Carcinoma corticosuprarrenal virilizante en un niño / Virilizing adrenocortical carcinoma in a child

Introducción: Los tumores suprarrenales en niños son poco frecuentes y el carcinoma suprarrenal representa menos de un 10 %. En el prepúber, la manifestación más típica es el desarrollo de pubertad precoz. Objetivo: Describir las características clínicas, los procederes diagnósticos y terapéuticos de un paciente con carcinoma adrenal en edad pediátrica. Presentación de caso: Paciente de 8 años, masculino y de piel blanca con antecedentes de salud. Acude a la consulta por crecimiento de vello pubiano y aumento del pene en longitud y grosor de aproximadamente 2 años de evolución. En el examen físico se constatan aumento de la velocidad de crecimiento y signos sugestivos de virilización (voz gruesa, vello axilar, vello sexual púbico y genitales externos estadio III de Tanner). Se realizaron estudios hormonales que corroboraron el hiperandrogenismo por secreción endógena autónoma, con niveles de gonadotropinas suprimidas, niveles de testosterona y dehidroepiandrosterona elevados. También se realizaron estudios imagenológicos que evidenciaron edad ósea acelerada y la existencia de un tumor. Se realizó una adrenalectomía izquierda y se confirmó por anatomía patológica el carcinoma corticosuprarrenal virilizante izquierdo en estadío 2. Inició un tratamiento con quimioterapia por dicho diagnóstico y actualmente se mantiene en seguimiento. Conclusiones: Los carcinomas corticosuprarrenales en niños son mayoritariamente funcionantes y constituyen una de las causas de pubertad precoz periférica. Estos son infrecuentes y agresivos, por lo que la realización de estudios genéticos en familias con síndromes hereditarios contribuiría a su diagnóstico precoz para un adecuado tratamiento y mejor pronóstico(AU)

Introduction: Adrenal tumors in children are rare and adrenal carcinoma represents less than the 10 percent. In the prepubescent, the most typical manifestation is the development of early puberty. Objective: Describe the clinical characteristics and diagnostic and therapeutic procedures of a patient with adrenal carcinoma in a pediatric age. Case presentation: 8-year-old male, white-skinned patient with a history of health conditions. He attentds to the consultation due to pubic hair growth and penis enlargement in length and thickness of approximately 2 years of evolution. Physical examination shows increased growth rate and signs suggestive to virilization (deep voice, axillary hair, pubic sexual hair and external genitalia in Tanner's stage III). Hormonal studies were carried out that corroborated hyperandrogenism by autonomic endogenous secretion, with suppressed gonadotropin levels, elevated testosterone and dehydroepiandrosterone levels. Imaging studies were also performed that showed accelerated bone age and the existence of a tumor. A left adrenalectomy was performed and stage 2 left virilizing adrenocrotical carcinoma was confirmed by pathological anatomy studies. He began chemotherapy treatment for this diagnosis and is currently being followed up. Conclusions: Adrenocortical carcinomas in children are mostly functioning and are one of the causes of peripheral early puberty. These are uncommon and aggressive, so genetic studies in families with hereditary syndromes would contribute to their early diagnosis for adequate treatment and better prognosis(AU)

Carcinoma adrenocortical: Presentación y desenlaces en una institución oncológica / Adrenocortical carcinoma: Presentation and outcomes at an oncological institute

Resumen Introducción: El carcinoma adrenocortical es una neoplasia endocrina infrecuente pero con un comportamiento altamente agresivo y pobre pronóstico. Dado su baja prevalencia, la experiencia de los centros de referencia es fundamental para aumentar el conocimiento de esta entidad. Métodos: Se elaboró una serie de casos de pacientes con carcinoma adrenocortical, tratados en una institución oncológica de referencia entre enero de 2007 y diciembre de 2017. Se describieron las características clínicas e histopatológicas de los pacientes. Se estimó el tiempo de supervivencia libre de progresión y el tiempo de supervivencia global (SG) de forma gráfica y con funciones de tiempo al evento mediante la función de Kaplan-Meier. Resultados: Se identificaron 19 pacientes, 14 de los cuales fueron mujeres con edad media al diagnóstico de 43.4 años (rango 20 - 65). El 58% de los pacientes tuvo secreción hormonal, siendo el síndrome de Cushing el predominante. 7 pacientes tuvieron compromiso metastásico al momento del diagnóstico. Todos los pacientes fueron llevados a adrenalectomía y el estado postquirúrgico en 10 pacientes fue R0. Al final del periodo de estudio, 11 pacientes estaban vivos. La mediana de supervivencia libre de progresión fue de 18 meses +/- 7.86 y la mediana de supervivencia global fue de 30 meses +/-19.80. Conclusión: En la población de pacientes analizada, se encontraron desenlaces de supervivencia libre de progresión y supervivencia global similares a lo reportado en centros de alta experiencia en patología adrenal.

Abstract Introduction: Adrenocortical carcinoma is a rare endocrine neoplasm, but with highly aggressive behavior and a poor prognosis. Given its low prevalence, the experience of reference centers is essential to characterize the factors associated with this disease. Methods: It is a case series of patients with adrenocortical carcinoma, treated at a reference oncology institute between January 2007 and December 2017. The clinical and histopathological characteristics of patients are described. Progression-free survival and overall survival (OS) were estimated graphically and with time-to-event data using the Kaplan-Meier function. Results: 19 patients were identified; 14 of them were women with a mean age at diagnosis of 43.4 years (range 20-65). 58% of the patients had hormone secretion, with Cushing's syndrome being the predominant one. 7 patients had metastatic compromise at the time of diagnosis. All patients underwent adrenalectomy, and R0 was the post-surgical status in 10 of them. At the end of the study period, 11 patients were alive. The median progression-free survival was 18 months +/- 7.86, and the median overall survival was 30 months +/- 19.8. Conclusion: In the analyzed patient population, outcomes of progression-free survival and overall survival were similar to that reported at centers with extensive experience in adrenal disease.

Giant virilising adrenal cortical carcinoma

Androgen secreting adrenocortical carcinoma (ACC) is a very rare disease with a poor prognosis. Approximately 80% of tumors are functional, most commonly secreting glucocorticoids. We herewith report a case of a huge functional ACC of the right adrenal gland in a 33-year-old female who presented with complaints of hirsutism, amenorrhea and an abdominal lump. On abdominal examination a large lump was palpable in the right hypochondrium reaching up to the umbilicus. Contrast-enhance computed tomography (CECT) revealed a mass in the right suprarenal region. The tumor measured 29 cm × 20 cm × 12 cm and weighed 7.8 kg, the largest reported case of ACC in the world to the best of our knowledge.

Predictors of complication after adrenalectomy

ABSTRACT Purpose: To investigate risk factors for complications in patients undergoing adrenalectomy. Materials and Methods: A retrospective search of our institutional database was performed of patients who underwent adrenalectomy, between 2014 and 2018. Clinical parameters and adrenal disorder characteristics were assessed and correlated to intra and post-operative course. Complications were analyzed within 30-days after surgery. A logistic regression was performed in order to identify independent predictors of morbidity in patients after adrenalectomy. Results: The files of 154 patients were reviewed. Median age and Body Mass Index (BMI) were 52-years and 27.8kg/m2, respectively. Mean tumor size was 4.9±4cm. Median surgery duration and estimated blood loss were 140min and 50mL, respectively. There were six conversions to open surgery. Minor and major post-operative complications occurred in 17.5% and 8.4% of the patients. Intra-operative complications occurred in 26.6% of the patients. Four patients died. Mean hospitalization duration was 4-days (Interquartile Range: 3-8). Patients age (p=0.004), comorbidities (p=0.003) and pathological diagnosis (p=0.003) were independent predictors of post-operative complications. Tumor size (p<0.001) and BMI (p=0.009) were independent predictors of intra-operative complications. Pathological diagnosis (p<0.001) and Charlson score (p=0.013) were independent predictors of death. Conclusion: Diligent care is needed with older patients, with multiple comorbidities and harboring unfavorable adrenal disorders (adrenocortical carcinoma and pheocromocytoma), who have greater risk of post-operative complications. Patients with elevated BMI and larger tumors have higher risk of intra, but not of post-operative complications.

Síndromes de neoplasia endocrina múltiple: revisión radiológica / Multiple Endocrine Neoplasia Syndromes: Radiological Review

Los síndromes de neoplasia endocrina múltiple (MEN), incluyen una serie de enfermedades con alteraciones genéticas que se caracterizan por la presencia de tumores que afectan a dos o más glándulas endocrinas. Son síndromes con una herencia autosómica dominante e incluyen tres patrones: MEN 1 (síndrome de Wermer), MEN 2 (que incluye MEN 2A o síndrome de Sipple y MEN 2B o síndrome de Wagenmann-Froboese) y MEN 4. Los adenomas paratiroideos y el carcinoma medular tiroideo, son los tumores más frecuentes del MEN tipo 1 y 2 respectivamente. Esos síndromes son más comunes en pacientes jóvenes, con patología de afectación bilateral, múltiple o multifocal y, sobre todo, en pacientes con antecedentes familiares. Es necesario el trabajo en equipo de endocrinólogos, cirujanos, oncólogos y radiólogos para optimizar el tratamiento de esos pacientes.

Multiple endocrine neoplasia (MEN) encompasses a serial of familial genetically disorders in wich tumors simultaneusly occur in two or more endocrine organs. MEN síndromes are autosomal-dominant disorders categorized into three main patterns: MEN 1 (Wermer syndrome), MEN 2 (includes MEN 2A o Sipple syndrome and MEN 2B o Wagenmann-Froboese syndrome) and MEN 4. Parathyroid adenomas and medullary thyroid carcinoma are the most frecuent tumors in MEN 1 and MEN 2 respectively. These entities will be suspected in younger patients, bilateral, multiple or multifocal disease and, specially, in patients with family background. Cooperation between endocrinologist, surgeons, oncologists and radiologists is pivotal for optimizing patient treatment.

Alterações genômicas no carcinoma adrenocortical de pacientes portadores da Síndrome de Li-Fraumeni / Genomic alterations profile in adrenocortical carcinoma of Li-Fraumeni Syndrome patients

A Síndrome de Li Fraumeni (LFS) tem caráter autossômico dominante associada ao risco aumentado de câncer hereditário. Embora rara no mundo, no Brasil é frequente devido à ocorrência de uma mutação fundadora, a p.R337H TP53. A ocorrência de câncer e a idade de acometimento são variáveis mesmo em portadores da mesma mutação. Pacientes com mutações no gene TP53 podem desenvolver um amplo espectro de tumores, incluindo o carcinoma adrenocortical (ADR). Os mecanismos moleculares envolvidos na carcinogênese adrenocortical assim como os dados epidemiológicos associados a estes tumores são pouco explorados em literatura. Neste estudo, foram coletados e analisados os dados epidemiológicos dos ADR incluindo os efeitos de idade, período e coorte utilizando o banco de dados SEER, o qual reúne dados de 18 registros de câncer de base populacional dos EUA. Foi avaliado o perfil de alterações genômicas (CytoScan HD Array, Affymetrix) em ADR de pacientes com e sem a mutação p.R337H. Foi também comparado o perfil mutacional (sequenciamento do genoma) de três pacientes (tumor e tecido normal de 2 adultos e 1 criança) com ADR portadores da mutação TP53 p.R337H. Entre os casos de ADR diagnosticados nos EUA, aproximadamente 80% ocorreram após a quarta década de vida. Nas análises de sobrevida, houve diferença estatística (p<0,05) para gênero, com uma melhor sobrevida para as mulheres. Pacientes diagnosticados até os 19 anos e com doença localizada apresentaram uma sobrevida maior. A análise genômica em sete casos revelou 644 alterações. Os três casos positivos para a mutação p.R337H apresentaram 175 alterações genômicas (127 ganhos, 27 cnLOH e 21 perdas). Os quatros casos negativos para a mutação apresentaram 469 alterações (326 ganhos, 63 cnLOH e 80 perdas). Apesar do pequeno número amostral, os casos ADR positivos para a mutação TP53 p.R337H apresentaram um baixo nível de instabilidade genômica quando comparados com os casos não mutados. A análise de sequenciamento do genoma revelou alterações em genes previamente associados o ADR (como TP53, CTNNB1 e ATRX). Foram identificadas alterações em cinco genes com potencial associação ao desenvolvimento do ADR: HBB, MSR1, SH3TC2, LSS e ABCA4. Apesar do pequeno número amostral, foram identificados novos genes que podem estar associados ao ADR, no entanto esses achados deverão ser confirmados em estudos conduzidos em um grupo amostral maior (AU)

Li-Fraumeni syndrome (LFS) is an autosomal dominant disease with high risk to develop hereditary tumors. Although LFS is a worldwide rare disorder, in Brazil its incidence is higher due to the occurrence of a founder mutation, TP53 p.R337H. The cancer occurrence and age of onset are variable even considering patients with the same mutation. Patients carrying TP53 mutations can develop a large spectrum of tumors, including the adrenocortical carcinoma (ADR). The main molecular mechanisms and the epidemiological factors associated with these tumors are poorly explored in literature. In this study, epidemiological data of ADR were collected and analyzed, including the effects of age, period and cohort. The SEER database, which collects and publishes cancer incidence and survival data from 18 cancer registries from the USA, was used for this analysis. The genomic profile (CytoScan HD Array, Affymetrix) of ADR positive or negative for TP53 p.R337H was also investigated. Furthermore, the mutational profile (Whole Genome Sequencing- WGS) of three ADR patients (normal and tumor samples - 2 adults and 1 pediatric case), all of them positive for TP53 p.R337H mutation, were analyzed. Approximately 80% of the ADR cases diagnosed in the USA developed after the fourth decade of life. In the survival analyses, a statistical difference (p <0.05) was observed for gender, with women showing better survival. Patients diagnosed up to the age of 19 and with localized disease presented better survival. The genomic analysis of seven cases revealed 644 genomic alterations. The three TP53 p.R337H positive cases showed 175 genomic alterations (127 gains, 27 cnLOH and 21 losses). The four negative mutated cases presented 469 alterations (369 gains, 63 cnLOH and 80 losses). Despite the small set of samples, mutated cases presented lower level of chromosome instability compared to cases not carrying this mutation. The WGS analysis identified alterations in genes previously associated with ADR (as TP53, CTNNB1 and ATRX). In addition, five genes (HBB, MSR1, SH3TC2, LSS and ABCA4) potentially associated with the development of ADR were identified. This study revealed new genes that might be associated with ADR. However, further analysis are necessary in a larger number of samples to confirm our findings (AU)

Primary malignant tumors of the adrenal glands

Malignancy must be considered in the management of adrenal lesions, including those incidentally identified on imaging studies. Adrenocortical carcinomas (ACCs) are rare tumors with an estimated annual incidence of 0.7-2 cases per year and a worldwide prevalence of 4-12 cases per million/year. However, a much higher incidence of these tumors (>15 times) has been demonstrated in south and southeastern Brazil. Most ACCs cause hypersecretion of steroids including glucocorticoids and androgens. ACC patients have a very poor prognosis with a 5-year overall survival (OS) below 30% in most series. Pheochromocytoma or paraganglioma (PPGL) is a metabolically active tumor originating from the chromaffin cells of the adrenal medulla. The incidence of PPGL is 0.2 to 0.9 cases per 100,000 individuals per year. Pheochromocytomas are present in approximately 4-7% of patients with adrenal incidentalomas. Classically, PPGL manifests as paroxysmal attacks of the following 4 symptoms: headaches, diaphoresis, palpitations, and severe hypertensive episodes. The diagnosis of malignant PPGL relies on the presence of local invasion or metastasis. In this review, we present the clinical and biochemical characteristics and pathogenesis of malignant primary lesions that affect the cortex and medulla of human adrenal glands.

Mecanismos moleculares do efeito citotóxico de FGF2 em células transformadas por RAS / Molecular mechanisms of the cytotoxic effect of FGF2 in rastransformed cells

O FGF2 (Fibroblast Growth Factor 2) é um clássico fator peptídico de crescimento que ativa vias intracelulares de sinalização molecular promovendo a transição G0 → G1 e o comprometimento com o ciclo celular. Não surpreendentemente, seus papéis pró-tumoral e angiogênico estão bem caracterizados e estabelecidos na literatura. No entanto, um crescente corpo de evidências tem indicado que o FGF2 também pode exercer efeitos anti-tumorais in vitro e in vivo, em modelos murinos e também humanos. Neste contexto, nosso grupo publicou em 2008 que o FGF2 exerce um efeito antiproliferativo seletivo em células murinas malignas dependentes de alta atividade de K-Ras e H-Ras. Os genes ras compõem a família de oncogenes mais frequentemente mutada em tumores malignos humanos, alcançando aproximadamente 30% de todos os casos. O desenvolvimento de terapias contra tumores dependentes de Ras fracassou, apesar dos intensos esforços e investimentos desde a descoberta em 1982 de suas mutações ativadoras em múltiplos cânceres. O objetivo deste trabalho foi desvendar os mecanismos moleculares pelo quais o FGF2 inibe irreversivelmente a proliferação de células malignas dependentes da atividade de Ras, empregando como modelos experimentais a linhagem murina Y1 de células adrenocorticais, e 4 linhagens humanas derivadas de sarcomas de Ewing. Identificamos que o efeito citotóxico do FGF2 não se processa por um mecanismo novo e independente das viasproliferativas classicamente ativadas por fatores peptídicos de crescimento. Ao contrário, seu efeito tóxico é resultado de sinalização mitogênica exagerada decorrente de estimulação sustentada por FGF2. A ativação da via de MAPK, principal sinalização mitogênica intracelular, a níveis elevados e sustentados provoca estresse mitogênico, que se propaga para a fase S na forma de estresse replicativo. Nesta situação, a célula passa a depender exageradamente da sinalização protetora de ATR, de modo que a combinação de estimulação com FGF2 e inibição de ATR foi altamente letal para as células malignas dependentes de Ras empregadas neste trabalho. Também analisamos as bases moleculares de resistência a FGF2 exibida por células Y1 anteriormente selecionadas para resistir ao efeito tóxico do FGF2 (Y1FRs). Descobrimos que a pressão seletiva do FGF2 não teve efeito na expressão de seus receptores, mas provocou a eliminação de um dos dois cromossomos que portam a amplificação gênica de ras nesta linhagem, enquanto o segundo cromossomo foi mantido por ser a única fonte de genes ribossomais ativos. Suas cópias de ras, no entanto, mostraram-se transcricionalmente silenciadas. Além disso, as sublinhagens Y1FRs não expressam o principal RasGEF, GRP4, encontrado nas células parentais Y1, o que pode ter influenciado o surgimento do fenótipo resistente ao FGF2. As linhagens resistentes mostraram grande redução no número de cromossomos e aumento da frequência de fusões entre cromossomos não homólogos em relação às células parentais

FGF2 (Fibroblast Growth Factor 2) is a classic peptide growth factor that activates intracellular molecular signaling pathways promoting the G0 → G1 transition and cell cycle commitment. Not surprisingly, its pro-tumor and angiogenic roles are well characterized and established in the literature. However, a growing body of evidence has indicated that FGF2 may also exert anti-tumor effects in vitro and in vivo in murine and human models. In this context, our group reported in 2008 that FGF2 exerts a selective antiproliferative effect in murine cells dependent on high activity of K-Ras and H-Ras. Ras genes make up the most frequently mutated oncogene family in human malignant tumors, reaching approximately 30% of all cases. The development of therapies against Ras-dependent tumors has failed despite intense efforts and investments since the discovery in 1982 of its activating mutations in multiple cancers. The objective of this work was to uncover the molecular mechanisms by which FGF2 irreversibly inhibits the proliferation of malignant cells dependent on Ras activity, using as experimental models the Y1 murine lineage of adrenocortical malignant cells and 4 human lineages derived from Ewing sarcomas. We showed that the cytotoxic effect of FGF2 did not involve novel cell cycle regulatory pathways; instead, this cytotoxic effect is a result of sustainedhyper mitogenic stimulation by FGF2. Activation of the KRas/MAPK pathway, the major intracellular mitogenic signaling, at high and sustained levels provokes mitogenic stress, which is propagated to S phase as replicative stress. In this situation, the cell dependence on the ATR protective signaling is enhanced, so that the combination of stimulation with FGF2 and inhibition of ATR was highly lethal for the Ras dependent malignant cells employed in this work. We also analyzed the molecular basis of FGF2 resistance exhibited by Y1 cells previously selected for resistance to FGF2. We found that the selective pressure of FGF2 had no effect on the expression of its receptors but promoted the elimination of one of the two marker chromosomes that carry the K-ras amplified copies, while the second chromosome was maintained because it is the only source of active ribosomal genes; however, its K-ras amplified copies were transcriptionally silenced. In addition, the Y1FRs sublines did not express the main RasGEF, GRP4, found in the parental Y1 cells, which might have played a role in the emergence of the FGF2-resistant phenotype. The resistant Y1FRs sublines showed a large reduction in chromosome numbers and increased frequency of fusions between non-homologous chromosomes in relation to parental cells

Carcinoma de la corteza suprarrenal. presentación de un caso / Carcinoma of the adrenal cortex. case presentation

Se realizó un estudio clínico anatomopatológico sobre la base de la metodología cualitativa para la descripción de un caso de carcinoma de la corteza suprarrenal en el Hospital General Docente "Dr Agostinho Neto" de Guantánamo en el año 2015. Se describió el caso de un paciente con antecedentes de buena salud, que acude por presentar molestia dolorosa de intensidad gravativa en región posterior izquierda lumboabdominal, se indica chequeo general y mediante la ecografía se diagnostica tumoración suprarrenal izquierda se realizó supraadrenelectomia. El resultado histopatológico señala carcinoma de la corteza suprarrenal(AU)

A pathological clinical study was carried out based on the qualitative methodology for the description of a case of carcinoma of the adrenal cortex at Guantanamo General Teaching Hospital in 2015. A case of a patient with a history of good health, but presenting painful discomfort of gravel intensity in the left posterior lumbo-abdominal region is presented besides general check by ultrasound were indicated. Left adrenal tumor is diagnosed and supra adrenelectomy is performed. Histopathologic results indicate carcinoma of the adrenal cortex(AU)

Adjuvant radiotherapy for the primary treatment of adrenocortical carcinoma: are we offering the best?

ABSTRACT Purpose: To evaluate the role of ARDT after surgical resection of ACC. Materials and Methods: Records of patients from our institutional ACC database were retrospectively assessed. A paired comparison analysis was used to evaluate the oncological outcomes between patients treated with surgery followed by ARDT or surgery only (control). The endpoints were LRFS, RFS, and OS. A systematic review of the literature and meta-analysis was also performed to evaluate local recurrence of ACC when ARDT was used. Results: Ten patients were included in each Group. The median follow-up times were 32 months and 35 months for the ARDT and control Groups, respectively. The results for LRFS (p=0.11), RFS (p=0.92), and OS (p=0.47) were similar among subsets. The mean time to present with local recurrence was significantly longer in the ARDT group compared with the control Group (419±206 days vs. 181±86 days, respectively; p=0.03). ARDT was well tolerated by the patients; there were no reports of late toxicity. The meta-analysis, which included four retrospective series, revealed that ARDT had a protective effect on LRFS (HR=0.4; CI=0.17-0.94). Conclusions: ARDT may reduce the chance and prolong the time to ACC local recurrence. However, there were no benefits for disease recurrence control or overall survival for patients who underwent this complementary therapy.

Caracterização clínica e histopatológica da síndrome de Li-Fraumeni e síndrome Li-Fraumeni like em pacientes brasileiros / Clinical and histopathologic characterization of Li-Fraumeni syndrome and Li-Fraumeni like syndrome in Brazilian patients

INTRODUÇÃO: a Síndrome de Li-Fraumeni (LFS; OMIM#151623) é uma síndrome rara de predisposição hereditária ao câncer, de caráter autossômico dominante e de alta penetrância, relacionada a mutações germinativas no gene TP53. Os tumores típicos da LFS são sarcomas de partes moles e ósseos, leucemias, tumores do sistema nervoso central (SNC), tumores adrenocorticais e tumores de mama. No entanto, há uma variação no espectro tumoral de acordo com o genótipo. No Brasil, há uma alta prevalência da mutação germinativa p.R337H (presente em 0.3% da população do Sul e Sudeste) devido a um efeito fundador. O conhecimento do real espectro tumoral da síndrome associada a esta mutação fundadora ainda é objeto de discussão. PACIENTES E MÉTODOS: foram avaliados dados clínicos, retrospectivamente, a partir de prontuários médicos, de 247 pacientes com LFS e LFS portadores de mutações germinativas no gene TP53, atendidos no Departamento de Oncogenética do A.C.Camargo Cancer Center de 2001 a 2015. As características dos tumores apresentados pelos pacientes portadores de mutação (espectro tumoral, idade do diagnóstico do primeiro tumor e dos tumores subsequentes, tipo histológico dos tumores) foram comparadas entre o grupo de portadores da mutação p.R337H e o grupo de pacientes com as demais mutações patogênicas no gene TP53. As taxas de frequência das mutações (p.R337H versus outras mutações), assim como sexo (masculino e feminino) foram correlacionados com o status de óbito, desenvolvimento ou não de câncer, a idade do diagnóstico do primeiro câncer, tempo do primeiro câncer até aparecimento do segundo câncer, através do teste qui-quadrado ou teste exato de Fisher. Foi aplicado o Teste T para amostras independentes. O estimador de Kaplan-Meier e o teste de log rank foram utilizados para avaliar a influência das variáveis nos tempos de sobrevida global, tempo de aparecimento do primeiro câncer e tempo do primeiro câncer até aparecimento do segundo câncer. RESULTADOS: de 247 portadores de LFS incluídos no estudo, 193 pacientes eram portadores da mutação p.R337H. Deste total de 193 portadores da mutação p.R337H, 101 pacientes apresentaram câncer (52.3%) e 23,8% dos pacientes com câncer tiveram dois ou mais tumores ao longo da vida; enquanto dos 54 pacientes portadores de outras mutações no gene TP53 (21.9% da população total), 39 pacientes tiveram câncer (72.2%), p=0.009. A idade média de diagnóstico do primeiro câncer nos portadores da mutação p.R337H foi de 30.8 anos, comparada a 28.9 anos nos portadores de outras mutações no gene TP53, p=0.604. nos portadores da mutação p.R337H, o primeiro tumor também ocorreu em idade mais precoce nas pacientes femininas (média de 34.7 anos versus 50.4 anos, p<0.001). Em relação ao espectro dos tumores p.R337H na nossa população, câncer de mama e sarcoma de partes moles foram os tumores mais frequentes, seguidos de carcinoma adrenocortical, perfazendo 70,5% dos tumores apresentados nesta população. Nos portadores de outras mutações no gene TP53 , câncer de mama, sarcoma de partes moles, tumor de sistema nervoso central e sarcoma ósseo corresponderam a 69.3% de todos os tumores observados. Nossos dados revelam uma alta frequência de carcinoma adrenocortical (21.5%), carcinoma papilífero de tireoide (6.8%), adenocarcinoma de pulmão (4.9%) e carcinoma renal (4.3%) nos portadores da mutação p.R337H. Interessantemente carcinoma colorretal foi observado apenas nos portadores de outras mutações não-p.R337H. O sarcoma de partes moles nos portadores p.R337H mais frequente foi o leiomiossarcoma e a idade média de diagnóstico foi 46.8 anos; nos portadores das outras mutações, rabdomiossarcoma e leiomiossarcoma foram os subtipos mais frequentes e a idade média do diagnóstico foi 24 anos (p=0.001). A idade média de diagnóstico de câncer de mama foi 42.8 anos nos portadores da mutação p.R337H e 37 anos nos portadores das demais mutações no gene TP53 (p=0.029). O câncer de mama nos portadores das outras mutações apresentavam hiperexpressão de HER2 em 62.5% dos casos, comparado a 19% nos tumores de mama das portadoras da mutação p.R337H. CONCLUSÕES: nossos dados mostram um espectro tumoral distinto para os portadores da LFS com a mutação p.R337H. Esses dados podem ajudar a estabelecer um programa de rastreamento para esses portadores diferente do preconizado para os portadores das demais mutações no gene TP53.

INTRODUCTION: Li Fraumeni syndrome (LFS, OMIM #151623) is a rare autosomal dominant genetic disorder inherited by germline TP53 mutations. Carriers have a high lifetime risk of developing multiple early-onset childhood and adult cancers, including soft tissue and bone sarcomas, central nervous system (CNS) tumors, adrenocortical tumors (ACT), breast cancer and leucemia. However, tumor spectrum may have difference according to genotype. In Brazil, it is observed a high prevalence of a founder germline mutation p.R337H (present in 0.3% of the population in South and Southeast). The exact tumor profile associated to p.R337H carriers is unknown. PATIENTS AND METHODS: we have analyzed medical records of a cohort of 247 germline TP53 mutation carriers, members of Brazilian families who fulfilled LFS/LFL clinical criteria, between 2001 and 2015 from the Oncogenetics Department at A.C.Camargo Cancer Center, Sao Paulo, Brazil. Clinical data were retrospectively evaluated and the tumor characteristics of carriers (tumor spectrum, age at diagnosis, histological subtype) were compared between p.R337H carriers and carriers of other mutations in TP53 gene. The mutation status (p.R337H and other mutations) and gender (male and female) were correlated with death rate, cancer risk, age at diagnosis of cancer, interval between the first and the second cancer diagnosis, using the chi-squared test or Fisher's exact test. The T test was used for independent samples analysis. The Kaplan-Meier and log rank test were used to evaluate the influence of variables on overall survival, time and cancer the first time until onset of the second cancer. RESULTS: the study evaluated 247 patients with LFS, 193 patients had the mutation p.R337H. Among 193 p.R337H carriers, 101 patients had cancer (52.3%) and 23.8% of cancer-affected carriers had two or more tumors lifetime; whereas from 54 non-p.R337H mutation carriers, 39 patients were cancer-affected (72.2%), p = 0.009. The mean age at diagnosis of first cancer in p.R337H carriers was 30.8 years old (yo) compared to 28.9 yo in non-p.R337H mutation carriers, p = 0.604. In p.R337H patients, the first tumor occurred at an earlier age in female patients (mean age at 34.7 yo vs. 50.4 yo, p <0.001). Regarding the tumor spectrum in p.R337H carriers, breast cancer and soft tissue sarcoma were the most frequent tumors, followed by adrenocortical carcinoma (70.5% of the total of tumors). In non-p.R337H mutation carriers, breast cancer, soft tissue sarcoma, central nervous system tumor and bone sarcoma accounted for 69.3% of all tumors observed. Our results showed a high frequency of adrenocortical carcinoma (21.5%), papillary thyroid carcinoma (6.8%), lung adenocarcinoma (4.9%) and renal cell carcinoma (4.3%) in p.R337H patients. Interestingly, colorectal carcinoma was observed only in nonp.R337H mutation patients. Leiomyosarcoma was the most frequent sarcoma subtype in p.R337H carriers and the mean age at diagnosis was 46.8 yo; in non-p.R337H mutation patients, rhabdomyosarcoma and leiomyosarcoma were the most frequent subtypes and the mean age at diagnosis was 24 yo (p = 0.001). The mean age at diagnosis of breast cancer was 42.8 yo in p.R337H patients and 37 yo in non-p.R337H mutation patients (p = 0.029). The breast cancer in non-p.R337H mutation patients showed overexpression of HER2 in 62.5% of cases, compared to 19% in breast tumors from p.R337H carriers. CONCLUSIONS: our clinical cohort revealed a different tumor spectrum associated with p.R337H TP53 mutation. The major limitation in our study was the relatively small sample of nonp.R337H mutation carriers to compare with p.R337H carriers. Notwithstanding, our findings offer insight into exploring a distinct cancer screening protocol for p.R337H mutation carriers in Brazil.

Beyond biology: the impact of marital status on survival of patients with adrenocortical carcinoma

Purpose: To analyze the association of marital status and survival of patients with ACC using a population-based database. Material and Methods: Patients with ACC were abstracted from the Surveillance Epidemiology and End Results (SEER) database from 1988-2010 (n=1271). Variables included marital status (married vs single/divorced/widowed (SDW)), gender, age, race, tumor (T) and node (N) classification, receipt of surgery, and SEER stage. Statistical analysis was performed using Cox proportional hazard models to generate hazard ratios and 95% confidence intervals. Results: There were 728 (57.3%) females and median age was 56 years (IQR 44-66). Patients who were alive were more frequently married (65.6% vs 61.6%, p=0.008), female (61.1% vs 58.0%, p=0.001), younger (median 51 vs 57 years, p=0.0001), submitted to adrenalectomy (88.6% vs 63.8%, p<0.0001), and more favorable SEER stage (localized-64.9% vs 29.9%; regional–25.1% vs 30.1%; distant 4.8% vs 31.5%, p<0.0001) compared to patients dead of disease (DOD). On multivariable analysis, factors significantly associated with all-cause mortality were SDW status (HR 1.28, 95% CI 1.091.51), age, non-operative management, and N+ disease. Risk factors for disease-specific mortality included SDW status (HR 1.30, 95% CI 1.07-1.56), age, non-operative management, T-classification, and N+ disease. Conclusions: Marital status is significantly associated with survival in patients with ACC. Our results suggest that the decreased survival seen among SDW individuals highlights an area for further research and needed intervention to reduce disparity.

Análise dos genes DICER1 e TARBP2 em tumores do córtex da suprarrenal de crianças e adultos / DICER1 and TARBP2 gene analysis in adult and pediatric adrenocortical tumors

INTRODUÇÃO: O carcinoma cortical da suprarrenal é uma neoplasia rara com uma incidência estimada em 0,5-2,0 por milhão por ano em adultos. No momento, poucas opções terapêuticas para os pacientes com doença metastática são disponíveis, e novas descobertas sobre a sua patogênese são necessárias. O perfil de expressão gênica dos microRNAs (miRNAs) em tumores humanos tem sido caracterizado por uma redução global da expressão dos miRNAs. A enzima DICER1 e seu cofator TRBP (codificado pelo gene TARBP2) estão envolvidos em uma etapa essencial do processamento dos miRNAs. De forma interessante, a desregulação do processamento dos miRNAs em células cancerosas devido ao silenciamento da DICER1 propiciou a emergência de células com fenótipo mais agressivo, acelerando a progressão tumoral. Recentemente, mutações somáticas missense recorrentes no domínio de clivagem RNase IIIb da enzima DICER1 foram identificadas em 29% tumores de ovários não-epiteliais esteroidogênicos (e em até 60% de tumores ovarianos de células de Leydig). Adicionalmente, mutações inativadoras no éxon 5 do gene TARBP2, com consequente prejuízo da função da DICER1, foram identificadas em linhagens celulares de tumores com instabilidade cromossômica. OBJETIVOS: Determinar a expressão gênica e proteica da DICER1 e TRBP em tumores do córtex da suprarrenal de adultos e crianças; Investigar variantes genéticas no domínio de clivagem RNAse IIIb do gene DICER1; Investigar variantes genéticas no éxon 5 do gene TARBP2; Estudar a expressão dos miR-103 e miR-107, envolvidos na regulação da DICER1, e do miR-497, envolvido na regulação da TRBP. MÉTODOS: A expressão proteica da DICER1 e da TRBP foi avaliada por imunohistoquímica em uma micromatriz tecidual contendo 198 tumores do córtex da suprarrenal [154 em adultos (75 adenomas e 79 carcinomas) e 44 em crianças (38 clinicamente benignos e 6 clinicamente malignos)]. A expressão gênica da DICER1 e TARBP2 foi avaliada em um subgrupo de 84...

INTRODUCTION: Adrenocortical cancer is a rare neoplasia with an estimated incidence of 0.5-2.0/million/year in adults. There are currently few therapeutic options for patients with adrenocortical cancer, and new insights into the pathogenesis of this lethal disease are needed. The microRNA (miRNA) expression profile of human tumors has been characterized by an overall miRNA downregulation. DICER1 enzyme and its cofactor TRBP are a key component of the miRNA processing machinery. It was recently demonstrated that escaping miRNA control in cancer cells due to Dicer downregulation may allow the phenotypic emergence of more aggressive genetic variants, accelerating cancer progression. Recently, DICER1 mutations in the RNase IIIb domain were found in 29% of nonepithelial ovarian tumors, predominantly in Sertoli-Leydig cell tumors (60%). In addition, TARBP2 truncating mutations, causing DICER1 destabilization, were identified in tumor cell lines with microsatellite instability. AIM: To study the mRNA and protein expression of DICER1 and TRBP in adult and pediatric adrenocortical tumors; To investigate DICER1 mutations in metal biding sites located at the RNase IIIb domain; To investigate inactivating mutations in the exon 5 of TARBP2 gene; To determine the expression of miR-103 and miR-107, DICER1 regulators, and miR-497, a TRBP regulator. METHODS: Protein expression of DICER1 and TRBP was evaluated by immunohistochemistry in a tissue microarray with 198 adrenocortical tumors [154 in adults (75 adenomas and 79 carcinomas) and 44 in children (38 clinically benign and 6 malignant)]. Expression of DICER1 and TARBP2 genes was assessed in a subgroup of 84 tumors (61 adults and 23 children) and miRNA expression in 82 tumors (59 adults and 23 children). The DICER1 and TARBP2 gene sequencing was performed in a subgroup of 83 tumors. RESULTS: In adults, a strong DICER1 expression was demonstrated in 39 out of 79 carcinomas (51%) and in 24 out of 75 adenomas...

Papel do LIN28, uma proteína ligadora de RNAs, na tumorigênese adrenocortical / Role of LIN28, an RNA-binding protein, in adrenocortical tumorigenesis

INTRODUÇÃO: O carcinoma adrenocortical é uma neoplasia rara que carreia um prognóstico reservado. Recentemente, uma série de estudos demonstrou o potencial do perfil de miRNAs na diferenciação entre adenomas e carcinomas adrenocorticais, estratificação de risco e prognóstico. Entretanto, pouco se sabe ainda sobre a regulação pós-transcricional de miRNAs. Nesse contexto, o LIN28 é uma proteína ligadora de RNAs altamente conservada que surgiu como um modulador do let-7, uma importante família de miRNAs amplamente conhecida por seus efeitos supressivos tumorais. Além do let-7, o LIN28 também mostrou regular e ser regulado pelo mir-9, mir-30 e mir-125. OBJETIVOS: Analisar a expressão gênica e proteica do LIN28 em uma grande coorte de tumores adrenocorticais (TACs) de adultos e pediátricos, além de investigar a variação no número de cópias dos genes LIN28A e LIN28B e a expressão dos miRNAs regulatórios do LIN28 (família let-7, mir-9, mir-30 e mir-125) em um subgrupo desta coorte. MÉTODOS: A expressão proteica do LIN28 foi avaliada em um total de 266 TACs de adultos (78 adenomas e 188 carcinomas) e 44 pediátricos (35 clinicamente benignos e 9 clinicamente malignos). A expressão dos genes LIN28A e LIN28B foi avaliada em um subgrupo de 86 TACs adultos e pediátricos e a análise da variação no número de cópias destes genes em 58 TACs. O estudo de expressão das famílias dos miRNAs let-7, mir-9, mir-30 e mir-125 foi realizado em 28 carcinomas adrenocorticais de adultos. RESULTADOS: Em adultos, o gene LIN28A mostrou-se hiperexpresso em carcinomas agressivos quando comparado a adenomas [7,0 (0 a 174,3) vs. 3,6 (0 a 18,3); p = 0,006, respectivamente] e observou-se uma tendência a maior expressão quando comparados a carcinomas não agressivos [7,0 (0 a 174,3) vs. 7,1 (0 a 17,1); p = 0,092]. A expressão do LIN28B foi negativa na grande maioria (92%) dos TACs de adultos. Curiosamente, uma imunorreatividade fraca para o LIN28 foi significativamente associada com...

INTRODUCTION: Adrenocortical carcinoma is a rare neoplasm with overall poor prognosis. Recently, several studies demonstrated the potential of miRNA profiling in differentiating between adrenocortical adenomas and carcinomas, risk stratification and prognosis. Nevertheless, little is known about posttranscriptional regulation of miRNAs. LIN28 is a highly conserved RNA-binding protein that has emerged as a modulator of the processing of let-7, an important family of miRNAs widely known for its tumor-suppressive effects. Besides from let-7, LIN28 has also shown to regulate and be regulated by mir-9, mir-30 and mir-125. OBJECTIVES: To analyze LIN28 gene and protein expression in a large cohort of adult and pediatric adrenocotical tumors (ACTs), and investigate the copy number variation analysis for LIN28A and LIN28B genes and the expression of LIN28 regulatory microRNAs (let-7 family, mir-9, mir-30 e mir-125) in a subgroup of this cohort. METHODS: LIN28 protein expression was assessed in a total of 266 adult (78 adenomas and 188 carcinomas) and 44 pediatric ACTs (35 clinically benign and 9 clinically malignant). LIN28A and LIN28B gene expression was evaluated in a subgroup of 86 adult and pediatric ACTs and copy number variation analysis of these genes in 58 ACTs. The expression of let-7 family, mir-9, mir-30 and mir-125 was performed in 28 adult carcinomas. RESULTS: In adults, LIN28A gene was overexpressed in aggressive carcinomas when compared with adenomas [7.0 fold change (from 0 to 174.3) vs. 3.6 (from 0 to 18.3); p = 0.006, respectively] and a trend towards greaten expression when compared with non-aggressive carcinomas [7.0 (from 0 to 174.3) vs. 7.1 (from 0 to 17.1); p = 0.092]. LIN28B expression was undetectable in the great majority (92%) of adult ACTs. Surprisingly, weak LIN28 staining was significantly associated with reduced disease-free survival in this population (p = 0.01), but for overall survival only a trend was detectable (p= 0.117). In...

Escore clínico-patológico para predizer o risco de metástases e recorrência local em pacientes com carcinoma cortical adrenal e papel do algoritmo da reticulina na distinção entre adenomas e carcinomas corticais adrenais / Clinicopathological score for predicting the risk of metastases and local recurrence in patients with adrenal cortical carcinoma and role of the reticulin algorithm in distinguishing between adrenal cortical adenomas and carcinomas

INTRODUÇÃO: o padrão-ouro para o diagnóstico histológico dos tumores corticais adrenais (TCAs) e sua diferenciação entre adenomas e carcinomas é o sistema de Weiss, cuja aplicação é limitada pela baixa reprodutibilidade de alguns dos critérios que o compõe. Recentemente foi proposto e validado um algoritmo diagnóstico para os TCAs baseado na integridade do arcabouço de reticulina e da membrana basal. Os carcinomas adrenais são tumores raros e apresentam prognóstico reservado, mesmo nos pacientes com doença aparentemente localizada. Além do estadiamento e da extensão da ressecção cirúrgica, outros dados foram reportados na literatura como tendo importância prognóstica, tais como idade ao diagnóstico, padrão funcional, tamanho tumoral, extensão local do tumor primário e alguns achados histológicos e imuno-histoquímicos, com destaque à taxa mitótica e ao índice de Ki-67. O sistema de Weiss, embora permita o diagnóstico diferencial entre adenomas e carcinomas, não foi testado completamente como uma ferramenta para distinguir os carcinomas com boa evolução clínica daqueles com desfecho desfavorável. OBJETIVOS: o presente estudo teve como objetivo primário construir um nomograma para estimar o risco de metástases e recorrência local em portadores de carcinoma adrenal, a partir de dados clínico-patológicos. O objetivo secundário foi avaliar o desempenho do algoritmo da reticulina no diagnóstico diferencial entre adenomas e carcinomas do córtex adrenal. MÉTODOS: para a construção do nomograma, foram analisados dados clínico-patológicos de 129 portadores de carcinomas adrenais atendidos no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo entre 1976 e 2010. A avaliação do desempenho do algoritmo da reticulina para o diagnóstico histológico dos TCAs foi feita a partir do exame de 89 lâminas (45 adenomas e 44 carcinomas adrenais)...

INTRODUCTION: The gold standard for the histological diagnosis of adrenal cortical tumors (ACTs) and for the differentiation between adenomas and carcinomas is the Weiss system, whose application is limited by poor reproducibility of some of its criteria. Recently, a diagnostic algorithm for ACT diagnosis based on the integrity of the reticulin network and the basal membrane has been proposed and validated. Adrenal carcinomas are rare tumors and have a poor prognosis, even in patients with apparently localized disease. Besides tumor staging and extent of surgical resection, other data have been reported in the literature as having prognostic importance, such as age at diagnosis, the functional pattern, tumor size, local extension of the primary tumor and some histological and immunohistochemical findings, such as the mitotic rate and the Ki-67 index. The Weiss system, while allowing the differential diagnosis between adrenal cortical adenomas and carcinomas, has not been fully tested as a tool for distinguishing carcinomas with favorable clinical outcome from those with unfavorable outcome. OBJECTIVES: The primary objective of this study was to construct a nomogram for estimating the risk of metastasis and local recurrence in patients with adrenal cortical carcinoma, based on clinical and pathological data. The secondary objective was to evaluate the performance of the reticulina algorithm in the differential diagnosis between adenomas and carcinomas of the adrenal cortex. METHODS: For the construction of the nomogram, clinical and pathological data from 129 patients with adrenal cortical carcinomas treated at the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo between 1976 and 2010 were analyzed. The evaluation of the performance of the reticulin algorithm for the histological diagnosis of ACTs was made from the examination of 89 slides (45 adenomas and 44 adrenal carcinomas)...

Carcinoma adrenal de rápida evolución / Rapidly evolving adrenal carcinoma

Introducción: el carcinoma suprarrenal primario es un tumor poco frecuente, altamente agresivo, de crecimiento rápido, con mayor incidencia entre los 40 y 60 años de edad. Los carcinomas funcionantes representan hasta un 79 por ciento de los tumores corticales, más frecuentes en el sexo femenino, y de estos el 50 por ciento se manifiestan clínicamente como un síndrome de Cushing. La extensión del tumor a estructuras vecinas es común y empeora el pronóstico. La supervivencia media es de 2 años desde el diagnóstico, en particular, cuando existen metástasis en hígado y pulmón. Objetivo: describir las características clínicas, los procederes diagnósticos y terapéuticos de una paciente con carcinoma adrenal de rápida evolución. Presentación del caso: paciente LRS, femenina, blanca, de 49 años de edad, con antecedentes de hipertensión arterial y diabetes mellitus tipo 2, que asiste a consulta por descontrol metabólico y de la hipertensión arterial. Al examen físico, se constatan signos sugestivos de hipercortisolismo, sintomatología que a los 2 meses se acentuó notablemente. Se realizaron estudios basales, dinámicos, imagenológicos y anatomopatológicos, que corroboraron el diagnóstico presuntivo. Se realiza adrenalectomía izquierda con adenectomía regional, y se confirma por anatomía patológica el diagnóstico de carcinoma suprarrenal izquierdo. A los pocos meses de la intervención la paciente fallece con metástasis óseas en columna vertebral. Conclusiones: el reconocimiento temprano de los síntomas y signos de hiperfunción adrenal es muy importante para el diagnóstico y tratamiento oportuno del carcinoma adrenal(AU)

Introduction: primary suprarrenal carcinoma is a highly aggressive rare carcinoma of rapid growth, with greater incidence in 40-60 years age group. The functioning carcinomas represent up to 79 percent of cortical tumors that are more frequent in females, and 50 percent of them clinically manifests as Cushing syndrome. The extension of the tumor to neighboring structures is common and worsens the prognosis. Mean survival rate is 2 years from the time of diagnosis, particularly when there are liver and lung metastases. Objective: to describe the clinical characteristics, the diagnostic and therapeutic procedures in a female patient with rapidly evolving adrenal carcinoma. Case presentation: a patient LRS, female, Caucasian, 49 years-old, with a history of blood hypertension and type 2 diabetes mellitus, who went to the hospital because of lack of metabolic control and blood hypertension. On physical examination, there were observed some signs suggestive of hypercortisolism, symptomatology that became notably acute two months later. Basal, dynamic, imaging and anatomopathological studies were made to corroborate the presumptive diagnosis. Left adrenalectomy with regional adenectomy was performed, and the diagnosis of left suprarenal carcinoma was confirmed through pathological anatomy. Few months later, the patient died from osseous metastasis in her spinal cord. Conclusions: early recognition of symptoms and signs of adrenal hyperfunction is very important for diagnosis and timely treatment of adrenal carcinoma(AU)