title: Histopathological and genetic characterization of aldosterone-producing adenomas with concurrent subclinical cortisol hypersecretion: a case series.
abstract: OBJECTIVE
  Aldosterone-producing adenomas with concurrent subclinical cortisol hypersecretion are reported in an increasing number of patients. Five aldosterone-producing adenomas from patients with primary aldosteronism and subclinical hypercortisolism were examined.
  
  
  OBJECTIVE
  (1) to analyze pathological features and immunohistochemical expression of CYP11B1 (11β-hydroxylase) and CYP11B2 (aldosterone synthase) in these tumors; (2) to investigate somatic mutations involved in adrenal steroid hypersecretion and/or tumor growth.
  
  
  METHODS
  Archival micro-dissected paraffin-embedded slides from tumor specimens were used for histological and molecular studies. Immunohistochemistry was performed using monoclonal anti-CYP11B1 and anti-CYP11B2 antibodies. Cellular composition was determined by examining for known features of zona fasciculata and zona glomerulosa, and immunoreactivity for CYP11B1 and CYP11B2 by McCarty H-score. Spot regions for mutations in KCNJ5, ATP1A1, ATP2B3, CACNA1D, PRKACA, and CTNNB1 gene sequences were evaluated.
  
  
  RESULTS
  Four APAs showed a predominant (≥50%) zona fasciculata-like cell pattern: one tumor had CYP11B1 H-score = 150, no detectable CYP11B2 expression, and harbored a PRKACA p.Leu206Arg mutation (that we have reported previously elsewhere), one had no CYP11B1 expression, CYP11B2 H-score = 40, and no mutations; the remaining two adenomas had high CYP11B1 H-score (160 and 240, respectively) and low CYP11B2 H-score (30 and 15, respectively), with the latter harboring a CTNNB1 p.Ser45Phe activating mutation. One of five aldosterone-producing adenomas had a predominant zona glomerulosa-like pattern, CYP11B1 H-score = 15, CYP11B2 H-score = 180, and no mutations.
  
  
  CONCLUSIONS
  The majority of aldosterone-producing adenomas with concurrent subclinical cortisol hypersecretion were composed mainly of zona fasciculata-like cells, while CYP11B1 and CYP11B2 immunostaining demonstrated clear heterogeneity. In a subset of cases, different somatic mutations may be involved in hormone excess and tumor formation.
authors.affiliation: Clinica Medica 3, Department of Medicine, University of Padova, Padova, Italy. francesco.fallo@unipd.it.
authors.forename: Francesco
authors.identifier: http://orcid.org/0000-0002-7511-0226
authors.initials: F
authors.lastname: Fallo
authors.affiliation: Division of Pathology, Department of Medical Sciences, University of Torino, Torino, Italy.
authors.forename: Isabella
authors.initials: I
authors.lastname: Castellano
authors.affiliation: Endocrine Section, G.V. (Sonny) Montgomery VA Medical Center and University of Mississipi Medical Center, Jackson, MS, USA.
authors.forename: Celso E
authors.initials: CE
authors.lastname: Gomez-Sanchez
authors.affiliation: Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität, Munich, Germany.
authors.forename: Yara
authors.initials: Y
authors.lastname: Rhayem
authors.affiliation: Clinica Medica 3, Department of Medicine, University of Padova, Padova, Italy.
authors.forename: Catia
authors.initials: C
authors.lastname: Pilon
authors.affiliation: Endocrinology Unit, University of Bologna, Bologna, Italy.
authors.forename: Valentina
authors.initials: V
authors.lastname: Vicennati
authors.affiliation: Pathology Unit, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy.
authors.forename: Donatella
authors.initials: D
authors.lastname: Santini
authors.affiliation: Cytopathology Unit, Department of Medicine, University of Padova, Padova, Italy.
authors.forename: Valeria
authors.initials: V
authors.lastname: Maffeis
authors.affiliation: Cytopathology Unit, Department of Medicine, University of Padova, Padova, Italy.
authors.forename: Ambrogio
authors.initials: A
authors.lastname: Fassina
authors.affiliation: Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Torino, Torino, Italy.
authors.forename: Paolo
authors.initials: P
authors.lastname: Mulatero
authors.affiliation: Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität, Munich, Germany.
authors.forename: Felix
authors.initials: F
authors.lastname: Beuschlein
authors.affiliation: Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität, Munich, Germany.
authors.forename: Martin
authors.initials: M
authors.lastname: Reincke
mesh_terms: D000236:Adenoma / Q000235:genetics / Q000378:metabolism* / Q000473:pathology*; D000311:Adrenal Glands / Q000473:pathology; D018246:Adrenocortical Adenoma / Q000235:genetics / Q000378:metabolism* / Q000473:pathology*; D000328:Adult; D000368:Aged; D000450:Aldosterone / Q000378:metabolism*; D014408:Biomarkers, Tumor / Q000032:analysis / Q000235:genetics; D019405:Cytochrome P-450 CYP11B2 / Q000097:blood / Q000235:genetics; D005260:Female; D006801:Humans; D006854:Hydrocortisone / Q000097:blood* / Q000378:metabolism; D006929:Hyperaldosteronism / Q000209:etiology / Q000378:metabolism / Q000473:pathology; D007150:Immunohistochemistry; D008297:Male; D008875:Middle Aged; D013252:Steroid 11-beta-Hydroxylase / Q000097:blood / Q000235:genetics; D015383:Zona Fasciculata / Q000378:metabolism / Q000473:pathology
chemical_list: D014408:Biomarkers, Tumor; D000450:Aldosterone; D019405:Cytochrome P-450 CYP11B2; D013252:Steroid 11-beta-Hydroxylase; D006854:Hydrocortisone
keywords: Aldosterone-producing adenoma; Histopathology; Subclinical hypercortisolism