Histopathology 2013, 62, 771-777. DOI: 10.1111/his.12083
Primary rhabdoid adrenocortical carcinoma: a clinicopathological and immunohistochemical study of three cases
Annikka Weissferdt, Alexandria Phan,1 Saul Suster2 & Cesar A Moran
Department of Pathology, MD Anderson Cancer Center, Houston, TX, 1 Department of GI Medical Oncology, MD Anderson Cancer Center, Houston, TX, and 2 Department of Pathology, Medical College of Wisconsin, Milwaukee, WI, USA
Date of submission 29 October 2012 Accepted for publication 6 December 2012
Weissferdt A, Phan A, Suster S & Moran C A (2013) Histopathology 62, 771-777
Primary rhabdoid adrenocortical carcinoma: a clinicopathological and immunohistochemical study of three cases
Aims: We describe three cases of primary adrenocor- tical carcinoma (ACC) with prominent rhabdoid fea- tures and study their clinicopathological and immunohistochemical properties.
Methods and results: The patients were three females aged 45-55 years (mean 49 years), none of whom had any hormone-related symptoms. Histologically, the characteristic features were rhabdoid tumour cells with prominent eosinophilic cytoplasmic inclusions, eccentric vesicular nuclei and prominent nucleoli. Areas of more conventional ACC were present in all cases. Immunohistochemically, the rhabdoid compo- nent showed a similar staining pattern to conven- tional ACC, being positive for steroid receptor cofactor 1, inhibin, melan A, calretinin and synaptophysin, while negative for high molecular weight cytokeratin
and Pax8. In addition, antimitochondrial antibodies showed a weak reaction and nuclear expression of in- tegrase interactor 1 (INI1) was preserved. Clinical fol- low-up information for two patients demonstrated that one patient was alive 237 months after diagno- sis, and one patient had died of disease 4 months after diagnosis.
Conclusions: ACC with rhabdoid features are rare tumours that seem to mirror the clinical and immu- nohistochemical features of conventional ACC. In addition, they appear to display similar biological behaviour. Adrenocortical carcinoma should be included in the differential diagnosis when evaluating tumours of unknown origin with rhabdoid morphol- ogy.
Keywords: adrenocortical carcinoma, endocrine tumour, immunohistochemistry, rhabdoid change
Introduction
Tumours with rhabdoid morphology are a diverse group of neoplasms. The quintessential prototype of tumours composed of rhabdoid cells is the malignant rhabdoid tumour of infancy, a solid tumour of child- hood that commonly affects children under 2 years of
age.1-6 These tumours can occur in virtually any anatomical site, but arise most often in the kidney or the soft tissues. Classically, malignant rhaboid tumours grow in a discohesive and patternless arrangement of cells. The archetypical cytomorpholo- gy of these tumours is characterized by a monoto- nous proliferation of polygonal cells with eccentric nuclei, large nucleoli and abundant cytoplasm con- taining eosinophilic globular inclusions. Ultrastructur- al findings typically include large cytoplasmic whorls of intermediate filaments displacing the nucleus to
Address for correspondence: A Weissferdt MD, FRCPath, Depart- ment of Pathology, MD Anderson Cancer Center, Houston, TX 77030, USA. e-mail: aweissferdt@doctors.org.uk
the periphery, and large nucleoli which exhibit large nucleolonemata.5 In addition to the typical cytomor- phology, malignant rhabdoid tumours are defined essentially by inactivation of the tumour suppressor gene integrase interactor 1 (INI1),7,8 which correlates with loss of INI1 protein expression. However, malig- nant rhabdoid tumours are not the only tumours showing rhabdoid cytomorphology. Similar histologi- cal findings are shared with a variety of adult tumours, most often metastatic melanoma,9-11 malig- nant mesothelioma12 and various types of carci- noma.13-16 However, these tumours usually display a classifiable ‘parent’ component and nearly always lack the characteristic INI1 gene alteration.2,5,8
To date, rhabdoid features in adrenocortical neo- plasms have been the subject only of sporadic case reports.17,18 During a review of a series of adrenocor- tical carcinoma (ACC), we identified three cases showing extensive rhabdoid features. The clinical, histopathological and immunohistochemical charac- teristics of these tumours are discussed in this study.
Materials and methods
During a review of 77 cases of ACC, three cases (3.9%) with rhabdoid features were identified from the surgical pathology files of the MD Anderson Can- cer Center, Houston, Texas and the Medical College of Wisconsin, Milwaukee, Wisconsin. Haematoxylin and eosin (H&E)-stained sections from adrenalectomy specimens were available for review in each case. Representative paraffin blocks were available in all cases for immunohistochemical studies. Deparaffinized tissue sections were incubated with antibodies direc- ted against high molecular weight cytokeratin (HMWCK; Dako, Carpinterina, CA, USA; 1:50), CAM5.2 (BD Biosciences, San Jose, CA, USA; 1:50), inhibin (AbD Serotec, Raleigh, NC, USA; 1:50), melan A (Novocastra, Buffalo Grove, IL, USA; 1:25), chro- mogranin (Dako; 1:100), synaptophysin (Dako; 1:200), calretinin (Invitrogen, Carlsbad, CA, USA; 1:40), steroid receptor cofactor 1 (SRC-1; Cell Sig- naling, Danvers, MA, USA; 1:100), Pax8 (Protein Tech, Chicago, IL, USA; 1:100) antimitochondrial antigen (Biogenex, Freemont, CA, USA; 1:500), Ki67 (Dako; 1:200) and INI1 (BD Biosciences; 1:50) using the polymeric biotin-free horseradish peroxidase method. Appropriate negative and posi- tive controls were run for all antibodies tested. Clin- ical and follow-up information was obtained from the patients’ charts or from referral information where available.
Results
CLINICAL FEATURES
The main clinical features are summarized in Table 1. The patients were three women aged 45-55 years (mean 49 years). None of the patients presented with symptoms related to hormone secretion. One patient presented with pulmonary embolism due to tumour thrombosis and two patients complained of flank/ abdominal pain. The left adrenal gland was affected in two cases and the right adrenal gland in one case. Only one patient had a history of previous malig- nancy (breast cancer). Pre-operative staging accord- ing to the 7th edition of the American Joint Committee on Cancer (AJCC) Cancer Staging Manual showed that one patient had T4 and another T2 dis- ease; for one patient no staging information was available. Treatment consisted of adrenalectomy in all cases. Adjuvant chemotherapy was not administered in any of the cases.
GROSS FEATURES
The lesions were described as variably encapsulated tumours with lobulated or bosselated, fleshy, tan-yel- low cut surfaces, ranging in size from 7 to 10.5 cm. Weight information was recorded for only one case (154 g). Areas of necrosis and haemorrhage were a frequent finding. Yellow-golden strips of normal adre- nal gland tissue were identified in two cases.
HISTOLOGICAL FEATURES
The histological features were similar in all cases. At low magnification all tumours exhibited either diffuse or alveolar growth patterns (Figure 1A). At higher power, all tumours were composed of medium-sized to large tumour cells with eosinophilic cytoplasmic inclusions and large eccentric vesicular nuclei with prominent eosinophilic nucleoli (Figure 1B,C). In some areas the cells demonstrated peripheral cyto- plasmic vacuolation, with formation of so-called ‘spi- der cells’ (Figure 1D). Scattered multinucleate cells or bizarre tumour cells were identified in all cases. This rhabdoid change was seen in 70-90% of the tumour volume submitted. The mitotic count ranged from 2 to more than 14 mitoses per 10 high-power fields (Figure 1E). Atypical mitotic forms were identified in one of the cases. Tumour necrosis was present in all cases, ranging from 10 to 60%. Areas of more con- ventional ACC characterized by eosinophilic or lipid- rich clear cells were present in all cases as a minor
| Case | Sex | Age (years) | Functional state | Laterality | Tumour stage | Tumour size (cm) | Tumour weight (g) | Rhabdoid cells (%) | Mitoses (per 10 | HPF) | Atypical mitoses | Necrosis (%) | Vascular invasion | Haemorrhage (%) | Follow- up |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | F | 55 | NF | Right | T4 | 10.5 | NK | 70 | 14 | Present | 60 | Present | 10 | Deceased at 4 months | |
| 2 | F | 45 | NF | Left | T2 | 7 | 154 | 90 | 2 | Absent | 10 | Absent | 0 | A&W at 237 months | |
| 3 | F | 47 | NK | Left | NK | NK | NK | 90 | 4 | Absent | 15 | Absent | 0 | NK |
F, Female; NK, Not known; NF, Non-functioning; HPF, High-power fields; A&W, Alive and well.
component. A small rim of normal adrenal gland was present in two cases.
IMMUNOHISTOCHEMICAL FEATURES
Immunohistochemical studies were performed in all cases. All three cases were positive for SRC-1, inhibin, and calretinin, while melan A and synaptophysin positivity was only observed in two cases (Figure 2A- D). CAM5.2 was expressed focally and weakly in all cases. Negative markers included HMWCK, chro- mogranin and Pax8. The Ki67 proliferative index ranged from <5% to 10%. Antimitochondrial antibod- ies showed focal weak staining in all cases, while INI1 expression was retained throughout (Figure 2E-
F).
CLINICAL FOLLOW -UP
Follow-up information available for two patients dem- onstrated that one patient was alive and well with a follow-up period of 237 months, while the other patient had died of her disease after only 4 months. One patient was lost to follow-up (Table 1).
Discussion
ACC are rare tumours of the adrenal cortex, with an incidence of 0.7-2 cases per million population.19 Their rarity has so far prevented large-scale research, and to date no standardized treatment exists despite their aggressive clinical behaviour. From a morpho- logical viewpoint, a wide range of architectural pat- terns can be displayed by these tumours, and variants incorporated into the World Health Organi- zation (WHO) classification of 2004 include onco- cytic, myxoid and sarcomatoid ACC.20
During a recent review of a large series of ACC, we identified three cases that showed prominent rhabd- oid changes as a major tumour component. These tumours appeared to be a morphologically distinct subtype of ACC that, to date, has not been character- ized fully. Only two previous case reports mention rhabdoid features in association with adrenocortical neoplasms. In the first of these publications, Dundr et al.17 described an adrenocortical tumour detected in a 16-year-old girl that was composed of equal proportions of rhabdoid cells arranged in solid and trabecular patterns, as well as more conventional tumour cells with eosinophilic cytoplasm and solid growth. A third, minor tumour component com- posed of lipid-rich tumour cells was also apparent.
A
B
C
D
E
A
B
C
C
D
E
F
Immunohistochemically, all tumour cells were positive for vimentin, synaptophysin, melan A and inhibin. Although this tumour displayed increased mitotic activity and focal necrosis, based on specific criteria for malignancy in adrenocortical neoplasms in children the tumour was placed in the benign cat- egory (adrenocortical adenoma). A few years later, rhabdoid change was also noted in an ACC affecting a 57-year-old male patient.18 In this report, histologi- cal examination revealed a tumour composed of large nests of rhabdoid tumour cells and no evidence of any clear cell component more typical for conven- tional ACC. The tumour cells were positive for vimen- tin, showed perinuclear staining for pancytokeratin and also expressed CD10. Conversely, inhibin, MART1 and synaptophysin were reported as nega- tive. Ultrastructural examination revealed cytoplasmic collections of intermediate filaments and occasional paranuclear bundles of tonofilament typical for rhabdoid change. In addition, the tumours were investigated immunohistochemically for the INI1 gene product with positive results, excluding a diag- nosis of a genuine primary rhabdoid tumour. Based on these findings, the tumour was classified as pri- mary ACC with rhabdoid differentiation.
In the present report, we describe three cases of ACC with prominent rhabdoid changes. Based on our experience, these tumours appear to be a rare sub- type amounting to fewer than 4% of ACC. When compared to conventional ACC, our cases show cer- tain similarities in terms of female preponderance, age at presentation, presenting symptoms, gross fea- tures and immunohistochemical phenotype.19,21 Whether or not they also mirror conventional ACC in terms of survival is difficult to establish based on the limited number of cases; however, it seems that at least some can display an aggressive clinical course as shown by one of our patients, who died after just 4 months. This is in keeping with the biological behaviour of ACC in general. ACC are aggressive neo- plasms that often show recurrence or early metastasis and a mean survival of <30 months.22-24 In addition, rhabdoid change in general has been proposed to rep- resent divergent differentiation of a subset of tumour cells reflecting clonal progression to a more aggres- sive biological state.5 Whether the rhabdoid variant of ACC is associated with even worse outcome than the conventional type, as has been proposed for rhabdoid variants of other tumours, remains to be seen, and warrants further studies with a larger patient population (Table 2). The less aggressive behaviour in one of our cases compared to the other that showed a more expected clinical course can
| Survival | (<30 months) Poor | Can be poor | |||||
|---|---|---|---|---|---|---|---|
| A, | (+/-): | HMWCK, Pax8 | AB (-) | ||||
| chemistry Immunohisto- | (+): SRC1, melan inhibin, calretinin, | synaptophysin CAM5.2 (-): chromogranin, | antimitochondrial As above (+) INI1 | ||||
| or clear oncocytic, | sarcomatoid | ||||||
| Histology | Eosinophilic cells; | myxoid, subtypes | Rhabdoid cells | ||||
| nested, | |||||||
| or | |||||||
| rhabdoid ACC | Growth pattern | Diffuse, trabecular, | cord-like | Diffuse alveolar g | |||
| g | 154 | ||||||
| (ACC) and | and (g) | 428 | cm; | ||||
| (cm) | cm; | ||||||
| size Tumour weight | 11.4 | 7-10.5 | |||||
| carcinoma | Functioning | functioning | |||||
| Functional | (50-60%) | ||||||
| state | Non- | ||||||
| adrenocortical | decade | decade | |||||
| conventional | (years) Age | 5th | 5th | ||||
| of | 1.5:1 | ||||||
| = | |||||||
| Comparison | Sex | F:M | F | ||||
| ACC | |||||||
| Table 2. | of | ||||||
| Type | Conventional | Rhabdoid | |||||
F, Female; M, Male; SRC1, Steroid receptor cofactor 1; HMWCK, High molecular weight cytokeratin; AB, Antibody.
probably be attributed to the lower clinical stage at presentation, as well as low mitotic activity and absence of any invasive features (Table 1). Interest- ingly, the percentage of rhabdoid cells did not seem to correlate with outcome in our cases.
Recognition of the occurrence of rhabdoid change in ACC is important for the differential diagnosis of these tumours. Neoplasms that can mimic rhabdoid ACC include primarily the malignant rhabdoid tumour, rhabdoid renal cell carcinoma, rhabdomyo- sarcoma and the oncocytic variant of ACC. Although all these tumours may share overlapping morphologi- cal features, there are certain clinical, immunohisto- chemical or molecular characteristics that allow their distinction. Malignant rhabdoid tumours affect a pae- diatric population almost exclusively, and display a distinct mutation involving the tumour suppressor gene INI1. None of our patients belonged to the pae- diatric age group, and retained expression of INI1 by immunohistochmemical staining excluded such a diagnosis. Renal cell carcinomas with rhabdoid change enter the differential diagnosis based on their close anatomical relationship with the adrenal gland. Renal cell carcinomas will not usually show immuno- reactivity for markers associated typically with ACC such as SRC-1, inhibin, calretinin and melan A, but often express Pax8, a marker which was negative in all of our cases. In a similar fashion, rhabdomyosar- comas would not be expected to show the immuno- histochemical phenotype typical for ACC that was present in our cases but, rather, would demonstrate clear-cut myoid differentiation. The most difficult dif- ferential diagnosis in this scenario is the separation of rhabdoid ACC from oncocytic ACC. The latter are a distinct subset of ACC that are thought to pursue a more favourable clinical course than conventional ACC.25 Hence, separation from rhabdoid ACC becomes important, as at least one of our cases dem- onstrated a similarly aggressive biological behaviour to conventional ACC. In oncocytic ACC the tumour cells are usually arranged in a diffuse pattern and dis- play cells with abundant granular eosinophilic cyto- plasm, central nucleus and at least focal high-grade nuclear atypia. In this context, immunohistochemis- try with antimitochondrial antibody can help to rec- ognize oncocytic differentiation reflected by strong, diffuse and granular staining of the tumour cells. Conversely, it should be noted that weak staining with this antibody can be seen in the normal adrenal cortex and conventional ACC due to the presence of increased mitochondria in steroidogenic cells. Strong and diffuse staining typical for oncocytic neoplasms is not expected in the rhabdoid variant of ACC, in
which the rhabdoid change is thought to represent paranuclear accumulation of intermediate filaments.
In summary, we have presented a series of three cases of ACC with prominent rhabdoid features and have described their clinicopathological and immuno- histochemical properties. This study expands the spec- trum of morphological variants of ACC and neoplasms with rhabdoid features in general. It is important to recognize this subtype and separate it from oncocytic ACC, as these two variants may dis- play different biological behaviour.
Competing interests
None.
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