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Late relapse of adrenocortical carcinoma in Beckwith-Wiedemann syndrome. Clinical, endocrinological and genetic aspects
NT Hertel1, N Carlsen1, G Kerndrup2, IL Pedersen3, N Clausen4, JMD Hahnemann5 and BB Jacobsen1
Department of Paediatrics1 and the Institute of Pathology2, Odense University Hospital, Odense; Department of Paediatrics3, Herning Hospital, Herning; Department of Paediatrics4, Aarhus University Hospital, Skejby; Department of Medical Genetics5, The John F. Kennedy Institute, Glostrup, Denmark
Hertel NT, Carlsen N, Pedersen IL, Kerndrup G, Clausen N, Hahnemann JMD, Jacobsen BB. Late relapse of adrenocortical carcinoma in Beckwith-Wiedemann syndrome. Clinical, endocrinological and genetic aspects. Acta Paediatr 2003: 92: 439-443. Stockholm. ISSN 0803-5253
We report on a girl with an unusual Beckwith-Wiedemann syndrome (BWS) and hemihyper- trophy, who developed an adrenocortical carcinoma with atypical clinical behaviour. At 4 y of age the girls was admitted to hospital with cushingoid features, virilization, increased excretion of steroids and low serum ACTH. A right-sided adrenocortical carcinoma was removed. At age 12.5 y the cushingoid features reappeared together with a tumour in the left thigh. A CT scan of the thorax and abdomen revealed pulmonary metastasis only. Corticosteroid excretion was increased and serum ACTH level suppressed. The femoral and the pulmonary metastases were removed and histology showed adrenocortical carcinoma. Excretion of corticosteroids subsequently normalized. Meningeal and pulmonary metastases with similar histologies appeared one year later with normal hormone values. Twenty-two months after the recurrence the girl died of an intracranial metastasis. Southern blot analysis of the LIT1 transcript in the KvLQT1 gene in the BWS region on chromosome 11p15 revealed hypomethylation of the maternal allele.
Conclusion: Adrenocortical carcinoma in childhood may recur years after onset and at rare sites and hormonal levels may be an insufficient indicator of small metastases.
Key words: Adrenocortical carcinoma, Beckwith-Wiedemann syndrome, childhood, hemihyper- trophy, LIT1
Niels Thomas Hertel, Department of Paediatrics H, Odense University Hospital, DK-5000 Odense C, Denmark (Tel. +45 65 412 082, fax. +45 65 911 862, e-mail. thomas.hertel@dadlnet.dk)
Adrenal tumours are rare in childhood and symptoms in children consist primarily of virilization, but cushingoid symptoms are also seen (1). There is evidence for a strong genetic component in the aetiology of paediatric adrenocortical carcinoma (ADCC). ADCCs have a female preponderance, there is an increased risk of a secondary primary cancer after ADCC, and ADCC has been found with increased frequency in children with Beckwith-Wiedemann syndrome (BWS) or Li-Fraume- ni syndrome (2). Mutations in the tumour suppressor gene p53 or overexpression of the p53 protein are frequently found in these carcinomas (3).
Surgery is the principal mode of treatment. In the previously reported series median survival was found to range from 20 to 52 mo (2,4). To date, no alternative treatment has proved beneficial (5).
We report on an unusual case of a girl with hemihypertrophy, BWS and abnormal LIT1 methyla- tion who underwent radical surgery for an adrenocor- tical carcinoma at 4 y of age and who died of metastatic recurrence of the adrenocortical tumour at 14 y of age, eight years after the primary removal.
Case report
The patient was born normally at term after an uneventful pregnancy. Birthweight was 3750 g and length at birth 51 cm. The parents were healthy with no clinical indications and no family history of BWS or increased incidence of cancer.
The patient was followed clinically until 15 mo of age due to a right-sided hemihypertrophy and suspected BWS. There were, however, no signs of neonatal hypoglycaemia or external clinical characteristics com- patible with BWS. No routine ultrasound studies were done.
At the age of 4 y she was admitted to hospital owing to suspected Cushing syndrome, presenting with moon face, acne, hairy eyebrows, pubic hair development (Tanner stage II) and mild clitoromegaly; blood pressure was elevated (Table 1). Plasma glucose and electrolytes were normal. Ultrasound- (US) and a CT scan of the abdomen revealed an enlarged right adrenal gland. Urine analysis showed increased excretion of corticosteroids, mineralocorticoids and androgens
| At diagnosis | At recurrence | Following surgery for 1st relapse* | 2nd relapse* | Following surgery for 2nd relapse* | |
|---|---|---|---|---|---|
| Age (y) | 4.17 | 12.33 | 12.37 | 12.75 | 12.92 |
| Height (cm) | 98 | 145 | 145 | 150.5 | 153 |
| Weight (kg) | 17.6 | 41 | 41 | 38.4 | 38 |
| Body surface (m2) | 0.69 | 1.28 | 1.28 | 1.26 | 1.27 |
| Blood pressure (mmHg) | 145/105 | 129/69 | ND | 110/50 | ND |
| Urinary steroid levels. Normal ranges in parentheses | |||||
| Urinary free cortisol (nmol d-1 m2-1 - (n: 60-100 nmol d-1 m2-1)) | 1330 | 496 | 524 | 100 | 41 |
| Urinary cortisol metabolites# (mg 24 h-1) | 6.46 (0.5-2.5) | 9.45 (1-7) | 5.70 (1-7) | 3.41 (1-7) | 2.80 (1-7) |
| 17-OH ketosteroids# (mg 24 h-1) | 5.48 (<0.75) | 14.37 (0.5-3.7) | 7.07 (0.5-3.7) | 2.55 (0.5-3.7) | 0.86 (0.5-3.7) |
| Urinary corticosterone metabolitesª (mg 24 h-1) | 5.24 (0-1) | 4.91 (0-3) | 0.48 (0-3) | 0.00 (0-3) | 0.00 (0-3) |
| Serum levels | |||||
| ACTH (pmol L-1) (nl: 2-14) | 0.7 | <1 | 13 | 2 | 1 |
| DHEAS (nmol L-1) | 9400 (0-300) | 12700 (800-3200) | ND | 1100 (800-3200) | ND |
| Androstendione (nmol L-1) (nl: < 0.7) | 3.8 | ND | ND | ND | ND |
| Testosterone (nmol L-1) (nl: < 0.7) | 2.5 | 6.1 | ND | <0.7 | ND |
| Free testosterone (nmol L-1) (nl: 0.0008- 0.0131) | 0.051 | 0.10 | ND | <0.006 | ND |
| DHT (nmol L-1) (n: 0.1-0.89 (girls 9- | 0.29 | 0.71 | ND | ND | ND |
| 11 y)) | |||||
| Oestradiol (pmol L-1) | <40 | 38 | ND | 180 | ND |
* The patient was treated with hydrocortisone 2.5 mg three times a day during this period.
a Urinary cortisol metabolites were: tetrahydrocortisol (THF), allo-THF, tetrahydrocortisone (THE), alpha-cortolon and beta-cortolon.
# Urinary corticosterone metabolites were: tetrahydrocorticosterone (THB), allo-tetrahydrocorticosterone (allo-THB) and tetrahydro-11-dehydro- corticosterone (THA).
17-OH-ketosteroids were: androsterone, ethiocholanolon, dehydroepiandrosterone, 11-OH-androsterone, 11-OH-ethiocholanolon and 11-keto- ethiocholanolon.
nl = Normal reference values; ND = not measured.
(Table 1). Bone age a.m. Greulich-Pyle was one year retarded. An encapsulated tumour (6 x 5 cm) weighing 30 g was removed. Histology showed a malignant adrenocortical carcinoma with areas of glomerular and trabecular structure with numerous small vessels and nuclear pleomorphism as well as many mitoses. The tumour was microscopically radically removed and staged as pT2, N0, M0 (5). No radiotherapy or chemotherapy was given.
The clinical symptoms of Cushing’s syndrome disappeared. The girl was followed in the oncological outpatient clinic with repeated US studies for two years. Basal and stimulated cortisol values (by a Synacthen® test) were normal (data not shown).
At 12 y of age the girl was readmitted due to the development of a tumour in the left thigh. Cushingoid signs were noted (moon face, acne, barbae), axillary hair development stage III and pubic hair stage IV; no clitoromegaly was noted. Breast development (stage II) was seen, suggesting onset of puberty. US examination revealed a large tumour in the left thigh (m. adductor longis) and a CT scan of the thorax, abdomen and extremities showed a large tumour in the left lung. No abdominal tumours were found. Urinary steroid hor- mone excretion was increased 2-4 times above the normal age-related values; serum ACTH was sup- pressed (Table 1). Serum electrolytes were normal.
Bone age was still retarded by one year. A 9 x 7 x 6 cm large tumour weighing 206 g was removed from the left thigh, and a tumour measuring 8 x 4 x 4 cm weighing 110 g was removed from the left lung. Histological examination of both metastases showed adrenal carci- noma, with a histology similar to that of the primary tumour. The tumours were positive for synaptophysin, but negative for keratin, desmin, chromagranin, and S100. They displayed significant areas of necrosis, and a pleomorphic malignant tumour tissue with cytoplasm- rich cells with granular cytoplasm and with a high mitotic index (proliferation index of 39%) as well as local invasion and penetration of the pseudo-capsule.
After removal of the tumours in the thigh and left lung, the hormone levels normalized (Table 1).
Four months later, the left lung was removed due to two smaller metastases (measuring 25 and 14 mm in diameter). The histology had not changed. No steroid excess was found this time (Table 1), Further pubertal development was normal without any signs of viriliza- tion or hypercortisolism. One year later, signs of increased intracranial pressure developed, and two meningeal metastases in the right parietal and frontal region were removed. The largest measured 1.5 x 1.5 × 1 cm with the same histological pattern as the primary and all previous metastases. Four months later another metastasis was removed, this time from the
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left cerebellar region in the meninges. After a further 6 mo the girl died of a new intracranial metastasis.
Genetic investigations
Genetic analysis of the tumour tissue
Immunohistochemical analysis showed expression of the p53 protein in almost all the tumour cells. Cytogenetic analysis (G banding) of the thigh metas- tasis revealed a complex abnormal karyotype in 9 of 25 cells examined (Fig. 1). No abnormalities of 11p were found in the metastasis.
Chromosome analysis of the proband
The girl had a normal female karyotype 46,XX (lymphocytes, QFQ banding). The parents also had normal karyotypes.
Microsatellite DNA marker analysis
Genotyping proband and parents with a number of DNA markers showed normal biparental inheritance of chromosome 11p in the girl, thus excluding uniparental disomy (UPD). Three markers in 11p15 were informa- tive.
Methylation-specific Southern blot analysis of LIT1
A methylation-specific Southern blot analysis of the LIT1 transcript in the KvLQT1 gene in the BWS region in chromosome 11p15, as described by Mitsuya et al. (6), was carried out twice on genomic DNA extracted from blood leucocytes. The DNA was digested using the restriction endonucleases BamHI and NotI. The Southern blot analysis revealed an abnormal methyla- tion pattern with a hypomethylation of the maternal
allele (Fig. 2). This finding confirmed theclinical diagnosis of BWS.
Discussion
The patient described here had an unexpectedly aggressive and to some extent atypical course of disease. Most children with adrenocortical carcinoma present with virilization symptoms only, but in 30-50% a combined symptomatology has been found, as in our case (4, 7). The initial tumour was classified as a stage I tumour according to Sandrini et al. (7) suggesting a good prognosis. However, in our patient metastases were found in the left thigh and lung after 8 event-free years. Several metastases subsequently developed in the left lung and intracranially, all of which were removed surgically. The metastatic spread of this tumour is generally local, in regional lymph nodes or in the liver or lungs (7). Our patient, however, had metastases in the left thigh and lung at recurrence and later on developed intracranial metastases. To our knowledge, a muscular metastasis from an adrenocortical carcinoma has not been reported before. Intracranial metastases in children with adrenocortical carcinoma are rare, with only three reported cases (8, 9). Median survival is poor but long- term survival has been reported in several patients following surgery (2). A relapse as late as that seen in our patient has only previously been reported in a patient who developed a local relapse 11 y after surgery (8). No information on genetic mutations exists in that patient.
The original adrenal tumour in our patient weighed 30 g, but behaved malignantly, which contrasts with a former study where tumour behaviour was benign in tumours weighing less than 150 g (10). We suggest that
ADCC in children with BWS or other genetic cancer predisposition may behave more aggressively.
At birth, the patient was suspected of having BWS due to hemihypertrophy. BWS in general is associated with alterations in two imprinting domains on chromo- some 11p15, where the telomeric domain includes the genes H19 and IGF2, and the centromeric domain includes the LIT1 transcript in the KvLQT1 gene, and the CDKNIC gene. After the discovery of an abnormal methylation pattern in LIT1 in up to 50% of BWS patients (6, 11), we confirmed the clinical diagnosis of BWS in our patient by LIT1 analysis. It is well documented that BWS patients have an increased risk of childhood tumours, including Wilms’ tumour, adrenocortical carcinoma, and other neoplasias. Two studies have suggested that the tumour predisposition is related to abnormal H19 methylation, with or without UPD of 11p15, while BWS patients with LIT1 hypomethylation only, without UPD, do not have an increased risk of tumours (12, 13). Another recent study, however, found that patients with abnormalities in the centromeric imprinting domain on 11p15, including patients with hypomethylation of the CpG island KvDMR1 in the LIT1, also have an increased risk of tumours. In addition, Weksberg et al. (14) observed that the type of tumours in BWS patients with telomeric alterations differed from those with centromeric altera- tions, with Wilms’ tumour dominating in the telomeric group, and other tumours such as hepatoblastoma, rhabdomyosarcoma and gonadoblastoma in the centro- meric group. The occurrence of an adrenocortical carcinoma in our patient with isolated LIT1 hypo- methylation supports the observations by Weksberg et al. Future increased knowledge about the genetic basis of BWS and genotype phenotype correlations may be of importance for planning clinical control in patients suspected of having BWS. The karyotype of the metastasis revealed a complex pattern in accordance with other reports on the karyotype in primary adrenocortical carcinoma (15). However, no aberration of chromosome 11p15 was encountered in the metas- tasis, as has been described for adrenocortical carcino- mas (16). The p53 protein was expressed in the metastasis, suggesting a somatic p53 gene mutation, as reported elsewhere (17). Mutations in the p53 gene have been described in adrenocortical tumours, but they have also been found in a large proportion of other cancers and as such are not considered to be specific for the development of tumours in BWS (18).
The tumour in our patient was originally endocrino- logically active, as demonstrated by the clinical symptoms and biochemical analyses at diagnosis. At the time of the first recurrence the patient also demonstrated virilization and cushingoid symptoms and increased excretion of urinary steroid metabolites with suppressed serum ACTH. After removal of both the femoral metastasis and the lung metastases, the urinary steroid output normalized. However, hormonal
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levels may be an insufficient indicator of small metastases, as increased excretion of steroids was not found at the time of the later relapses. This could be due to either a progressive change in the function of the tumour cells, or a reduction in the amount of tumour tissue (at first recurrence the tumour weighed 300 g and at later relapses less than 10 g). Other authors have also suggested tumour size as the determining factor for the magnitude of steroid production (2).
This report demonstrates that adrenocortical carcino- ma in childhood may recur many years after onset and at rare sites and that long-term follow-up including genetic and imaging studies thus seem mandatory in these children.
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Received Mar. 13, 2002; revision received Oct. 4, 2002; accepted Oct. 21, 2002