the tumor suppressor gene *menin*, together with the more frequent endocrine tumors that are characteristic of the syndrome, adrenocortical adenomas or macronodular bilateral hyperplasias may also occur (Burgess et al., 1996; Skogseid et al.,

 **Other genes** – There were some rare reports of activating mutations of the ACTH receptor (MC2R) gene in adrenal tumors and AIMAH (Swords et al., 2002). Moreover, AIMAH has also been reported in patients with: familial polyposis coli and a mutation in the adenomatous polyposis coli (APC) gene (Kartheuser et al., 1999); in patients with mutations in the fumarate hydratase gene (FH) (Matyakhina et al., 2005) on chromosome 1 (1q42.3-43); and in patients with germline mutations in phosphodiesterase 11A isoform

Usually AIMAH cases can be discovered after an incidental radiological finding or following the investigation of an adrenal hypersecretion syndrome and can be distinguished from ACTH-dependent macronodular hyperplasia by a suppressed plasma

 Increased serum and urinary cortisol and undetectable plasma ACTH in the basal state (Doppman et al., 2000; Swain et al., 1998; Kirschner et al., 1964; Bourdeau et al., 2001,

As in any cause of adrenal cortisol hypersecretion, dexamethasone suppression test fails

An exception to this general pattern occurs in patients with GIP-dependent Cushing's syndrome in whom cortisol hypersecretion occurs in response to meals and serum cortisol

 Steroid hormone synthesis is relatively inefficient in AIMAH as a consequence of decreased steroidogenic enzymatic activity resulting frequently in elevated 17 hydroxyprogesterone levels after stimulation with ACTH (Bourdeau et al., 2001). Serum 18-hydroxycorticosterone, corticosterone and estrone may cause hypertension or

The diagnosis of AIMAH is usually suspected after typical imaging studies, which can be variable. At the computed tomography (CT) the adrenal glands in patients with AIMAH are greatly enlarged with multiple macronodules up to 5 cm in diameter. These adrenals'

feminization in the patients in whom they are increased (Wada et al., 2002).

weight may vary between 24 to 500g (Doppman et al., 2000; Malchoff et al., 1989).

4 gene (PDE11A) (Libé et al., 2008) located on chromosome 2 (2q31-35).

The most common laboratory findings associated with AIMAH are the following:

to suppress cortisol production (Christopoulos et al., 2005).

may be low in the fasting state (Resnik et al., 1992; Lacroix et al., 1992).

**11.2 AIMAH diagnosis and clinical presentation** 

ACTH (<5 pg/mL *vs.* ≥15 pg/mL).

Lieberman et al., 1994).

(Swords et al., 2002):

2003).

1992).

The asymmetric appearance of the adrenal macronodules in AIMAH has been described (Liebermann et al., 1994; Lacroix et al., 2001) and also, according to a study including patients with surgically proven AIMAH, adrenal masses measuring up to 5 cm of soft tissue density can distort and obscure the adrenal glands (Doppman et al., 1991). This may conduct to the erroneous diagnosis of a unilateral adenoma.

Therefore, other clinical and molecular features must be used in diagnosing AIMAH.

One important suggestion consist of evaluating **all** patients with AIMAH and clinical and sub-clinical Cushing's syndrome for the presence of aberrant receptors, that are very frequently present in AIMAH (Lacroix et al., 2001; Mircescu et al., 2000).

In this scenario, tests that modulate the levels of ligands for those receptors may be useful determining cortisol and other steroid changes. These tests include physiological tests, such as upright posture and mixed meals, and pharmacological tests including gonadotropinreleasing hormone, thyrotropin-releasing hormone, vasopressin, glucagon and metoclopramide (Lacroix et al., 2001; Mircescu et al., 2000). Cortisol increases ≥25% are considered as significant, provided there is no increase in ACTH. If necessary, these tests should be carried out under Dexamethasone suppression. Responses between 25% and 49% are considered partial responses and if ≥50% complete responses. Any positive change should prompt the continuation of the study to identify all the receptors that may be involved (Lacroix et al., 2001)


The importance of identifying these aberrant receptors is the possibility to have specific therapeutical weapons that may permit avoiding bilateral adrenalectomy:

(Adapted from Lacroix et al., 2009 ACTH independent macronodular hyperplasia. Best Practice and Research Clinical Endocrinology and Metabolism. Vol 23. Pp 245-259)

Table 5. Receptors involved in AIMAH, in vivo screening tests and possible medical treatments

Adrenal Cortex Tumors and Hyperplasias 337

Most commonly patients with PPNAD present signs and symptoms of hypercortisolism such as weight gain, obesity, hypertension, and menstrual cycle disorders. However, in many of them these symptoms are subtle and slowly progressive. Besides, sometimes the cortisol hypersecretion can be cyclical rendering these cases difficult to diagnose. On the other hand, there are several characteristics that are unique to this type of micronodular

The majority of patients with PPNAD are diagnosed at a young age, usually before

 Another hallmark is the paradoxical cortisol response to Dexamethasone suppression test, meaning that cortisol raises in response to dexamethasone instead of being reduced

Most of the nodules found in these patients are less than 4 mm, and reasonably well

As already mentioned, in some patients with this pathology the development of hypercortisolism symptoms can be cyclic and irregular what causes some typical Cushing's syndrome symptoms to be variable or discrete, therefore complicating its diagnosis. On the other hand, in patients with PPNAD, due to the presence of elevated cortisol levels, osteoporosis and avascular hip necrosis have been reported (Ruder et al., 1974; Carney &

PPNAD occurs as part of Carney complex in more than 60% of the cases (Bertherat et al.,

This syndrome is an autosomal dominant form of multiple neoplasia. The main signs that characterize this condition are the presence of spotty skin pigmentation (lentiginosis), the presence of endocrine tumors, including PPNAD (the most common endocrine finding in Carney's complex), testicular large cell calcifying Sertoli cells tumors, GH secreting pituitary adenomas and thyroid adenomas and carcinomas, and non-endocrine tumors, including atrial myxomas, cutaneous myxomas, breast ductal adenomas, psammomatous melanotic schwannomas, and osteochondromyxomas (Stratakis et al., 2001; Carney et al., 1985; Stratakis et al., 1997). Cushing's syndrome caused by PPNAD occurs in many of the cases of Carney Complex. However, if one considers also the subclinical cases of Cushing's syndrome, the percentage will surely be higher (Bertherat et al., 2009; Stratakis et al., 2001). Three genetic loci were associated with the Carney Complex: 2p16, 17q22-24 and 17p12- 13. More than 70% Carney Complex cases have a PRKAR1A mutation (Bertherat et al.,

For being a heterogeneous disease that can present with different signs and symptoms, its diagnosis is usually difficult (Carson et al., 1988; Gunther et al., 2004), especially if it shows

The most important steps for its diagnosis can be the same as for the diagnosis of Cushing's syndrome. Therefore initial phases must include confirming hypercortisolism, determining whether the hypercortisolism is ACTH-dependent or ACTH-independent, and whether there is paradoxical response to Dexamethasone suppression test. Then it will be necessary

unusual clinical manifestations and if it is not present in other family members.

**12.2 ACTH-independent micronodular hyperplasia – Diagnosis and clinical** 

hyperplasia (Carney & Young, 1992; Larsen et al., 1986; Stratakis et al., 2001).

At surgery the characteristic pigmentation can be observed.

demarcated from the adjacent atrophic cortex.

turning 30 years, and many cases occur in patients under 15 years of age.

**presentation** 

Young, 1992).

2009).

2009).

**12.3 Carney complex** 

(Stratakis et al., 1999).

## **12. ACTH-independent micronodular hyperplasias**

ACTH-independent micronodular hyperplasias are characterized by the presence of multiple cortical micronodules, with less than 1 cm in diameter (Louiset et al., 2010). These micronodular hyperplasias can be divided in two different subtypes, depending on the presence or absence of nodular pigment and internodular atrophy. The most common and predominant type of ACTH-independent micronodular adrenal hyperplasia is the primary pigmented nodular adrenocortical disease (PPNAD), characterized by multiple pigmented micronodules usually surrounded by internodular cortical atrophy. The pigmented nodules are observed in the zone between the cortex and the medulla and the cells have hybrid characteristics between cortical and medullar (for instance the high expression of synaptophysin). The pigment has been identified as lipofuscin (Louiset et al., 2010).

PPNAD is one of the possible causes of Cushing's syndrome. However, it must be stressed that it is a rare disease representing less than 1% of the cases of Cushing's syndrome. It may be sporadic or familial, and in this case it's one of the components of the Carney complex (Carney & Young, 1992; Stratakis et al., 2001).

## **12.1 ACTH-independent micronodular hyperplasia- pathogenesis**

A few genes were already identified as causal for the development of ACTH-independent micronodular hyperplasia:


Moreover, in addition to germline PRKAR1A mutations, somatic beta-catenin mutations have been found in the larger nodules of patients with PPNAD, suggesting that secondary events in the Wnt/beta-catenin signaling pathway can contribute to tumorigenesis in PPNAD (Tadjine et al., 2008; Gaujoux et al., 2008).

ACTH-independent micronodular hyperplasias are characterized by the presence of multiple cortical micronodules, with less than 1 cm in diameter (Louiset et al., 2010). These micronodular hyperplasias can be divided in two different subtypes, depending on the presence or absence of nodular pigment and internodular atrophy. The most common and predominant type of ACTH-independent micronodular adrenal hyperplasia is the primary pigmented nodular adrenocortical disease (PPNAD), characterized by multiple pigmented micronodules usually surrounded by internodular cortical atrophy. The pigmented nodules are observed in the zone between the cortex and the medulla and the cells have hybrid characteristics between cortical and medullar (for instance the high expression of synaptophysin). The pigment has been identified as lipofuscin (Louiset et

PPNAD is one of the possible causes of Cushing's syndrome. However, it must be stressed that it is a rare disease representing less than 1% of the cases of Cushing's syndrome. It may be sporadic or familial, and in this case it's one of the components of the Carney complex

A few genes were already identified as causal for the development of ACTH-independent

 **PRKAR1A** - Most patients with PPNAD, especially when the disease is a component of Carney complex, have germline-inactivating mutations of the PRKAR1A [protein kinase A (PKA) regulatory subunit type 1α] gene (Kirschner et al., 2000; Groussin et al., 2002a; Groussin et al., 2002b). These mutations code for a truncated protein that is not produced, and the loss of this protein leads to an increased activation of protein kinase A (PKA) by cyclic AMP (Nadella & Kirschner, 2005). In several different studies of patients with PPNAD associated with Carney complex, 65-82% had PRKAR1A mutations (Groussin et al., 2002; Veugelers et al., 2004; Bertherat et al

 **Phosphodiesterase 11A (PDE11A)** - PDE11A is a dual-specificity PDE with affinity both to cAMP and cGMP, expressed in several endocrine tissues (D'Andrea et al., 2005). Decreased expression of PDE11A has been correlated to increased adrenocortical levels of cAMP and cAMP-responsive element (CREB) phosphorylation presumably being the cause of adrenal hyperplasia. Besides having been identified in PPNAD and non-pigmented micronodular bilateral adrenocortical hyperplasias, in a study of Libé and colleagues, the PDE11A missense germline variants were also found in 18.8% of adrenocortical tumors (adrenocortical carcinomas, adenomas and bilateral macronodular adrenal hyperplasias) (Libé et al.,

**Other genes** - PDE8B gene mutations have also been described in patients with PPNAD

Moreover, in addition to germline PRKAR1A mutations, somatic beta-catenin mutations have been found in the larger nodules of patients with PPNAD, suggesting that secondary events in the Wnt/beta-catenin signaling pathway can contribute to tumorigenesis in

or nonpigmented variants of the disease (Horvath et al., 2008).

PPNAD (Tadjine et al., 2008; Gaujoux et al., 2008).

**12. ACTH-independent micronodular hyperplasias** 

(Carney & Young, 1992; Stratakis et al., 2001).

micronodular hyperplasia:

2009).

2008).

**12.1 ACTH-independent micronodular hyperplasia- pathogenesis** 

al., 2010).

## **12.2 ACTH-independent micronodular hyperplasia – Diagnosis and clinical presentation**

Most commonly patients with PPNAD present signs and symptoms of hypercortisolism such as weight gain, obesity, hypertension, and menstrual cycle disorders. However, in many of them these symptoms are subtle and slowly progressive. Besides, sometimes the cortisol hypersecretion can be cyclical rendering these cases difficult to diagnose. On the other hand, there are several characteristics that are unique to this type of micronodular hyperplasia (Carney & Young, 1992; Larsen et al., 1986; Stratakis et al., 2001).


As already mentioned, in some patients with this pathology the development of hypercortisolism symptoms can be cyclic and irregular what causes some typical Cushing's syndrome symptoms to be variable or discrete, therefore complicating its diagnosis. On the other hand, in patients with PPNAD, due to the presence of elevated cortisol levels, osteoporosis and avascular hip necrosis have been reported (Ruder et al., 1974; Carney & Young, 1992).

## **12.3 Carney complex**

PPNAD occurs as part of Carney complex in more than 60% of the cases (Bertherat et al., 2009).

This syndrome is an autosomal dominant form of multiple neoplasia. The main signs that characterize this condition are the presence of spotty skin pigmentation (lentiginosis), the presence of endocrine tumors, including PPNAD (the most common endocrine finding in Carney's complex), testicular large cell calcifying Sertoli cells tumors, GH secreting pituitary adenomas and thyroid adenomas and carcinomas, and non-endocrine tumors, including atrial myxomas, cutaneous myxomas, breast ductal adenomas, psammomatous melanotic schwannomas, and osteochondromyxomas (Stratakis et al., 2001; Carney et al., 1985; Stratakis et al., 1997). Cushing's syndrome caused by PPNAD occurs in many of the cases of Carney Complex. However, if one considers also the subclinical cases of Cushing's syndrome, the percentage will surely be higher (Bertherat et al., 2009; Stratakis et al., 2001).

Three genetic loci were associated with the Carney Complex: 2p16, 17q22-24 and 17p12- 13. More than 70% Carney Complex cases have a PRKAR1A mutation (Bertherat et al., 2009).

For being a heterogeneous disease that can present with different signs and symptoms, its diagnosis is usually difficult (Carson et al., 1988; Gunther et al., 2004), especially if it shows unusual clinical manifestations and if it is not present in other family members.

The most important steps for its diagnosis can be the same as for the diagnosis of Cushing's syndrome. Therefore initial phases must include confirming hypercortisolism, determining whether the hypercortisolism is ACTH-dependent or ACTH-independent, and whether there is paradoxical response to Dexamethasone suppression test. Then it will be necessary

Adrenal Cortex Tumors and Hyperplasias 339

Aubert, S., Buob, D., Leroy, X., Devos, P., Carnaille, B., Do Cao, C., Wemeau, JL. & Leteurtre,

adrenocortical malignancy. *Ann* Pathol, Vol. 25, No. 6, pp. (545-54), ISSN. Azziz, R., Sanchez, LA., Knochenhauer, ES., Moran, C., Lazenby, J., Stephens, KC., Taylor,

consecutive patients. *J Clin Endocrinol Metab*, Vol. 89, pp. (453–62), ISSN. Barzon, L., Chilosi, M., Fallo, F., Martignoni, G., Montagna, L., Palù, G. & Boscaro, M. (2001).

Barzon, L., Sonino, N., Fallo, F., Palu, G. & Boscarom M. (2003). Prevalence and natural history of adrenal incidentalomas. *Eur J Endocrinol*, Vol. 149, pp. (273–85), ISSN. Baudin, E., Pellegriti, G., Bonnay, M., Penfornis, A., Laplanche, A., Vassal, G. &

Bernard, MH., Sidhu, S., Berger, N., Peix, JL., Marsh, DJ., Robinson, BG., Gaston, V., Le

Berruti, A., Terzolo, M., Sperone, P., Pia, A., Casa, SD., Gross, DJ., Carnaghi, C., Casali, P.,

Bertherat, J., Horvath, A., Groussin, L., Grabar, S., Boikos, S., Cazabat, L., Libe, R., René-

genotypes. *J Clin Endocrinol Metab*, Vol. 94, No. 6, pp. (2085-91), ISSN. Beuschlein, F., Reincke, M., Karl, M., Travis, WD., Jaursch-Hancke, C., Abdelhamid, S.,

Birch, JM. (1994). Li-Fraumeni syndrome. *Eur J Cancer*, Vol. 30A, pp. (1935-41), ISSN.

hyperaldosteronism. *Ann Intern Med*, Vol. 121, pp. (877-85), ISSN.

Blumenfeld, JD., Sealey, JE., Schlussel, Y., Vaughan, ED., Sos, TA., Atlas, SA., Muller, FB.,

Boland, GW., Lee, MJ., Gazelle, GS., Halpern, EF., McNicholas, MM. & Mueller, PR. (1998).

Bonacci, R., Gigliotti, A., Baudin, E., Wion-Barbot, N., Emy, P., Bonnay, M., Cailleux, AF.,

neoplasms. *Cancer Research*, Vol. 54, pp. (4927–32), ISSN.

literature. *AJR Am J Roentgenol*, Vol.171, pp. (201–4), ISSN.

tumorigenesis. *J Clin Endocrinol Metab*, Vol. 88, pp. (998–1001), ISSN. Bernini, GP., Moretti, A., Oriandini, C., Bardini, M., Taurino, C. & Salvetti. A. (2005). Long-

adrenal incidentalomas. *Br J Cancer*, Vol. 92, pp. (1104 – 9), ISSN.

adrenocortical carcinoma. *Cancer*, Vol. 92, pp. (1385-92), ISSN.

*Endocrinol* , Vol. 145, pp. (207–12), ISSN.

Vol. 12, pp. (657-66), ISSN.

pp. (546-9), ISSN.

E. (2005). Weiss system: a still in-use diagnostic tool for the assessment of

K. & Boots, LR. (2004). Androgen excess in women: experience with over 1000

Molecular analysis of CDKN1C and TP53 in sporadic adrenal tumors. *Eur J* 

Schlumberger, M. (2001). Impact of monitoring plasma 1,1 dichlorodiphenildichloroethane (o,p'DDD) levels on the treatment of patients with

Bouc, Y. & Gicquel, C. (2003). A case report in favor of a multistep adrenocortical

term morphological and hormonal follow-up in a single unit on 115 patients with

Porpiglia, F., Mantero, F., Reimondo, G., Angeli, A. & Dogliotti, L. (2005). Etoposide, doxorubicin and cisplatin plus mitotane in the treatment of advanced adrenocortical carcinoma: a large prospective phase II trial. *Endocr Relat Cancer*,

Corail, F., Stergiopoulos, S., Bourdeau, I., Bei, T., Clauser, E., Calender, A., Kirschner, LS., Bertagna, X., Carney, JA. & Stratakis, CA. (2009). Mutations in regulatory subunit type 1A of cyclic adenosine 5'-monophosphate-dependent protein kinase (PRKAR1A): phenotype analysis in 353 patients and 80 different

Chrousos, GP. & Allolio, B. (1944). Clonal composition of human adrenocortical

Acevedo, R., Ulick, S. & Laragh, JH. (1994). Diagnosis and treatment of primary

Characterization of adrenal masses using unenhanced CT: an analysis of the CT

Nakib, I. & Schlumberger, M. Réseau Comète. (1998). Cytotoxic therapy with etoposide and cisplatin in advanced adrenocortical carcinoma. *Br J Cancer*, Vol. 78,

to identify the cause of that hypercortisolism. When investigating family members of patients affected by PPNAD or other forms of micronodular disease, the dexamethasone suppression tests should be used to identify subclinical adrenal disease, since for these patients, even subtle changes of cortisol secretion should be considered abnormal (plasma cortisol >1.8 µg/dL [50 nmol/L] following Liddle's test). ACTH suppression is also significant in this context. After that, the computerized tomography of the adrenals will help to distinguish unilateral from bilateral nodular disease or hyperplasia and so it must be performed next (Rockal et al., 2004). It must be stressed however that the adrenals are not very enlarged and so the interpretation of the images can be difficult (Bertherat et al., 2009). Treatment of PPNAD is often bilateral adrenalectomy, sometimes in two surgical timings years-apart, related to the fact that the development of this bilateral disease is frequently asymmetrical.

## **13. References**


to identify the cause of that hypercortisolism. When investigating family members of patients affected by PPNAD or other forms of micronodular disease, the dexamethasone suppression tests should be used to identify subclinical adrenal disease, since for these patients, even subtle changes of cortisol secretion should be considered abnormal (plasma cortisol >1.8 µg/dL [50 nmol/L] following Liddle's test). ACTH suppression is also significant in this context. After that, the computerized tomography of the adrenals will help to distinguish unilateral from bilateral nodular disease or hyperplasia and so it must be performed next (Rockal et al., 2004). It must be stressed however that the adrenals are not very enlarged and so the interpretation of the images can be difficult (Bertherat et al., 2009). Treatment of PPNAD is often bilateral adrenalectomy, sometimes in two surgical timings years-apart, related to the fact that the development of this bilateral disease is frequently

Abiven, G., Coste, J., Groussin, L., Anract, P., Tissier, F., Legmann, P., Dousset, B., Bertagna,

Adam, R., Chiche, L., Aloia, T., Elias, D., Salmon, R., Rivoire, M., Jaeck, D., Saric, J., Le Treut,

Advani, A., Johnson, SJ., Nicol, MR., Papacleovoulou, G., Evans, DB., Vaikkakara, S., Mason,

Agrons, GA., Lonergan, GJ., Dickey, GE. & Perez-Monte, JE. (1999). Adrenocortical

Allolio, B. & Fassnacht, M. (2006). Clinical review: Adrenocortical carcinoma: clinical

Allolio, B., Hahner, S., Weismann, D. & Fassnacht, M. (2004). Management of adrenocortical

Angeli, A., Osella, G., Alì, A. & Terzolo, M. (1997). Adrenal incidentaloma: an overview of

Angeli, A. & Terzolo, M. (2002). Adrenal incidentaloma — a modern disease with old

complications. *J Clin Endocrinol Metab*, Vol. 87, pp. (4869-71), ISSN.

update. *J Clin Endocrinol Metab*, Vol. 91, pp. (2027-37), ISSN.

carcinoma. *Clin Endocrinol (Oxf)*, Vol. 60, pp. (273-87), ISSN.

consecutive patients. *J Clin Endocrinol Metab*, Vol. 91, pp. (2650-5), ISSN. Abraham, J., Bakke, S., Rutt, A., Meadows, B., Merino, M., Alexander, R., Schrump, D.,

*Cancer*, Vol. 94, pp. (2333-43), ISSN.

Vol. 57, No. 7, pp. (651-6), ISSN.

4, pp. (989-1008), ISSN.

Vol. 47, pp. (279-83), ISSN.

pp. (524-35), ISSN.

X. & Bertherat, J. (2006). Clinical and biological features in the prognosis of adrenocortical cancer: poor outcome of cortisol-secreting tumors in a series of 202

Bartlett, D., Choyke, P., Robey, R., Hung, E., Steinberg, SM., Bates, S. & Fojo, T. (2002). A phase II trial of combination chemotherapy and surgical resection for the treatment of metastatic adrenocortical carcinoma: continuous infusion doxorubicin, vincristine, and etoposide with daily mitotane as a P-glycoprotein antagonist.

YP., Belghiti, J., Mantion, G. & Mentha, G., Association Française de Chirurgie. (2006). Hepatic resection for noncolorectal nonendocrine liver metastases: analysis of 1,452 patients and development of a prognostic model. *Ann Surg*, Vol. 244, No. 4,

JI. & Quinton, R. (2010). Adult-onset hypogonadotropic hypogonadism caused by aberrant expression of aromatase in an adrenocortical adenocarcinoma. *Endocr J*,

neoplasms in children: radiologic-pathologic correlation. *Radiographics*, Vol. 19, No.

clinical and epidemiological data from the National Italian Study Group. *Horm Res*,

asymmetrical.

**13. References** 


Adrenal Cortex Tumors and Hyperplasias 341

Christopoulos, S., Bourdeau, I. & Lacroix, A. (2005). Clinical and subclinical ACTH-

Cobb, WS., Kercher, KW., Sing, RF. & Heniford, BT. (2005). Laparoscopic adrenalectomy for

Conn JW. (1964). Plasma renin activity in primary aldosteronism. Importance in differential

Conn, JW. (1955). Presidential address. Part I. Painting the background. Part II. Primary aldosteronism, a new clinical syndrome. *J Lab Clin Med*, Vol. 45, pp. (3–17), ISSN. Dackiw, AP., Lee, JE., Gagel, RF. & Evans, DB. (2001). Adrenal cortical carcinoma. *World J* 

Daffara, F., De Francia, S., Reimondo, G., Zaggia, B., Aroasio, E., Porpiglia, F., Volante, M.,

D'Andrea, MR., Qiu, Y., Haynes-Johnson, D., Bhattacharjee, S., Kraft, P. & Lundeen, S.

DeChiara, TM., Robertson, EJ. & Efstratiadis A. (1991). Parental imprinting of the mouse

Decker, RA., Elson, P., Hogan, TF., Citrin, DL., Westring, DW., Banerjee, TK., Gilchrist, KW.

DeLellis, RA., Lloyd, RV., Heitz, PU. & Eng, C. (2004). *Pathology and Genetics of Tumours of* 

Derksen, J., Nagesser, SK., Meinders, AE., Haak, HR. & van de Velde, CJ. (1994).

Doppman, JL., Chrousos, GP., Papanicolaou, DA., Stratakis, CA., Alexander, HR. & Nieman,

Doppman, JL., Nieman, LK., Travis, WD., Miller, DL., Cutler, GB Jr., Chrousos, GP. &

adjuvantly. *Endocr Relat Cancer*, Vol. 15, No. 4, pp. (1043-53), ISSN.

insulin-like growth factor II gene. *Cell*, Vol. 64, pp. (849–59), ISSN.

*Endocrine Organs,* World Health Organization, ISBN, Lyon, France.

time for a rethink? *Eur J Endocrinol*, Vol. 161, No. 4, pp. (513-27), ISSN. Choi, M., Scholl, UI., Yue, P., Björklund, P., Zhao, B., Nelson-Williams, C., Ji, W., Cho, Y.,

hypertension. *Science*, Vol. 331, No. 6018, pp. (768-72), ISSN.

malignancy. *Am J Surg*, Vol. 189, pp. (405–11), ISSN.

*Horm Res*, Vol. 64, pp. (119–31), ISSN.

*Surg*, Vol. 25, pp. (914–26), ISSN.

No. 6, pp. (1006-13), ISSN.

pp. (968–73), ISSN.

3, pp. (797-802), ISSN.

*Cytochem*, Vol. 53, No. 7, pp. (895-903), ISSN.

*Assist Tomogr*, Vol. 15, No. 5, pp. (773–9), ISSN.

(222–5), ISSN.

fatal cancer that is similar to the risk of the adrenal lesion becoming malignant;

Patel, A., Men, CJ., Lolis, E., Wisgerhof, MV., Geller, DS., Mane, S., Hellman, P., Westin, G., Åkerström, G., Wang, W., Carling, T. & Lifton, RP. (2011). K+ channel mutations in adrenal aldosterone-producing adenomas and hereditary

independent macronodular adrenal hyperplasia and aberrant hormone receptors.

diagnosis and in research of essential hypertension. *J Am Med Ass*, Vol. 190, pp.

Termine, A., Di Carlo, F., Dogliotti, L., Angeli, A., Berruti, A. & Terzolo, M. (2008). Prospective evaluation of mitotane toxicity in adrenocortical cancer patients treated

(2005). Expression of PDE11A in normal and malignant human tissues. *J Histochem* 

& Horton, J. (1991). Eastern Cooperative Oncology Group study 1879: mitotane and adriamycin in patients with advanced adrenocortical carcinoma. *Surgery*, Vol. 110,

Identification of virilizing adrenal tumors in hirsute women. *N Engl J Med*, Vol. 331,

LK. (2000). Adrenocorticotropin-independent macronodular adrenal hyperplasia: an uncommon cause of primary adrenal hypercortisolism. *Radiology*, Vol. 216, No.

Norton, JA. (1991). CT and MR imaging of massive macronodular adrenocortical disease: a rare cause of autonomous primary adrenal hypercortisolism. *J Comput* 


Bonfig, W., Bittmann, I., Bechtold, S., Kammer, B., Noelle, V., Arleth, S., Raile, K. & Schwarz,

Boulle, N., Logié, A., Gicquel, C., Perin, L. & Le Bouc, Y. (1998). Increased levels of insulin-

Bourdeau, I., D'Amour, P., Hamet, P., Boutin, JM. & Lacroix, A. (2001). Aberrant membrane

Bovio, S., Cataldi, A., Reimondo, G., Sperone, P., Novello, S., Berruti, A., Borasio, P., Fava,

Brembeck, FH., Rosário, M. & Birchmeier, W. (2006). Balancing cell adhesion and Wnt

Bukowski, RM., Wolfe, M., Levine, HS., Crawford, DE., Stephens, RL., Gaynor, E. & Harker,

Burgess, JR., Harle, RA., Tucker, P., Parameswaran, V., Davies, P., Greenaway, TM. &

Caoili, EM., Korobkin, M., Brown, RK., Mackie, G. & Shulkin, BL. (2007). Differentiating

Carney, JA., Gordon, H., Carpenter, PC., Shenoy, BV. & Go, VL.. (1985). The complex of

Carney, JA. & Young, WF Jr. (1992). Primary pigmented nodular adrenocortical disease and

Carson, DJ., Sloan, JM., Cleland, J., Russell, CF., Atkinson, AB. & Sheridan, B. (1988).

Cawood, TJ., Hunt, PJ., O'Shea, D., Cole, D. & Soule, S. (2009). Recommended evaluation of

its associated conditions. *Endocrinologist*, Vol. 2, pp. (6), ISSN.

neoplasia type 1. *Arch Surg*, Vol. 131, No. 7, pp. (699-702), ISSN.

qualitative evaluation. *Acad Radiol*, Vol. 14, No. 4, pp. (468-75), ISSN. Caoili, EM., Korobkin, M., Francis, IR., Cohan, RH., Platt, JF., Dunnick, NR. & Raghupathi,

delayed enhanced CT. *Radiology*, Vol. 222, No. 3, pp. (629–33), ISSN. Carmina, E., Rosato, F., Janni, A., Rizzo, M. & Longo, RA. (2006). Extensive clinical

9, pp. (623-8), ISSN.

5, pp. (1713-20), ISSN.

pp. (5534-40), ISSN.

9), ISSN.

(161-5), ISSN.

9, pp. (12–6), ISSN.

2, pp. (173-80), ISSN.

Vol. 64, No. 4, pp. (270-83), ISSN.

*Endocrinol Invest*, Vol. 29, pp. (298–302), ISSN.

HP. (2003). Virilising adrenocortical tumours in children. *Eur J Pediatr*, Vol. 162, No.

like growth factor II (IGF-II) and IGF-binding protein-2 are associated with malignancy in sporadic adrenocortical tumors. *J Clin Endocrinol Metab*, Vol. 83, No.

hormone receptors in incidentally discovered bilateral macronodular adrenal hyperplasia with subclinical Cushing's syndrome. *J Clin Endocrinol Metab*, Vol. 86,

C., Dogliotti, L., Scagliotti, GV., Angeli, A. & Terzolo, M. (2006). Prevalence of adrenal incidentaloma in a contemporary computerized tomography series. *J* 

signaling, the key role of beta-catenin. *Curr Opin Genet Dev*, Vol. 16, No. 1, pp. (51-

WG. (1993). Phase II trial of mitotane and cisplatin in patients with adrenal carcinoma: a Southwest Oncology Group study. *J Clin Oncol*, Vol. 11, No. 1, pp.

Shepherd, JJ. (1996). Adrenal lesions in a large kindred with multiple endocrine

adrenal adenomas from nonadenomas using (18)F-FDG PET/CT: quantitative and

KI. (2002). Adrenal masses: characterization with combined unenhanced and

experience: relative prevalence of different androgen excess disorders in 950 women referred because of clinical hyperandrogenism. *J Clin Endocrinol Metab*, Vol.

myxomas, spotty pigmentation, and endocrine overactivity. *Medicine (Baltimore)*,

Cyclical Cushing's syndrome presenting as short stature in a boy with recurrent atrial myxomas and freckled skin pigmentation. *Clin Endocrinol (Oxf)*, Vol. 28, No.

adrenal incidentalomas is costly, has high false-positive rates and confers a risk of

fatal cancer that is similar to the risk of the adrenal lesion becoming malignant; time for a rethink? *Eur J Endocrinol*, Vol. 161, No. 4, pp. (513-27), ISSN.


Adrenal Cortex Tumors and Hyperplasias 343

Giordano, TJ., Kuick, R., Else, T., Gauger, PG., Vinco, M., Bauersfeld, J., Sanders, D.,

Gittler, RD. & Fajans, SS. (1995). Primary aldosteronism (Conn's syndrome). *J Clin Endocrinol* 

Gold, PW., Loriaux, DL., Roy, A., Kling, MA., Calabrese, JR., Kellner, CH., Nieman, LK.,

Gonzalez, RJ., Shapiro, S., Sarlis, N., Vassilopoulou-Sellin, R., Perrier, ND., Evans, DB. &

Gordon, MD. & Nusse, R (2006). Wnt signaling: Multiple pathways, multiple receptors, and multiple transcription factors. *J Biol Chem*, Vol. 281, pp. (22429–33), ISSN. Groussin, L., Jullian, E., Perlemoine, K., Louvel, A., Leheup, B., Luton, JP., Bertagna, X. &

Groussin, L., Kirschner, LS., Vincent-Dejean, C., Perlemoine, K., Jullian, E., Delemer, B.,

Groussin, L., Perlemoine, K., Contesse, V., Lefebvre, H., Tabarin, A., Thieblot, P., Schlienger,

Groussin, L., Bonardel, G., Silvéra, S., Tissier, F., Coste, J., Abiven, G., Libé, R., Bienvenu, M.,

Grumbach, MM., Biller, BM., Braunstein, GD., Campbell, KK., Carney, JA., Godley, PA.,

tumors. *J Clin Endocrinol Metab*, Vol. 87, No. 5, pp. (1980-5), ISSN.

(2559–65), ISSN.

(1329-35), ISSN.

pp. (1433-42), ISSN.

*Res*, Vol. 15, No. 2, pp. (668-76), ISSN.

note. *Surgery*, Vol. 138, No. 6, pp. (1078–85), ISSN.

*Metab*, Vol. 87, No. 9, pp. (4324-9), ISSN.

*Metab*, Vol. 94, No. 5, pp. (1713-22), ISSN.

*Intern Med*, Vol. 138, No. 5, pp. (424–9), ISSN.

*Metab*, Vol. 80, pp. (3438–41), ISSN.

tumors: Study on a series of 82 tumors. *J Clin Endocrinol Metab*, Vol. 82, No. 8, pp.

Thomas, DG., Doherty, G. & Hammer, G. (2009). Molecular classification and prognostication of adrenocortical tumors by transcriptome profiling. *Clin Cancer* 

Post, RM., Pickar, D. & Gallucci, W. (1986). Responses to corticotropin-releasing hormone in the hypercortisolism of depression and Cushing's disease. Pathophysiologic and diagnostic implications. *N Engl J Med*, Vol. 314, No. 21, pp.

Lee, JE. (2005). Laparoscopic resection of adrenal cortical carcinoma: a cautionary

Bertherat, J. (2002a). Mutations of the PRKAR1A gene in Cushing's syndrome due to sporadic primary pigmented nodular adrenocortical disease. *J Clin Endocrinol* 

Zacharieva, S., Pignatelli, D., Carney, JA., Luton, JP., Bertagna, X., Stratakis, CA. & Bertherat, J. (2002b). Molecular analysis of the cyclic AMP-dependent protein kinaseA (PKA) regulatory subunit1A (PRKAR1A) gene in patients with Carney complex and primary pigmented nodular adrenocortical disease (PPNAD) reveals novel mutations and clues for pathophysiology: augmented PKA signaling is associated with adrenal tumorigenesis in PPNAD. *Am J Hum Genet*, Vol. 71, No. 6,

JL., Luton, JP., Bertagna, X. & Bertherat, J. (2002c). The ectopic expression of the gastric inhibitory polypeptide receptor is frequent in adrenocorticotropinindependent bilateral macronodular adrenal hyperplasia, but rare in unilateral

Alberini, JL., Salenave, S., Bouchard, P., Bertherat, J., Dousset, B., Legmann, P., Richard, B., Foehrenbach, H., Bertagna, X. & Tenenbaum, F. (2009). 18F-Fluorodeoxyglucose positron emission tomography for the diagnosis of adrenocortical tumors: a prospective study in 77 operated patients. *J Clin Endocrinol* 

Harris, EL., Lee, JK., Oertel, YC., Posner, MC., Schlechte, JA. & Wieand, HS. (2003). Management of the clinically inapparent adrenal mass ("incidentaloma"). *Ann* 


Dunnick, NR., Korobkin, M. & Francis, I. (1996). Adrenal radiology: distinguishing benign from malignant adrenal masses. *AJR Am J Roentgenol*, Vol. 167, pp. (861-7), ISSN. Edge, SB., Byrd, DR., Compton, CC., Fritz, AG., Greene, FL., Trotti, A. (Eds.). (2010). AJCC

Fassnacht, M. & Allolio, B. (2009). Clinical management of adrenocortical carcinoma. *Best* 

Fassnacht, M., Johanssen, S., Quinkler, M., Bucsky, P., Willenberg, HS., Beuschlein, F.,

Fassnacht, M., Libé R, Kroiss M, Allolio B. (2011). Adrenocortical carcinoma: a clinician's

Feige, JJ., Cochet, C., Savona, C., Shi, DL., Keramidas, M., Defaye, G. & Chambaz, EM.

Fottner, C., Hoeflich, A., Wolf, E. & Weber, MM. (2004). Role of the insulin-like growth

Fragoso, MC., Domenice, S., Latronico, AC., Martin, RM., Pereira, MA., Zerbini, MC., Lucon,

Fraumeni, JF Jr. & Miller, RW. (1967). Adrenocortical neoplasms with hemihypertrophy, brain tumors, and other disorders. *J Pediatr*, Vol. 70, pp. (129-38) ISSN. Fuhrman, SA., Lasky, LC. & Limas, C. (1982). Prognostic significance of morphologic

Gaujoux, S., Tissier, F., Groussin, L., Libé, R., Ragazzon, B., Launay, P., Audebourg, A.,

Gicquel, C., Bertagna, X., Gaston, V., Coste, J., Louvel, A., Baudin, E., Bertherat, J., Chapuis,

Gicquel, C., Raffin-Sanson, ML., Gaston, V., Bertagna, X., Plouin, PF., Schlumberger, M.,

*Clin Endocrinol Metab*, Vol. 93, No. 10, pp. (4135-40), ISSN.

*Metab*, Vol. 78, No. 6, pp. (1444–53), ISSN.

Terzolo, M., Mueller, HH., Hahner, S. & Allolio, B., German Adrenocortical Carcinoma Registry Group, European Network for the Study of Adrenal Tumors. (2009). Limited prognostic value of the 2004 International Union Against Cancer staging classification for adrenocortical carcinoma: proposal for a Revised TNM

(1991). Transforming growth factor beta 1: an autocrine regulator of adrenocortical

factor system in adrenocortical growth control and carcinogenesis. *Horm Metab Res*,

AM. & Mendonca, BB. (2003). Cushing's syndrome secondary to adrenocorticotropin-independent macronodular adrenocortical hyperplasia due to activating mutations of GNAS1 gene. *J Clin Endocrinol Metab*, Vol. 88, No. 5, pp.

parameters in renal cell carcinoma. *Am J Surg Patho*, Vol. 6, No. 7, pp. (655-63),

Dousset, B., Bertagna, X. & Bertherat, J. (2008). Wnt/beta-catenin and 3',5'-cyclic adenosine 5'-monophosphate/protein kinase A signaling pathways alterations and somatic beta-catenin gene mutations in the progression of adrenocortical tumors. *J* 

Y., Duclos, JM., Schlumberger, M., Plouin, PF., Luton, JP. & Le Bouc, Y. (2001). Molecular markers and long-term recurrences in a large cohort of patients with sporadic adrenocortical tumors. *Cancer Res*, Vol. 61, No. 18, pp. (6762–7), ISSN. Gicquel, C., Bertagna, X., Schneid, H., Francillard-Leblond, M., Luton, JP., Girard, F. & Le

Bouc, Y. (1994). Rearrangements at the 11p15 locus and overexpression of insulinlike growth factor-II gene in sporadic adrenocortical tumors. *J Clin Endocrinol* 

Louvel, A., Luton, JP. & Le Bouc, Y. (1997). Structural and functional abnormalities at 11p15 are associated with the malignant phenotype in sporadic adrenocortical

*Pract Res Clin Endocrinol Metab*, Vol. 23, No. 2, pp. (273-89); ISSN.

Cancer Staging Manual, 7th Ed. Springer, Chicago.

Classification. *Cancer*, Vol. 115, No. 2, pp. (243-50), ISSN.

update. Nat Rev Endocrinol. Vol. 7, No 6, pp. (323-35).

steroid genesis. *Endocr Res*, Vol. 17, pp. (267–79), ISSN.

Vol. 36, pp. (397–405), ISSN.

(2147), ISSN.

ISSN.

tumors: Study on a series of 82 tumors. *J Clin Endocrinol Metab*, Vol. 82, No. 8, pp. (2559–65), ISSN.


Adrenal Cortex Tumors and Hyperplasias 345

Hughes, JM., Hichens, M., Booze, GW. & Thorner, MO. (1986). Cushing's syndrome from the

Ilvesmaki, V., Kahri, AI., Miettinen, PJ. & Voutilainen, R. (1993). Insulin-like growth factors

Invitti, C., Pecori Giraldi, F., de Martin, M. & Cavagnini, F. (1999). Diagnosis and

Jhala, NC., Jhala, D., Eloubeidi, MA., Chhieng, DC., Crowe, DR., Roberson, J. & Eltoum, I.

glands: analysis of 24 patients. *Cancer*, Vol. 102, No. 5, pp. (308-14), ISSN. Kaltsas, GA., Isidori, AM., Kola, BP., Skelly, RH., Chew, SL., Jenkins, PJ., Monson, JP.,

Kamenicky, P., Houdoin, L., Ferlicot, S., Salenave, S., Brailly, S., Droupy, S., Meduri, G.,

Kartheuser, A., Walon, C., West, S., Breukel, C., Detry, R., Gribomont, AC., Hamzehloei, T.,

Kebebew, E., Reiff, E., Duh, QY., Clark, OH. & McMillan, A. (2006) Extent of disease at

Kendrick, ML., Lloyd, R., Erickson, L., Farley, DR., Grant, CS., Thompson, GB., Rowland, C.,

Khan, TS., Sundin, A., Juhlin, C., Wilander, E., Oberg, K. & Eriksson, B. (2004). Vincristine,

Kirkman, S. & Nelson, DH. (1988). Alcohol-induced pseudo-Cushing's disease: a study of prevalence with review of the literature. *Metabolism*, Vol. 37, pp. (390-4), ISSN. Kirschner, LS., Carney, JA., Pack, SD., Taymans, SE., Giatzakis, C., Cho, YS., Cho-Chung, YS.

progress or status quo? *Arch Surg*, Vol. 136, No. 5, pp. (543-9), ISSN. Kettel, LM. (1989). Management of hirsutism. *Drug Ther Bull*, Vol. 27, pp. (49–51), ISSN. Khan, TS., Imam, H., Juhlin, C., Skogseid, B., Gröndal, S., Tibblin, S., Wilander, E., Oberg, K.

*Endocrinol Metab*, Vol. 88, No. 6, pp. (2634–43), ISSN.

*(Oxf)*, Vol. 66, No. 6, pp. (778-88), ISSN.

*Genet*, Vol. 36, No. 1, pp. (65-7), ISSN.

pp. (1281-7), ISSN.

77), ISSN.

*World J Surgery*, Vol. 30, No. 5, pp. (872-8), ISSN.

pp. (1848-9), ISSN.

ISSN.

therapeutic use of intramuscular dexamethasone acetate. *Arch Intern Med*, Vol. 146,

(IGFs) and their receptors in adrenal tumors: high IGF-II expression in functional adrenocortical carcinomas. *J Clin Endocrinol Metab*, Vol. 77, No. 3, pp. (852–8), ISSN.

management of Cushing's syndrome: results of an Italian multicentre study. Study Group of the Italian Society of Endocrinology on the Pathophysiology of the Hypothalamic-Pituitary-Adrenal Axis. *J Clin Endocrinol Metab*, Vol. 84, pp. (440-8),

(2004). Endoscopic ultrasound-guided fine-needle aspiration biopsy of the adrenal

Grossman, AB. & Besser, GM. (2003). The value of the low-dose dexamethasone suppression test in the differential diagnosis of hyperandrogenism in women. *J Clin* 

Sasano, H., Suzuki, T., Young, J. & Chanson, P. (2007). Benign cortisol-secreting adrenocortical adenomas produce small amounts of androgens. *Clin Endocrinol* 

Hoang, P., Maiter, D., Pringot, J., Rahier, J., Khan, PM., Curtis, A., Burn, J., Fodde, R. & Verellen-Dumoulin, C. (1999). Familial adenomatous polyposis associated with multiple adrenal adenomas in a patient with a rare 3' APC mutation. *J Med* 

presentation and outcome, for adrenocortical carcinoma: have we made progress?

Young, WF Jr. & van Heerden, JA. (2001). Adrenocortical carcinoma: surgical

& Eriksson, B. (2000). Streptozocin and o,p'DDD in the treatment of adrenocortical cancer patients: long-term survival in its adjuvant use. *Ann Oncol*, Vol. 11, No. 10,

cisplatin, teniposide, and cyclophosphamide combination in the treatment of recurrent or metastatic adrenocortical cancer. *Med Oncol*, Vol. 21, No. 2, pp. (167-

& Stratakis, CA. (2000). Mutations of the gene encoding the protein kinaseA type I-


Gunther, DF., Bourdeau, I., Matyakhina, L., Cassarino, D., Kleiner, DE., Griffin, K.,

Haak HR, Hermans J, van de Velde CJ, Lentjes EG, Goslings BM, Fleuren GJ, Krans HM.

Hahner, S. & Fassnacht, M. (2005). Mitotane for adrenocortical carcinoma treatment. *Curr* 

Hamrahian, AH., Ioachimescu, AG., Remer, EM., Motta-Ramirez, G., Bogabathina, H.,

Harrison, LE., Gaudin, PB. & Brennan, MF. (1999). Pathologic features of prognostic

Hedeland, H., Ostberg, G. & Hökfelt, B. (1968). On the prevalence of adrenocortical

Henley, DJ., van Heerden, JA., Grant, CS., Carney, JA. & Carpenter, PC. (1983). Adrenal

Heppner, C., Reincke, M., Agarwal, SK., Mora, P., Allolio, B., Burns, AL., Spiegel, AM. &

Herrera, MF., Grant, CS., van Heerden, JA., Sheedy, PF. & Ilstrup, DM. (1991). Incidentally

Hisada, M., Garber, JE., Fung, CY., Fraumeni, Jr JF. & Li, FP. (1998). Multiple primary

Holland, OB. & Carr, B. (1993). Modulation of aldosterone synthase messenger ribonucleic

Hollstein, M., Sidransky, D., Vogelstein, B. & Harris, CC. (1991). p53 mutations in human

Horiba, N., Suda, T., Aiba, M., Naruse, M., Nomura, K., Imamura, M. & Demura, H. (1995).

Horvath, A., Mericq, V. & Stratakis, CA. (2008). Mutation in PDE8B, a cyclic AMP-specific

consecutive series of 96 patients. Br J Cancer. 1994 May;69(5):947-51

experience. *J Clin Endocrinol Metab*, Vol. 90, No. 2, pp. (871-7), ISSN.

Vol. 89, no. 7, pp. (3173-82), ISSN.

134, pp. (181-5), ISSN.

pp. (1014-21), ISSN.

11), ISSN.

ISSN.

*Scand*, Vol. 184, pp. (211-4), ISSN.

*Opin Investig Drugs*, Vol. 6, pp. (386–94), ISSN.

*Endocrinol Metab*, Vol. 84, No. 1, pp. (216-9), ISSN.

*Endocrinology*, Vol. 132, pp. (2666-73), ISSN.

cancers. *Science*, Vol. 253, No. 5015, pp. (49–53), ISSN.

*Endocrinol Metab*, Vol. 80, No. 8, pp. (2336–41), ISSN.

Courkoutsakis, N., Abu-Asab, M., Tsokos, M., Keil, M., Carney, JA. & Stratakis, CA. (2004). Cyclical Cushing syndrome presenting in infancy: an early form of primary pigmented nodular adrenocortical disease, or a new entity? *J Clin Endocrinol Metab*,

Optimal treatment of adrenocortical carcinoma with mitotane: results in a

Levin, HS., Reddy, S., Gill, IS., Siperstein, A. & Bravo, EL. (2005). Clinical utility of noncontrast computed tomography attenuation value (hounsfield units) to differentiate adrenal adenomas/hyperplasias from nonadenomas: Cleveland Clinic

significance for adrenocortical carcinoma after curative resection. *Arch Surg*, Vol.

adenomas in an autopsy material in relation to hypertension and diabetes. *Acta Med* 

cortical carcinoma--a continuing challenge. *Surgery*, Vol. 94, No. 6, pp. (926-31),

Marx, SJ. (1999). MEN1 gene analysis in sporadic adrenocortical neoplasms. *J Clin* 

discovered adrenal tumors: an institutional perspective. *Surgery*, Vol. 110, No. 6,

cancers in families with Li-Fraumeni syndrome. *J Natl Cancer Inst*, Vol. 90, pp. (606-

acid levels by dietary sodium and potassium and by adrenocorticotropin.

Lysine vasopressin stimulation of cortisol secretion in patients with adrenocorticotropinindependent macronodular adrenal hyperplasia. *J Clin* 

phosphodiesterase in adrenal hyperplasia. *N Engl J Med*, Vol. 358, pp. (750-2), ISSN.


Adrenal Cortex Tumors and Hyperplasias 347

Lau, SK. & Weiss, LM. (2009). The Weiss system for evaluating adrenocortical neoplasms: 25

Lee, MH., Reynisdottir, I. & Massague, J. (1995). Cloning of p57kip2, a cyclindependent

Lefevre, M., Gerard-Marchant, R., Gubler, JP., Chaussain, JL. & Lemerle, J. (1983). *Adrenal* 

Li, FP. & Fraumeni, JF Jr. (1969a). Soft-tissue sarcomas, breast cancer, and other neoplasms: a

Li, FP. & Fraumeni, Jr JF. (1969b). Rhabdomyosarcoma in children: epidemiologic study and

Li, FP., Fraumeni, Jr JF., Mulvihil, JJ., Blattner, WA., Dreyfus, MG., Tucker, MA. & Miller,

Libé, R. & Bertherat, J. (2005). Molecular genetics of adrenocortical tumours, from familial to

Libé, R., Fratticci, A. & Bertherat, J. (2007). Adrenocortical cancer: pathophysiology and Clinical management. *Endocr Relat Cancer*, Vol. 14, pp. (13–28), ISSN. Libé, R., Fratticci, A., Coste, J., Tissier, F., Horvath, A., Ragazzon, B., Rene-Corail, F.,

Liddle, GW. (1960). Tests of pituitary-adrenal suppressibility in the diagnosis of Cushing's

Lieberman, SA., Eccleshall, TR. & Feldman, D. (1994). ACTH-independent massive bilateral

Lin, SR., Lee, YJ. & Tsai, JH. (1994). Mutations of the p53 gene in human functional adrenal neoplasms. *J Clin Endocrinol Metab*, Vol. 78, No. 2, pp. (483-91), ISSN. Lindholm J, Juul S, Jorgensen JO, Astrup J, Bjerre P, Feldt-Rasmussen U, Hagen C, Jorgensen

Logie, A., Boulle, N., Gaston, V., Perin, L., Boudou, P., Le Bouc, Y. & Gicquel, C. (1999).

Louiset, E., Gobet, F., Libé, R., Horvath, A., Renouf, S., Cariou, J., Rothenbuhler, A.,

years later. *Hum Pathol*, Vol. 40, No. 6, pp. (757-68), ISSN.

*and endocrine tumors in children*, Nijhoff, ISBN, Boston.

familial syndrome? *Ann Intern Med*, Vol. 71, pp. (747-52), ISSN.

sporadic diseases. *Eur J Endocrinol*, Vol. 153, pp. (477-87), ISSN.

tumors. *Clin Cancer Res*, Vol. 14, No. 12, pp. (4016-24), ISSN.

H295R cell line. *J Mol Endocrinol*, Vol. 23, pp. (23–32), ISSN.

syndrome. *J Clin Endocrinol Metab*, Vol. 20, pp. (1539-60), ISSN.

(4970-3), ISSN.

73), ISSN.

ISSN.

*Endocrinol Metab* 86: 117-123

No. 1, pp. (18-24), ISSN

pp. (5358-62), ISSN.

Vol. 9, pp. (639–49), ISSN.

with sporadic adrenocortical tumors. *J Clin Endocrinol Metab*, Vol. 86, No. 10, pp.

kinase inhibitor with unique domain structure and tissue distribution. *Genes Dev*,

identification of a familial cancer syndrome. *J Natl Cancer Inst*, Vol. 43, pp. (1365-

RW. (1998). A cancer family syndrome in twenty-four kindreds. *Cancer Res*, Vol. 48,

Groussin, L., Bertagna, X., Raffin-Sanson, ML., Stratakis, CA. & Bertherat, J. (2008). Phosphodiesterase 11A (PDE11A) and genetic predisposition to adrenocortical

adrenal disease (AIMBAD): A subtype of Cushing's syndrome with major diagnostic and therapeutic implications. *Eur J Endocrinol*, Vol. 131, pp. (67–73),

J, Kosteljanetz M, Kristensen L, Laurberg P, Schmidt K, Weeke J. (2001). Incidence and late prognosis of Cushing's syndrome: a population based study. *J Clin* 

Autocrine role of IGF-II in proliferation of human adrenocortical carcinoma NCI

Bertherat, J., Clauser, E., Grise, P., Stratakis, CA., Kuhn, JM. & Lefebvre, H. (2010). ACTH-independent Cushing's syndrome with bilateral micronodular adrenal hyperplasia and ectopic adrenocortical adenoma. *J Clin Endocrinol Metab*, Vol. 95,

a regulatory subunit in patients with the Carney complex. *Nat Genet*, Vol. 26, No. 1, pp. (89-92), ISSN.


Kirschner MA, Powell RD Jr, Lipsett MB (1964). Cushing's syndrome: nodular cortical

Kjellman, M., Roshani, L., Teh, BT., Kallioniemi, OP., Höög, A., Gray, S., Farnebo, LO.,

Kloos, RT., Gross, MD., Francis, IR., Korobkin, M. & Shapiro, B. (1995). Incidentally

Koch, CA., Pacak, K. & Chrousos, GP. (2002). The molecular pathogenesis of hereditary and

Kocijancic, K., Kocijancic, I. & Guna, F. (2004). Role of sonographically guided fine-needle

Kopf, D., Goretzki, PE. & Lehnert, H. (2001). Clinical management of malignant adrenal

Korobkin, M., Francis, IR., Kloos, RT. & Dunnick, NR. (1996). The incidental adrenal mass.

Kudva, YC., Sawka, AM. & Young, WF. (2003). The laboratory diagnosis of adrenal

Lack, LEE. (1997). *Atlas of tumor pathology,* Armed Forces Institute of Pathology, ISBN,

Lacroix, A., Bolte, E., Tremblay, J., Dupré, J., Poitras, P., Fournier, H., Garon, J., Garrel, D.,

Lacroix, A., Tremblay, J., Rousseau, G., Bouvier, M. & Hamet, P. (1997). Propranolol therapy

Lacroix, A., N'diaye, N., Tremblay, J. & Hamet, P. (2001). Ectopic and abnormal hormone receptors in adrenal Cushing's syndrome. *Endocr Rev*, Vol. 22, pp. (75-110), ISSN. Lacroix, A., Baldacchino, V., Bourdeau, I., Hamet, P. & Tremblay, J. (2004). Cushing's

Lacroix A. (2009). ACTH-independent macronodular hyperplasia. *Best Practice and Research* 

Larsen, JL., Cathey, WJ. & Odell, WD. (1986). Primary adrenocortical nodular dysplasia, a

Latronico, AC., Pinto, EM., Domenice, S., Fragoso, MC., Martin, RM., Zerbini, MC., Lucon,

*Clinical Endocrinology and Metabolism*, Vol. 23, pp. (245-259), ISSN.

adrenocortical tumor. J Clin Endocrinol Metab. Vol.24, pp (947-55).

in 2p16. *J Clin Endocrinol Metab*, Vol. 84. No. 2, pp. (730-5), ISSN.

tumors. *J Cancer Res Clin Oncol*, Vol. 127, pp. (143-55), ISSN.

syndrome. *N Engl J Med*, Vol. 327, No. 14, pp. (974-80), ISSN.

*Radiol Clin North Am*, Vol. 34, pp. (1037-54), ISSN.

discovered adrenal masses. *Endocr Rev*, Vol. 16, pp. (460-484), ISSN.

pp. (89-92), ISSN.

87, pp. (5367-84), ISSN.

Vol. 32, pp. (12-6), ISSN.

pp. (4533-9), ISSN.

Washington, DC.

Vol. 337, pp. (429–34), ISSN.

*Metab*, Vol. 15, pp. (375-82), ISSN.

*Am J Med*, Vol. 80, pp. (976-84), ISSN.

a regulatory subunit in patients with the Carney complex. *Nat Genet*, Vol. 26, No. 1,

hyperplasia of adrenal glands with clinical and pathological features suggesting

Holst, M., Bäckdahl, M. & Larsson, C. (1999). Genotyping of adrenocortical tumors: very frequent deletions of the MEN1 locus in 11q13 and of a 1-centimorgan region

sporadic adrenocortical and adrenomedullary tumors. *J Clin Endocrinol Metab*, Vol.

aspiration biopsy of adrenal masses in patients with lung cancer. *J Clin Ultrasound*,

pheochromocytoma: the Mayo Clinic experience. *J Clin Endocrinol Metab*, Vol. 88,

Bayard, F., Taillefer, R., Flanagan & RJ. & Hamet, P.(1992). Gastric inhibitory polypeptide-dependent cortisol hypersecretion — a new cause of Cushing's

for ectopic b-adrenergenic receptors in adrenal Cushing's syndrome. *N Engl J Med*,

syndrome variants secondary to aberrant hormone receptors. *Trends Endocrinol* 

distinct subtype of Cushing's syndrome. Case report and review of the literature.

AM. & Mendonca, BB. (2001). An inherited mutation outside the highly conserved DNA-binding domain of the p53 tumor suppressor protein in children and adults with sporadic adrenocortical tumors. *J Clin Endocrinol Metab*, Vol. 86, No. 10, pp. (4970-3), ISSN.


Adrenal Cortex Tumors and Hyperplasias 349

Metser, U., Miller, E., Lerman, H., Lievshitz, G., Avital, S. & Even-Sapir, E. (2006). 18F-FDG

Meyer, A., Niemann, U. & Behrend, M. (2004). Experience with the surgical treatment of adrenal cortical carcinoma. *Eur J Surg Oncol*, Vol. 30, pp. (444-9), ISSN. Michalkiewicz, E., Sandrini, R., Figueiredo, B., Miranda, EC., Caran, E., Oliveira-Filho, AG.,

ISSN.

ISSN.

ISSN.

PET/CT in the evaluation of adrenal masses. *J Nucl Med*, Vol. 47, No. 1, pp. (32-7),

Marques, R., Pianovski, MA., Lacerda, L., Cristofani, LM., Jenkins, J., Rodriguez-Galindo, C. & Ribeiro, RC. (2004). Clinical and outcome characteristics of children with adrenocortical tumors: a report from the International Pediatric Adrenocortical Tumor Registry. *J Clin Oncol*, Vol. 22, No. 5, pp. (838-45), ISSN. Milliez, P., Girerd, X., Plouin, PF., Blacher, J., Safar, ME. & Mourad, JJ. (2005). Evidence for

an increased rate of cardiovascular events in patients with primary aldosteronism. *J* 

M., Någren, K. & Nuutila, P. (2004). Imaging of adrenal incidentalomas with PET using (11)C-metomidate and (18)F-FDG. *J Nucl Med*, Vol. 45, No. 6, pp. (972-9),

(2000). Are ectopic or abnormal membrane hormone receptors frequently present in adrenal Cushing's syndrome? *J Clin Endocrinol Metab*, Vol. 85, No. 10, pp. (3531-6),

Dewailly, D., Wemeau, JL. & Proye, C. (2004). Profile and outcome of pure androgen-secreting adrenal tumors in women: experience of 21 cases. *Surgery*, Vol.

findings in symptomatic and incidentally discovered pheochromocytomas. *Am J* 

overexpression of gastric inhibitory polypeptide receptor underlies food-dependent

immortalization and dysregulation of D-type cyclins. *Cancer Res*, Vol. 65, pp.

the clinically inapparent adrenal mass ("incidentaloma"). *NIH Consensus State-of-*

(2008). The diagnosis of Cushing's syndrome: an Endocrine Society Clinical Practice

Minn, H., Salonen, A., Friberg, J., Roivainen, A., Viljanen, T., Långsjö, J., Salmi, J., Välimäki,

Mircescu, H., Jilwan, J., N'Diaye, N., Bourdeau, I., Tremblay, J., Hamet, P. & Lacroix, A.

Moreno, S., Montoya, G., Armstrong, J., Leteurtre, E., Aubert, S., Vantyghem, MC.,

Motta Ramirez, G., Remer, E., Herts, B., Gill, I. & Hamrahian, A. (2005). Comparison of CT

N'diaye, N., Tremblay, J., Hamet, P., de Herder, WW. & Lacroix, A. (1998). Adrenocortical

National Institutes of Health. (2002). NIH state-of-the-science statement on management of

Ng, L. & Libertino, JM. (2003). Adrenocortical carcinoma: diagnosis, evaluation and

Nieman, L., Biller, B., Findling, J., Newell-Price, J., Savage, M., Stewart, P. & Montori, VM.

Patil, KK., Ransley, PG., McCullagh, M., Malone, M. & Spitz, L. (2002). Functioning adrenocortical neoplasms in children. *BJU Int*, Vol. 89, No. 6, pp. (562-5), ISSN.

guideline. *J Clin Endocrinol Metab*, Vol. 93, No. 5, pp. (1526-40), ISSN Ohgaki, H., Kleihues, P. & Heitz, PU. (1993). P53 mutations in sporadic adrenocortical

Cushing's syndrome. *J Clin Endocrinol Metab*, Vol. 83, pp. (2781–5), ISSN. Nadella, KS. & Kirschner, LS. (2005). Disruption of Protein Kinase A regulation causes

*Am Coll Cardiol*, Vol. 45, pp. (1243–8), ISSN.

136, No. 6, pp. (1192-8), ISSN.

(10307-15), ISSN.

*Roentgenol*, Vol. 185, pp. (684-688), ISSN.

*the-Science Statements*, Vol. 19, pp. (1–25), ISSN.

tumors. *Intern J Cancer*, Vol. 54, pp. (408–10), ISSN.

treatment. *J Urol,* Vol. 169, pp. (5-11), ISSN.


Luton, JP., Cerdas, S., Billaud, L., Thomas, G., Guilhaume, B., Bertagna, X., Laudat, MH.,

Lynch, HT., Mulcahy, GM., Harris, RE., Guirgis, HA. & Lynch, JF. (1978). Genetic and

Magee, BJ., Gattamaneni, HR. & Pearson, D. (1987). Adrenal cortical carcinoma: survival

Malchoff, CD., Rosa, J., DeBold, CR., Kozol, RA., Ramsby, GR., Page, DL., Malchoff, DM. &

Mansmann, G., Lau, J., Balk, E., Rothberg, M., Miyachi, Y. & Bornstein, SR. (2004). The

Mantero, F., Terzolo, M., Arnaldi, G., Osella, G., Masini, AM., Alì, A., Giovagnetti, M.,

Matsuoka, S., Edwards, MC., Bai, C., Parker, S., Zhang, P., Baldini, A., Harper, JW. &

Mattsson, C. & Young, WF Jr. (2006). Primary aldosteronism: diagnostic and treatment

Matyakhina, L., Freedman, RJ., Bourdeau, I., Wei, MH., Stergiopoulos, SG., Chidakel, A.,

Maurea, S., Klain, M., Mainolfi, C., Ziviello, M. & Salvatore, M. (2001). The diagnostic role of

Mayo-Smith, WW. & Dupuy, DE. (2004). Adrenal neoplasms: CT-guided radiofrequency ablation--preliminary results. *Radiology*, Vol. 231, pp. (225-30), ISSN. Mesiano, S., Mellon, SH., Gospodarowicz, D., Di Blasio, AM. & Jaffe, RB. (1991). Basic

Mesiano, S., Mellon, SH. & Jaffe, RB. (1993). Mitogenic action, regulation, and localization of

therapy. *N Engl J Med*, Vol. 322, No. 17, pp. (1195-201), ISSN.

after radiotherapy. *Clin Radiol*, Vol. 38, pp. (587-8), ISSN.

strategies. *Nat Clin Pract Nephrol*, Vol. 2, pp. (198), ISSN.

masses. *J Nucl Med*, Vol. 42, No. 6, pp. (884-92), ISSN.

*Metab*, Vol. 76, pp. (968–76), ISSN.

pp. (2055-64), ISSN.

(650–62), ISSN.

ISSN.

68, No. 4, pp. (855–60), ISSN.

*Rev*, Vol. 25, pp. (309-40), ISSN.

*Metab*, Vol. 85, No. 2, pp. (637-44), ISSN.

Louvel, A., Chapuis, Y., Blondeau, P., Bonnin, A. & Bricaire, H. (1990). Clinical features of adrenocortical carcinoma, prognostic factors, and the effect of mitotane

pathologic findings in kindred with hereditary sarcoma, breast cancer, brain tumors, leukemia, lung, laryngeal, and adrenal cortical carcinoma. *Cancer*, Vol. 41,

Orth, DN. (1989). Adrenocorticotropin-independent bilateral macronodular adrenal hyperplasia: an unusual cause of Cushing syndrome. *J Clin Endocrinol Metab*, Vol.

clinically inapparent adrenal mass: update in diagnosis and management. *Endocr* 

Opocher, G. & Angeli, A. (2000). A survey on adrenal incidentaloma in Italy. Study Group on Adrenal Tumors of the Italian Society of Endocrinology. *J Clin Endocrinol* 

Elledge, SJ. (1995). P57kip2, a structurally distinct member of the p21CIP1 Cdk inhibitor family, is a candidate tumor suppressor gene. *Genes Dev*, Vol. 9, No. 6, pp.

Walther, M., Abu-Asab, M., Tsokos, M., Keil, M., Toro, J., Linehan, WM. & Stratakis, CA. (2005). Hereditary leiomyomatosis associated with bilateral, massive, macronodular adrenocortical disease and atypical cushing syndrome: a clinical and molecular genetic investigation. *J Clin Endocrinol Metab*, Vol. 90, No. 6, pp. (3773-9),

radionuclide imaging in evaluation of patients with nonhypersecreting adrenal

fibroblast growth factor expression is regulated by corticotropin in the human fetal adrenal: a model for adrenal growth regulation. *PNAS*, Vol. 88, pp. (5428–32), ISSN.

insulin-like growth factors in the human fetal adrenal gland. *J Clin Endocrinol* 


Adrenal Cortex Tumors and Hyperplasias 351

Schteingart, DE., Motazedi, A., Noonan, RA. & Thompson, NW. (1982). Treatment of

Schteingart, DE., Doherty, GM., Gauger, PG., Giordano, TJ., Hammer, GD., Korobkin, M. &

Schulte, KM., Mengel, M., Heinze, M., Simon, D., Scheuring, S., Köhrer, K. & Röher, HD.

Sidhu, S., Marsh, DJ., Theodosopoulos, G., Philips, J., Bambach, CP., Campbell, P., Magarey,

Sidhu, S., Sywak, M., Robinson, B. & Delbridge, L. (2004). Adrenocortical cancer: recent clinical and molecular advances. *Curr Opin Oncol*, Vol. 16, pp. (13-8), ISSN. Skogseid, B., Larsson, C., Lindgren, PG., Kvanta, E., Rastad, J., Theodorsson, E., Wide, L.,

Soon, P., MsDonald, K., Robinson, B. & Sidhu, S. (2008). Molecular markers and the pathogenesis of adrenocortical cancer. *Oncologist*, Vol. 13, pp. (548-61), ISSN. Srivastava, S., Zou, ZQ., Pirollo, K., Blattner, W. & Chang, EH. (1990). Germ-line

Stojadinovic, A., Ghossein, RA., Hoos, A., Nissan, A., Marshall, D., Dudas, M., Cordon-

Stowasser, M. (2009). Update in primary aldosteronism. *J Clin Endocrinol Metab*, Vol 94, No.

Stratakis, CA., Courcoutsakis, NA., Abati, A., Filie, A., Doppman, JL., Carney, JA. &

adrenal tumors. J Clin Endocrinol Metab. Vol. 95, No. 10, pp. (161-71). Schlumberger, M., Ostronoff, M., Bellaiche, M., Rougier, P., Droz, JP. & Parmentier, C.

carcinoma. *Cancer*, Vol. 61, No. 8, pp. (1492-4), ISSN.

*Endocrinol Metab*, Vol. 87, No. 7, pp. (3467-74), ISSN.

syndrome. *Nature*, Vol. 348, pp. (747-9), ISSN.

Vol. 12, No. 3, pp. (667–80), ISSN.

8), ISSN.

1, pp. (76-81), ISSN.

50), ISSN.

pp (585-91).

10, pp. (3623-30), ISSN.

adrenal carcinomas. *Arch Surg*, Vol. 117, pp. (1142-6), ISSN.

High diagnostic and prognostic value of steroidogenic factor-1 expression in

(1988). 5-Fluorouracil, doxorubicin, and cisplatin regimen in adrenal cortical

Worden, FP. (2005). Management of patients with adrenal cancer: recommendations of an international consensus conference. *Endocr Relat Cancer*,

(2000). Complete sequencing and messenger ribonucleic acid expression analysis of the MEN I gene in adrenal cancer. *J Clin Endocrinol Metab*, Vol. 85, No. 1, pp. (441-

CJ., Russell, CF., Schulte, KM., Röher, HD., Delbridge, L. & Robinson, BG. (2002). Comparative genomic hybridization analysis of adrenocortical tumors. *J Clin* 

Wilander, E. & Oberg, K. (1992). Clinical and genetic features of adrenocortical lesions in multiple endocrine neoplasia type 1. *J Clin Endocrinol Metab*, Vol. 75, No.

transmission of a mutated p53 gene in a cancerprone family with Li-Fraumeni

Cardo, C., Jaques, DP. & Brennan, MF. (2002). Adrenocortical carcinoma: clinical, morphologic, and molecular characterization. *J Clin Oncol* , Vol. 20, No. 4, pp. (941-

Shawker, T. (1997). Thyroid gland abnormalities in patients with the syndrome of spotty skin pigmentation, myxomas, endocrine overactivity, and schwannomas (Carney complex). *J Clin Endocrinol Metab*, Vol. 82, No. 7, pp. (2037-43), ISSN. Stratakis CA, Sarlis N, Kirschner LS, Carney JA, Doppman JL, Nieman LK, Chrousos GP,

Papanicolaou DA. (1999) Paradoxical response to dexamethasone in the diagnosis of primary pigmented nodular adrenocortical disease. Ann Intern Med. Vol. 131(8),

Polakis, P. Wnt signaling and cancer. *Genes Dev*, Vol. 14, No. 15, pp. (1837-51), ISSN.


Polat, B., Fassnacht, M., Pfreundner, L., Guckenberger, M., Bratengeier, K., Johanssen, S.,

Reincke, M., Karl, M., Travis, WH., Mastorakos, G., Allolio, B., Linehan, HM. & Chrousos,

Resnik, Y., Allali Zerah, V., Chayvilalle, JA., Leroyer, R., Leymarie, P., Travert, G.,

Ribeiro, RC., Sandrini Neto, RS., Schell, MJ., Lacerda, L., Sambaio, GA. & Cat, I. (1990).

Ribeiro, RC., Michalkiewicz, EL., Figueiredo, BC., DeLacerda, L., Sandrini, F., Pianovsky,

Ribeiro, RC., Sandrini, F., Figueiredo, B., Zambetti, GP., Michalkiewicz, E., Lafferty, AR.,

Rockall, AG., Babar, SA., Sohaib, SA., Isidori, AM., Diaz-Cano, S., Monson, JP., Grossman,

Ruder, HJ., Loriaux, DL. & Lipsett, MB. (1974). Severe osteopenia in young adults associated

Sabbaga, CC., Avilla, SG., Schulz, C., Garbers, JC. & Blucher, D. (1993). Adrenocortical

Sandrini, R., Ribeiro, R. & DeLacerda, L. (1997). Extensive personal experience: childhood adrenocortical tumors. *J Clin Endocrinol Metab*, Vol. 82, pp. (2027-31), ISSN. Sbiera S, Schmull S, Assie G, Voelker HU, Kraus L, Beyer M, Ragazzon B, Beuschlein F,

Rosenfield, RL. Clinical practice. Hirsutism. *N Engl J Med*, Vol. 353, pp. (2578–88), ISSN. Ross, NS. (1994). Epidemiology of Cushing's syndrome and subclinical disease. *Endocrinol* 

polypeptide. *N Engl J Med*, Vol. 327, No. 14, pp. (981–6), ISSN.

*Med Biol Res*, Vol. 33, No. 10, pp. (1225-34), ISSN.

*Metab Clin North Am*, Vol. 23, pp (539-46), ISSN.

*Metab*, Vol. 39, pp. (1138-47), ISSN.

pp. (841-3), ISSN.

adrenocortical carcinoma. *Cancer*, Vol. 115, No. 13, pp. (2816-23), ISSN. Quddusi, S., Browne, P., Toivola, B. & Hirsch, IB. Cushing syndrome due to surreptitious glucocorticoid administration. *Arch Intern Med*, Vol. 158, pp. (294-6), ISSN. Quinkler, M., Hahner, S., Wortmann, S., Johanssen, S., Adam, P., Ritter, C., Strasburger, C.,

Kenn, W., Hahner, S., Allolio, B. & Flentje, M. (2009). Radiotherapy in

Allolio, B. & Fassnacht, M. (2008). Treatment of advanced adrenocortical carcinoma with erlotinib plus gemcitabine. *J Clin Endocrinol Metab*, Vol. 93, No. 6, pp. (2057-

GP. (1994). P53 mutations in human adrenocortical neoplasms: Immunohistochemical and molecular studies. *J Clin Endocrinol Metab*, Vol. 78, No. 3,

Lebrethon, MC., Budi, I., Balliere, AM. & Mahoudeau, J. (1992). Food-dependent Cushing's syndrome mediated by aberrant adrenal sensitivity to gastric inhibitory

Adrenocortical carcinoma in children: A study of 40 cases. *J Clin Oncol*, Vol. 8, pp.

MD., Sampaio, G. & Sandrini, R. (2000). Adrenocortical tumors in children. *Braz J* 

DeLacerda, L., Rabin, M., Cadwell, C., Sampaio, G., Cat, I., Stratakis, CA. & Sandrini, R. (2001). An inherited p53 mutation that contributes in a tissue-specific manner to pediatric adrenal cortical carcinoma. *Proc Natl Acad Sci U S A*, Vol. 98,

AB. & Reznek, RH. (2004). CT and MR imaging of the adrenal glands in ACTHindependent cushing syndrome. *Radiographics*, Vol. 24, No. 2, pp. (435-52), ISSN.

with Cushing's syndrome due to micronodular adrenal disease. *J Clin Endocrinol* 

carcinoma in children: clinical aspects and prognosis. *J Pediatr Surg*, Vol. 28, No. 6,

Willenberg HS, Hahner S, Saeger W, Bertherat J, Allolio B, Fassnacht M. (2010).

Polakis, P. Wnt signaling and cancer. *Genes Dev*, Vol. 14, No. 15, pp. (1837-51), ISSN.

62), ISSN.

pp. (790 –4), ISSN.

(67-74), ISSN.

No. 16, pp. (9330-5), ISSN.

High diagnostic and prognostic value of steroidogenic factor-1 expression in adrenal tumors. J Clin Endocrinol Metab. Vol. 95, No. 10, pp. (161-71).


Adrenal Cortex Tumors and Hyperplasias 353

Terzolo, M., Angeli, A., Fassnacht, M., Daffara, F., Tauchmanova, L., Conton, PA., Rossetto,

Tissier, F., Cavard, C., Groussin, L., Perlemoine, K., Fumey, G., Hagneré, AM., René-Corail,

Tissier, F. (2010). Classification of adrenal cortical tumors: what limits for the pathological approach? *Best Pract Res Clin Endocrinol Metab*, Vol. 24, No. 6, pp. (877-85), ISSN. Ulick, S., Wang, JZ. & Morton, DH. (1992). The biochemical phenotypes of two inborn errors in the biosynthesis of aldosterone. *J Clin Endocrinol Metab*, Vol. 74, pp. (1415-20), ISSN. van Ditzhuijsen, CI., van de Weijer, R. & Haak, HR. (2007). Adrenocortical carcinoma. *Neth J* 

Varley, JM., McGown, G., Thorncroft, M., James, LA., Margison, GP., Forster, G., Evans,

Veugelers, M., Wilkes, D., Burton, K., McDermott, DA., Song, Y., Goldstein, MM., La Perle,

Volante, M., Buttigliero, C., Greco, E., Berruti, A. & Papotti, M. (2008). Pathological and

Wada, S., Kitahama, S., Togashi, A., Inoue, K., Iitaka, M. & Katayama, S. (2002). Preclinical

Waggoner, W., Boots, LR. & Azziz, R. (1999). Total testosterone and DHEAS levels as

Wagner, J., Portwine, C., Rabin, K., Leclerc, JM., Narod, SA. & Malkin, D. (1994). High

Wajchenberg, BL., Albergaria Pereira, MA., Medonca, BB., Latronico, AC., Campos

molecular features of adrenocortical carcinoma: an update. *J Clin Pathol*, Vol. 61,

Cushing's syndrome due to ACTH-independent bilateral macronodular adrenocortical hyperplasia with excessive secretion of 18-hydroxydeoxycorticosterone and

predictors of androgen-secreting neoplasms: a populational study. *Gynecological* 

frequency of germline p53 mutations in childhood adrenocortical cancer. *J Natl* 

Carneiro, P., Alves, VA., Zerbini, MC., Liberman, B., Carlos Gomes, G. & Kirschner,

DG., Harris, M., Kelsey, AM. & Birch, JM. (1999). Are there low-penetrance TP53 Alleles? Evidence from childhood adrenocortical tumors. *Am J Hum Genet*, Vol. 65,

K., Vaughan, CJ., O'Hagan, A., Bennett, KR., Meyer, BJ., Legius, E., Karttunen, M., Norio, R., Kaariainen, H., Lavyne, M., Neau, JP., Richter, G., Kirali, K., Farnsworth, A., Stapleton, K., Morelli, P., Takanashi, Y., Bamforth, JS., Eitelberger, F., Noszian, I., Manfroi, W., Powers, J., Mochizuki, Y., Imai, T., Ko, GT., Driscoll, DA., Goldmuntz, E., Edelberg, JM., Collins, A., Eccles, D., Irvine, AD., McKnight, GS. & Basson, CT. (2004). Comparative PRKAR1A genotype-phenotype analyses in humans with Carney complex and PRKAR1a haploinsufficient mice. *Proc Natl Acad* 

Vol. 356, No. 23, pp. (2372-80), ISSN.

*Med*, Vol. 65, No. 2, pp. (55-60), ISSN.

*Sci U S A*, Vol. 101, No.39, pp. (14222-7), ISSN.

*Endocrinology*, Vol. 13, pp. (394–400), ISSN.

*Cancer Inst*, Vol. 86, No. 22, pp. (1707-10), ISSN.

corticosterone. *Intern Med*, Vol. 41, No. 4, pp. (304-8), ISSN.

No. 4, pp. (995-1006), ISSN.

No. 7, pp. (787-93), ISSN.

tumors. *Cancer Res*, Vol. 65, No. 17, pp. (7622–7), ISSN.

R., Buci, L., Sperone, P., Grossrubatscher, E., Reimondo, G., Bollito, E., Papotti, M., Saeger, W., Hahner, S., Koschker, AC., Arvat, E., Ambrosi, B., Loli, P., Lombardi, G., Mannelli, M., Bruzzi, P., Mantero, F., Allolio, B., Dogliotti, L. & Berruti, A. (2007). Adjuvant mitotane treatment for adrenocortical carcinoma. *N Engl J Med*,

F., Jullian, E., Gicquel, C., Bertagna, X., Vacher-Lavenu, MC., Perret, C. & Bertherat, J. (2005). Mutations of beta-catenin in adrenocortical tumors: Activation of the Wnt signaling pathway is a frequent event in both benign and malignant adrenocortical


Stratakis, CA., Kirschner, LS. & Carney, JA. (2001). Clinical and molecular features of the

Stratakis, CA. & Boikos, SA. (2007). Genetics of adrenal tumors associated with Cushing's

Sturgeon C, Shen WT, Clark OH, Duh QY, Kebebew E. (2006). Risk assessment in 457

Sullivan, M., Boileau, M. & Hodges, CV. (1978). Adrenal cortical carcinoma. *J Urol*, Vol. 120,

Sutter, JA. & Grimberg, A. (2006). Adrenocortical tumors and hyperplasias in childhood:

Swain, JM., Grant, CS., Schlinkert, RT., Thompson, GB., vanHeerden, JA., Lloyd, RV. &

a clinicopathologic correlation. *Arch Surg*, Vol. 133, No. 5, pp. (541–6), ISSN. Swords, FM., Baig, A., Malchoff, DM., Malchoff, CD., Thorner, MO., King, PJ., Hunyady, L.

Szolar, DH., Korobkin, M., Reittner, P., Berghold, A., Bauernhofer, T., Trummer, H.,

Tanabe, A., Naruse, M., Naruse, K., Hase, M., Yoshimoto, T., Tanaka, M., Seki, T., Demura,

Terzolo, M., Osella, G., Alì, A. & Angeli, A. (2000). Adrenal incidentalomas. *In*: De Herder

Terzolo M, Boccuzzi A, Bovio S, Cappia S, De Giuli P, Alì A, Paccotti P, Porpiglia F, Fontana

Terzolo, M., Bovio, S., Pia, A., Conton, PA., Reimondo, G., Dall'Asta, C., Bemporad, D., Angeli,

diagnosis of adrenocortical tumors. Urology. Vol. 57(1), pp (176-82). Terzolo, M., Bovio, S., Reimondo, G., Pia, A., Osella, G., Borretta, G. & Angeli, A. (2005a).

hypertension. *Hypertens Res*, Vol. 20, No. 2, pp. (85–90), ISSN.

*Kluwer Academic Publishers*, Vol. 7, pp. (191-211), ISSN.

*North Am*, Vol. 34, No. 2, pp. (423-39), ISSN.

*Clin Endocrinol Metab*, Vol. 86, pp. (4041-6), ISSN.

*Pract Endocrinol Metab*, Vol. 3, pp. (748–57), ISSN.

pp. (660–5), ISSN.

No. 1, pp. (32-9), ISSN.

12, pp. (2746-53), ISSN.

ISSN.

malignancy? J Am Coll Surg. Vol. 202(3), pp (423-30).

Carney complex: diagnostic criteria and recommendations for patient evaluation. *J* 

syndrome: a new classification for bilateral adrenocortical hyperplasias. *Nat Clin* 

adrenal cortical carcinomas: how much does tumor size predict the likelihood of

etiology, genetics, clinical presentation and therapy. *Pediatr Endocrinol Rev*, Vol. 4,

Young, WF. (1998). Corticotropin-independent macronodular adrenal hyperplasia:

& Clark, AJ. (2002). Impaired desensitization of a mutant adrenocorticotropin receptor associated with apparent constitutive activity. *Mol Endocrinol*, Vol. 16, No.

Schoellnast, H., Preidler, KW. & Samonigg, H. (2005). Adrenocortical carcinomas and adrenal pheochromocytomas: mass and enhancement loss evaluation at delayed contrast-enhanced CT. *Radiology*, Vol. 234, No. 2, pp. (479–85), ISSN. Tadjine, M., Lampron, A., Ouadi, L., Horvath, A., Stratakis, CA. & Bourdeau, I. (2008).

Detection of somatic beta-catenin mutations in primary pigmented nodular adrenocortical disease (PPNAD). *Clin Endocrinol (Oxf)*, Vol. 69, No. 3, pp. (367-73),

R. & Demura, H. (1997). Left ventricular hypertrophy is more prominent in patients with primary aldosteronism than in patients with other types of secondary

WW (ed). Functional and Morphological Imaging of the Endocrine System. *Boston:* 

D, Angeli A. (2001). Immunohistochemical assessment of Ki-67 in the differential

Subclinical Cushing's syndrome in adrenal incidentalomas. *Endocrinol Metab Clin* 

A., Opocher, G., Mannelli, M., Ambrosi, B. & Mantero, F. (2005b). Midnight serum cortisol as a marker of increased cardiovascular risk in patients with a clinically inapparent adrenal adenoma. *Eur J Endocrinol*, Vol. 153, No. 2, pp. (307-15), ISSN.


**15** 

*Italy* 

**Autoimmunity to Steroid-Producing Cells** 

*Department of Internal Medicine, Section of Internal Medicine and Endocrine and* 

Addison's disease, named after the English physician who provided its full description in 1855, is the result of the destruction or impaired function of adrenocortical cells. Of the 11 cases described by Addison, 10 were likely subsequent to an infiltrative disease (the most common being the secondary localization of *Mycobacterium tuberculosis* to the adrenal gland) and 1 was clinically idiopathic (likely of an autoimmune origin, on the basis of the current knowledge of disease mechanisms). In recent years the ethiologic spectrum of the disease has considerably expanded to include genetic causes not present in the 11 cases described by Thomas Addison. Accordingly, the definition of primary adrenal insufficiency (PAI) appears today more correct. Nevertheless, Autoimmune Addison's Disease (AAD) and posttuberculosis Addison's disease are still adequate definitions according to the clinical

Prevalence of PAI is estimated at 120-160 cases per million in western countries, corresponding to 1 case every 7,000-7,500 individuals (Laureti *et al*, 1999; Løvås *et al*, 2002). The clinical manifestations of the disease result from the glucorticoid, mineralcorticoid and androgen deficiency (Oelkers, 1996). In western countries and Japan, an autoimmune process is responsible for the destruction of the adrenocortical cells and for the clinical manifestations of PAI in around 70-90% of cases (Betterle *et al*, 2002; Nomura *et al*, 1994). AAD occurs frequently in concomitance with other organ-specific and non-organ-specific autoimmune diseases in the so-called autoimmune polyendocrine syndromes (APS). Since at least two-thirds of patients with AAD have one or more other manifestations of an ongoing autoimmune process against other endocrine glands or different tissues, AAD can be considered a paradigmatic disease for the study of endocrine autoimmunity. On the basis of the type of diseases present in the same patient, different APSs are recognized. APS 1 is caused by mutations of the AIRE (AutoImmune REgulator) gene, which is located on chromosome 21 (The Finnish-German APECED Consortium, 1997). This syndrome is characterized by the concomitant presence of at least two of three diseases: chronic mucocutaneous candidiasis, hypoparathyroidism and AAD. In first-degree relatives of APS1 patients a single disease manifestation is sufficient to formulate the diagnosis. No general agreement exists for the classification of the remaining APSs. Some authors discriminate APS 2, APS 3 and APS 4 according to the different combination of autoimmune diseases present in the same patients. With this classification, APS 2 would identify the association of clinical or pre-clinical AAD with thyroid autoimmune diseases

**1. Introduction** 

characteristics of the cases described in 1855.

Alberto Falorni and Stefania Marzotti

*Metabolic Sciences, University of Perugia* 

MA. (2000). Adrenocortical carcinoma: clinical and laboratory observations. *Cancer*, Vol. 88, No. 4, pp. (711-36), ISSN.

