title: Clinical and genetic heterogeneity, overlap with other tumor syndromes, and atypical glucocorticoid hormone secretion in adrenocorticotropin-independent macronodular adrenal hyperplasia compared with other adrenocortical tumors.
abstract: OBJECTIVE
  ACTH-independent macronodular adrenal hyperplasia (AIMAH) is often associated with subclinical cortisol secretion or atypical Cushing's syndrome (CS). We characterized a large series of patients of AIMAH and compared them with patients with other adrenocortical tumors.
  
  
  METHODS
  We recruited 82 subjects with: 1) AIMAH (n = 16); 2) adrenocortical cortisol-producing adenoma with CS (n = 15); 3) aldosterone-producing adenoma (n = 19); and 4) single adenomas with clinically nonsignificant cortisol secretion (n = 32).
  
  
  METHODS
  Urinary free cortisol (UFC) and 17-hydroxycorticosteroid (17OHS) were collected at baseline and during dexamethasone testing; aberrant receptor responses was also sought by clinical testing and confirmed molecularly. Peripheral and/or tumor DNA was sequenced for candidate genes.
  
  
  RESULTS
  AIMAH patients had the highest 17OHS excretion, even when UFCs were within or close to the normal range. Aberrant receptor expression was highly prevalent. Histology showed at least two subtypes of AIMAH. For three patients with AIMAH, there was family history of CS; germline mutations were identified in three other patients in the genes for menin (one), fumarate hydratase (one), and adenomatosis polyposis coli (APC) (one); a PDE11A gene variant was found in another. One patient had a GNAS mutation in adrenal nodules only. There were no mutations in any of the tested genes in the patients of the other groups.
  
  
  CONCLUSIONS
  AIMAH is a clinically and genetically heterogeneous disorder that can be associated with various genetic defects and aberrant hormone receptors. It is frequently associated with atypical CS and increased 17OHS; UFCs and other measures of adrenocortical activity can be misleadingly normal.
authors.affiliation: Section on Endocrinology and Genetics, Program on Developmental Endocrinology and Genetics, National Institute of Child Health and Human Development, National Institutes of Health, 10 Center Drive, Bethesda, MD 20892, USA.
authors.forename: Hui-Pin
authors.initials: HP
authors.lastname: Hsiao
authors.forename: Lawrence S
authors.initials: LS
authors.lastname: Kirschner
authors.forename: Isabelle
authors.initials: I
authors.lastname: Bourdeau
authors.forename: Margaret F
authors.initials: MF
authors.lastname: Keil
authors.forename: Sosipatros A
authors.initials: SA
authors.lastname: Boikos
authors.forename: Somya
authors.initials: S
authors.lastname: Verma
authors.forename: Audrey J
authors.initials: AJ
authors.lastname: Robinson-White
authors.forename: Maria
authors.initials: M
authors.lastname: Nesterova
authors.forename: André
authors.initials: A
authors.lastname: Lacroix
authors.forename: Constantine A
authors.initials: CA
authors.lastname: Stratakis
mesh_terms: D000302:Adrenal Cortex / Q000473:pathology*; D000306:Adrenal Cortex Neoplasms / Q000235:genetics* / Q000378:metabolism; D000324:Adrenocorticotropic Hormone / Q000502:physiology*; D000328:Adult; D002864:Chromogranins; D003346:Corticotropin-Releasing Hormone; D003907:Dexamethasone / Q000494:pharmacology; D005260:Female; D019205:GTP-Binding Protein alpha Subunits, Gs / Q000235:genetics; D018740:Genetic Heterogeneity; D005938:Glucocorticoids / Q000378:metabolism*; D006801:Humans; D006965:Hyperplasia; D008297:Male; D008875:Middle Aged
chemical_list: D002864:Chromogranins; D005938:Glucocorticoids; D003907:Dexamethasone; D000324:Adrenocorticotropic Hormone; D003346:Corticotropin-Releasing Hormone; C406732:GNAS protein, human; D019205:GTP-Binding Protein alpha Subunits, Gs