Assessment of prognostic factors in pediatric adrenocortical tumors: a systematic review and evaluation of a modified S-GRAS score
Maria Riedmeier1, Boris Decarolis2, Imme Haubitz1, Joachim Reibetanz3, Armin Wiegering(D3,4,5, Christoph Härtel1,5, Paul-Gerhardt Schlegel1,5, Martin Fassnacht D5,6 and Verena Wiegering D1,5
1Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, Department of Pediatrics, University Hospital, University of Wuerzburg, Wuerzburg, Germany, 2Department of Pediatric Oncology and Hematology, University Children’s Hospital of Cologne, Medical Faculty, Cologne, Germany, 3Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital, University of Wuerzburg, Wuerzburg, Germany, 4Department of Biochemistry and Molecular Biology, University of Wuerzburg, Wuerzburg, Germany, 5Comprehensive Cancer Centre Mainfranken, University of Wuerzburg Medical Centre, Wuerzburg, Germany, and 6Division of Endocrinology and Diabetes, Department of Medicine, University Hospital, University of Wuerzburg, Wuerzburg, Germany
Correspondence should be addressed to V Wiegering
Abstract
Objective: Pediatric adrenocortical carcinoma (pACC) is rare and prognostic stratification remains challenging. We summarized the clinical prognostic factors of pACC and determined the prognostic value of the pediatric scoring system (pS-GRAS) in adaption to the recommendation (S-GRAS) of the European Network for the Study of Adrenal Tumors for the classification of adult ACC.
Design: Analysis of pACC patients of 33 available retrospective studies in the literature.
Methods: We searched the PubMed and Embase databases for manuscripts regarding pACC. The pS-GRAS score was calculated as a sum of tumor stage (1 = 0; 2-3 = 1; 4 = 2 points), grade (Ki67 index/rate of mitosis 0-9%/low = 0; 10-19%/intermediate = 1; ≥20%/high = 2 points), resection status (RO = 0; RX = 1; R1 = 2; R2 = 3 points), age (<4 years = 0; ≥4 years = 1 point), hormone-related symptoms (androgen production = 0; glucocorticoid/mixed/no hormone production = 1 point) generating 10 scores and 4 groups (1: 0-2, 2: 3-4, 3: 5, 4: 6-9). The primary endpoint was overall survival (OS).
Results: We included 733 patients. The median age was 2.5 years and >85% of pACC showed hormone activity (mixed 50%, androgen 29%, glucocorticoid 21%). Androgen production was associated with a superior OS. Increasing age correlated with higher rates of inactive or only glucocorticoid-producing tumors, advanced tumor stage, and case fatality. Especially infants < 4 years showed more often low-risk constellations with an increased OS for all tumor stages. The pS-GRAS score correlated with clinical outcome; median OS was 133 months (95% CI: 36-283) in group 1 (n = 49), 110 months (95% CI: 2.9-314) in group 2 (n = 57), 49 months (95% CI: 5.8-278) in group 3 (n = 18), and 16 months (95% CI: 2.4-267) in group 4; (n = 11) P < 0.05).
Conclusion: The pS-GRAS score seems to have a high predictive value in the pACC patients, may serve as a helpful tool for risk stratification in future studies, and should be evaluated prospectively in an international context.
European Journal of Endocrinology (2022) 187, 751-763
Introduction
Pediatric adrenocortical carcinoma (pACC) is a rare malignancy with an estimated incidence of 1 per 1 000 000 children per year (1). The pathogenesis of pACC is not completely understood. According to current knowledge, pACC is strongly associated with heritable TP53-related cancer syndromes - such as Li-Fraumeni syndrome - mainly due to a specific inherited germline mutation at codon 337 in the TP53 suppressor gene. Up to 80% of patients, particularly in southern Brazil, have this association, which leads to an increased lifetime risk of developing cancer (2, 3, 4). As already known in adults, the IGF system also seems to play an important role in the pathogenesis of pACC but mediated through overexpression of IGF1R and not IGF2 as in adult tumors (5, 6).
In general, the clinical manifestations and biological behavior of pACC - especially of infants - seem to be different from their counterparts in the adult population, even though there may exist an overlap. Thus, data from the adult setting cannot be uncritically transferred to children (1, 7, 8, 9, 10). Our recent analysis of age-dependent influences on clinical appearance and outcome confirmed that younger children (<4 years) have a different profile of hormone production and a better prognosis than older children and adults (9). Different pathogenesis of early childhood ACC has been discussed by several authors (11, 12). Regarding prognostic parameters of pACC, the most common factors for improved survival were age < 4 years, virilization alone, low pathological tumor score (Wieneke, Weiss, Van Slooten), and low tumor stages (8, 9, 11, 13, 14).
Nonetheless, the optimal tools for the prediction of outcome and stratification of pACCs are a matter of debate. Despite considerable heterogeneity, the European Network for the Study of Adrenal Tumors (ENSAT) staging system is widely used as the standard classification system in ACC (15, 16). However in the pediatric cohort - besides the Wieneke criteria (13) - no reliable prognostic scores exist so far, as adult scores are not fully applicable to the pediatric population (8, 9). Reliable assessment of prognostic factors after ACC resection is critical to guide frequency of follow-up, adjuvant treatment, and to more accurately counsel patients regarding long-term outcomes (17).
The S-GRAS score for prognostic classification of adult ACC - established and recently tested in a very large multicentric, collaborative study on behalf of ENSAT (17) - includes the following parameters: tumor stage (1-2=0; 3=1; 4=2 points), grade (Ki67 index 0-9%=0; 10-19%=1; ≥20%=2 points), resection status (RO=0; RX=1; R1=2; R2=3), age (<50 years=0; ≥50 years=1
point), symptoms (no=0; yes = 1 point) which results in 4 prognostic categories (1: 0-1, 2: 2-3, 3: 4-5, 4: 6-9). The results of this recent international, multicentric ENSAT study for adults demonstrated superior prognostic value for disease-free survival and progression-free survival by the S-GRAS score in comparison to the current standard ACC prognostic tools (17, 18, 19). Given the distinct features of pACC (9), we aimed to assess whether an adapted S-GRAS score for pACC would provide reliable prognostic value to improve risk stratification in pACCs. We therefore performed a review of the literature to evaluate this score in heterogeneous pediatric cohorts retrospectively.
Methods
We searched the PubMed and Embase databases up to 1 July 2021 for manuscripts that were published after 1 January 1986. Search terms included ‘adrenocortical tumor’, ‘adrenocortical cancer/carcinoma’, ‘pediatric’, ‘paediatric’, and/or ‘childhood’. All types of studies with abstracts available in German or English were included in the first step. Duplications were automatically removed both by EndNote and manually. Two independent reviewers (M R, V W) screened the titles and abstracts of all studies. Potentially relevant articles underwent full-text review to determine eligibility for inclusion in this patient-level meta-analysis (20). Inclusion criteria were a minimum of 3 reported ACC patients younger than 21 years and reporting of clinical or pathological characteristics or treatment on an individual patient level. Any disagreement on manuscripts was discussed and solved by consensus. Excerpted data were double-checked (M R, V W). All previously published patients with adrenocortical tumour (ACT) were included in the analyses. If the same study population was examined in two different publications, we included only the most recent publication.
The database search identified 2961 articles. After removing duplicates, 2075 remained for further investigation. After screening by title and abstract, 269 manuscripts were admissible for inclusion. Full-text review of these reports identified 33 manuscripts in the literature describing clinical and pathological characteristics of 733 patients, which were included in our analysis (Table 1). We did not identify randomized controlled trials, only retrospective studies. The selection process is depicted in the flowchart in Fig. 1. The literature organization was performed using EndNote 20. Charts and tables were created with Microsoft Word and Microsoft PowerPoint.
Table 1 All the included manuscripts with individual patient’s information and the patient characteristics, which could be extracted and analyzed for the modified S-GRAS score for pediatric patients.
| Reference | All patients | Age, years | Data availability, n | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| <4 | 4-19 | Tumor stage | Tumor grade | Resection status | HR symptoms | ||||||||
| n | n | % | n | % | Yes | No | Yes | No | Yes | No | Yes | No | |
| Letouze et al. (22) | 25 | 18 | 72 | 7 | 28 | 25 | 0 | 0 | 25 | 25 | 0 | 25 | 0 |
| Jehangir et al. (23) | 22 | 9 | 41 | 13 | 59 | 22 | 0 | 0 | 22 | 12 | 0 | 0 | 22 |
| McDonnell et al. (24) | 12 | 7 | 58 | 5 | 42 | 0 | 12 | 0 | 12 | 12 | 0 | 12 | 0 |
| Mayer et al. (38) | 11 | 4 | 36 | 7 | 64 | 0 | 11 | 0 | 12 | 11 | 0 | 11 | 0 |
| Stewart et al. (46) | 9 | 8 | 89 | 1 | 11 | 9 | 0 | 0 | 9 | 9 | 0 | 9 | 0 |
| Wang et al. (47) | 12 | 10 | 83 | 2 | 17 | 0 | 12 | 0 | 12 | 0 | 12 | 12 | 0 |
| Wu et al. (48) | 13 | 9 | 69 | 4 | 31 | 0 | 13 | 13 | 0 | 13 | 0 | 13 | 0 |
| Cho et al. (28) | 3 | 1 | 33 | 2 | 67 | 0 | 3 | 0 | 3 | 3 | 0 | 3 | 0 |
| Doghman-Bouguerra | 57 | 35 | 61 | 22 | 39 | 57 | 0 | 0 | 57 | 57 | 0 | 57 | 0 |
| et al. (31) | |||||||||||||
| Loncarevic et al. (37) | 14 | 8 | 57 | 6 | 43 | 14 | 0 | 0 | 14 | 0 | 14 | 14 | 0 |
| Chatterjee et al. (27) | 13 | 11 | 85 | 2 | 15 | 13 | 0 | 13 | 0 | 0 | 13 | 0 | 13 |
| Das et al. (30) | 17 | 15 | 88 | 2 | 12 | 0 | 17 | 17 | 0 | 17 | 0 | 0 | 17 |
| Guntiboina et al. (34) | 25 | 19 | 76 | 6 | 24 | 0 | 25 | 22 | 0 | 22 | 0 | 0 | 25 |
| Mishra et al. (40) | 10 | 4 | 40 | 6 | 60 | 0 | 10 | 0 | 10 | 0 | 10 | 10 | 0 |
| Narasimhan et al. (42) | 9 | 8 | 89 | 1 | 11 | 0 | 9 | 0 | 9 | 9 | 0 | 9 | 0 |
| Federici et al. (32) | 12 | 6 | 50 | 6 | 50 | 0 | 12 | 0 | 12 | 12 | 0 | 12 | 0 |
| Mittal et al. (41) | 6 | 2 | 33 | 4 | 67 | 0 | 6 | 0 | 6 | 0 | 6 | 6 | 0 |
| Panamonta et al. (43) | 7 | 1 | 14 | 6 | 86 | 0 | 7 | 0 | 7 | 0 | 7 | 7 | 0 |
| Gönc et al. (33) | 18 | 9 | 50 | 9 | 50 | 0 | 18 | 0 | 18 | 0 | 18 | 18 | 0 |
| Sakoda et al. (45) | 29 | 18 | 62 | 11 | 38 | 29 | 0 | 0 | 29 | 29 | 0 | 0 | 29 |
| Zerbini et al. (50) | 32 | 10 | 31 | 22 | 69 | 0 | 32 | 0 | 32 | 0 | 32 | 32 | 0 |
| Barbosa et al. (25) | 8 | 3 | 38 | 5 | 63 | 0 | 8 | 0 | 8 | 0 | 8 | 8 | 0 |
| Bergada et al. (26) | 20 | 8 | 40 | 12 | 60 | 0 | 20 | 0 | 20 | 0 | 20 | 20 | 0 |
| Cordeiro AM 2014 | 39 | 31 | 79 | 8 | 21 | 39 | 0 | 0 | 39 | 0 | 39 | 39 | 0 |
| Damiani et al. (29) | 33 | 21 | 64 | 12 | 36 | 0 | 33 | 33 | 0 | 33 | 0 | 33 | 0 |
| Latronico et al. (35) | 21 | 17 | 81 | 4 | 19 | 0 | 21 | 0 | 21 | 0 | 21 | 21 | 0 |
| Leal et al. (36) | 58 | 47 | 81 | 11 | 19 | 58 | 0 | 0 | 58 | 0 | 58 | 58 | 0 |
| Mendonca et al. (10) | 18* | 14 | 78 | 4 | 22 | 0 | 18 | 18 | 0 | 0 | 18 | 18 | 0 |
| Parise et al. (44) | 48¢ | 36 | 75 | 12 | 25 | 48 | 0 | 48 | 0 | 48 | 0 | 48 | 0 |
| Zancanella et al. (49) | 11 | 4 | 36 | 7 | 64 | 11 | 0 | 0 | 11 | 11 | 0 | 11 | 0 |
| Michailkiewisc et al. (39) | 20 | 17 | 85 | 3 | 15 | 0 | 20 | 0 | 20 | 0 | 20 | 20 | 0 |
| Wieneke et al. (13)a | 74t | 39 | 53 | 35 | 47 | 8 | 64 | 74 | 0 | 74 | 0 | 74 | 0 |
| Mattone et al. (51) | 24 | - | 28 | - | 0 | 0 | 0 | 24 | 0 | 24 | 0 | 24 | |
All pS-GRAS items available for *13, *48, and +74 patients.
ªFor this manuscript, additional patient information was available, which is not published/only partly published in the original published manuscript. HR, hormone-related.
Statistical analyses were performed in MEDAS software (Grund EDV, Margetshöchheim, Germany). Categorical variables were compared between two groups using either chi-square or, when the values were expected to be small, the Fisher or Mehta and Patel exact test. Continuous measurements were compared between two groups by the Mann-Whitney U test. Comparisons of more than two groups were performed by rank variance analysis according to Kruskal and Wallis.
A modified, age-dependent pS-GRAS score for pACC patients was calculated: tumor stage according to the widely used staging system of Children Oncology Group (COG), firstly described by Sandrini and later modified, and the ENSAT staging system/modified TNM classification
(9, 14, 16, 21) (1=0; 2-3=1; 4=2 points), grade (Ki67 index 0-9%=0; 10-19%=1; ≥20%=2 points) respective/ alternative mitose rate: low (<2/10HPF)=0, moderate/ intermediate (>2-10/10HPF)=1, high (>10/HPF)=2 points), resection (R)-status (R0 complete resection=0; RX (information not reported)=1; R1(indicates the removal of all macroscopic disease, but microscopic margins are positive for tumor)=2; R2 (indicates macroscopis residual disease (primary tumor, regional nodes, macroscopic margin involvement)=3 points)), age at diagnosis (<4 years=0; ≥4 years = 1 point), hormone-related symptoms if due to adrenal hormone excess (androgen production=0; cortisone/mixed/no hormone production=1 point), generating 10 pS-GRAS scores and 4 pS-GRAS groups (1:
Identification
PubMed n = 1674
Embase n = 1287
Screening
Studies identified by database search n = 2961
Eliminated duplicate publications n = 886
n = 2075
Eligibility
Studies excluded on the basis of the titles and abstracts screen: n = 1806
n = 269
Studies excluded on the basis of the full text screen: n = 236
n = 33 733 patients
Inclusion
Patients: age at diagnosis: n = 544 tumor stage: n = 313 Ki67/ rate of mitosis: n = 267 resection status: n = 544 hormone status: n = 424 Patients with all characteristics required for pS-GRAS: n = 135
Patients excluded due to missing characteristics required for the pS- GRAS score: n = 189
0-2, 2: 3-4, 3: 5, 4: 6-9) (see Table 2). The endpoint of the retrospective study was death and overall survival (OS).
Continuous variables were presented as median and interquartile range and categorical variables as counts and percentages. For survival endpoints, we performed Kaplan- Meier survival curves according to the pS-GRAS component as well as for the pS-GRAS score (stage, Ki67 index, resection status, age, hormone activity). The prognostic effect of pS-GRAS score and its individual components was examined using univariable Cox regression and test of Tarone. Hazard ratio and 95% CIs were reported. For the discriminative performance of the five pS-GRAS groups, a multivariate analysis of Cox wasperformed. P-values < 0.05 were considered significant.
Results
Patient characteristics
In total, we included clinical and pathological characteristics of 733 patients from 33 publications of retrospective studies (10, 13, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52). Forty percent (n=292) of patients were reported from Brazilian cohorts and 60% (n=441) in an international context. The mean age was 4.6 ± 4.7 years (median=2.5 years). The age distribution was as follows: <4 years 63.5%, 4 -< 10 years 21.4%, 10 -< 14 years 7.5%, and >14 years 7.6%. Of the patients, 36% were male and 64% were female. There was no association between sex and age.
With regard to tumor-specific characteristics, most of the patients showed hormone activity (>85%), most of them only androgen (29%) or mixed hormone activity (50%). The stage distribution according to ENSAT/ modified TNM classification (16) was as follows: 36% stage I, 28% stage II, 21% stage III, and 14% stage IV. Thirty percent received chemotherapy, and 23% had high Ki67 level and/or mitose indices (see Table 3). In approximately only 40% of patients, details about Ki67 level/mitosis indices were available. The results show that cases with higher Ki67 level/mitosis indices were associated with higher tumor stages (P<0.05) Regarding hormone activity, in principle, each combination of hormone activity was described in each stage, but the distribution between stages differed significantly (P<0.01). Further association with hormone activity was shown for patients with TP53- related cancer syndromes: they had a marked association with only androgen/mixed hormone activity (P<0.001) (Supplementary Table 1, see section on supplementary materials given at the end of this article). By comparing the multinational cohort to the Brazilian cohort, the Brazilian cohort was more often associated with TP53- related cancer syndromes and showed certain differences in hormone activity, age, and stage distribution as shown in Supplementary Table 2.
Relationship between age and tumor characteristics and/ or outcome
Age was a significant factor regarding hormone activity and the kind of hormones produced, as well as case fatality,
| pS-GRAS componentsª/classification | Points | Patients, n (%) | Sum, n (%) |
|---|---|---|---|
| Tumor stage (ENSAT stage system, modified TNM classification) | |||
| 1 | 0 | ||
| 2-3 | 1 | ||
| 4 | 2 | ||
| Grading (according to Ki67 index rep. rate of mitosis) | |||
| 0-9%, low | 0 | ||
| 10-19%, intermediate | 1 | ||
| ≥20%, high | 2 | ||
| Resection (R)-status | |||
| R0 | 0 | ||
| RX (not reported) | 1 | ||
| R1 | 2 | ||
| R2 | 3 | ||
| Age at diagnosis | |||
| <4 years | 0 | ||
| ≥4 years | 1 | ||
| Hormone status | |||
| Androgen production | 0 | ||
| Only glucocorticoid/mixed/no hormone production | 1 | ||
| pS-GRAS groupsb | |||
| 1 | |||
| 0 | 1 (0.7) | 1 (0.7) | |
| 1 | 13 (9.6) | 14 (10.4) | |
| 2 | 35 (25.9) | 49 (36.3) | |
| 2 | 3 | 35 (26.7) | 84 (63.0) |
| 4 | 21 (15.6) | 105 (78.5) | |
| 3 | 5 | 20 (14.8) | 125 (93.3) |
| 4 | 6 | 9 (6.7) | 134 (99.3) |
| 7 | 1 (0.7) | 135 (100.0) | |
| 8 | 0 (0) | 135 (100.0) | |
| 9 | 0 (0) | 135 (100.0) |
ªDefinition of pS-GRAS components: tumor stage, grading, resection (R)-status, age at diagnosis, hormone status; classification, and scoring system: 0-9 points; bScoring group distribution of 135 pACC patients according to the scoring points (group 1: 0-2, group 2: 3-4; group 3: 5; group 4: 6-9 points) from the selected original publications identified by the systematic review: number of patients (n; %; as sum and as sum %).
stage distribution, TP53-related cancer syndromes, and chemotherapy application. In general, with increasing age, patients more frequently presented with hormone-inactive or only glucocorticoid-producing tumors, had a higher tumor stage, received more often chemotherapy, and had more deaths of disease (Fig. 2 and Table 4). Considering the subgroups, especially patients below the age of 4 years showed more often low-risk constellations with improved OS as shown in Fig. 2. Regarding the distribution of the tumor stages in the subgroups (<4 years, ≥4 years -< 20 years) in detail, we see that the tumor stages 1-4 occur in every age, but pACCs in children < 4 years more often present with lower tumor stages (see Fig. 4). Furthermore, the prognosis for each stage group was age-independently (data not shown).
Characteristics and survival
The median follow-up was 4 years (68% CI: 0.9-12 years). The OS was 88.9% after 1 year, 81.5% after 2 years, 76% after 5 years, and 74.2% after 10 years (Fig. 2). Due to the higher proportion of low-risk patients, the Brazilian cohort tended to have a better survival than the international cohort (P=0.054). Regarding hormone activity, interestingly only androgen production alone was correlated with a better survival (P=0.03). We demonstrated a strong correlation of survival to the less advanced tumor stage, R0 resection, and low mitose index (P<0.001). There was no significant association between TP53-related cancer syndromes/p53 and survival.
Age < 4 years at diagnosis was a favorable factor regarding 2-year survival 90% vs 65% (4-11.9 years) vs 72%
Table 3 Clinical characteristics of a cohort of 733 pACC patients from the selected original publications identified by the systematic review.
| Clinical characteristicsª | Values, n (%) |
|---|---|
| Age | |
| <4 years | 339 (62.3) |
| 4-11.9 years | 136 (25.0) |
| 12-19 years | 69 (12.7) |
| No information available | 189 (25.8)b |
| Sex | |
| Female | 431 (62.3) |
| Male | 245 (37.7) |
| No information available | 57 (0.1)b |
| Country | |
| International | 441 (60.2) |
| Brazil | 292 (39.8) |
| Hormone activity | |
| No | 67 (11.8) |
| Mixed | 164 (28.8) |
| Androgen | 285 (50.0) |
| Glucocorticoid | 54 (9.5) |
| No information available | 163 (22.2)b |
| Tumor stage | |
| I | 163 (36.5) |
| II | 125 (28.0) |
| III | 95 (21.3) |
| IV | 64 (14.3) |
| No information available | 286 (39.0)b |
| P53/TPS | |
| no | 112 (42.1) |
| yes | 154 (57.9) |
| No information available | 467 (63.7)b |
| Medical therapy | |
| No | 273 (69.3) |
| Yes | 121 (30.7) |
| No information available | 341 (46.5)b |
| Rate of mitosis/Ki67 | |
| Low; 0-9% | 172 (55.1) |
| Intermediate; 10-19% | 68 (21.8) |
| High; ≥20% | 72 (23.1) |
| No information available | 421 (57.4)b |
| Resection status | |
| R0 | 123 (22.6) |
| RX (not reported) | 409 (75.2) |
| R1 | 4 (0.01) |
| R2 | 8 (0.01) |
aAge, sex, country, hormone activity, tumor stage, p53/tumor predisposition syndrome (TPS), medical therapy (chemotherapy and/or Mitotane), rate of mitosis/Ki67, resection status (patient number in total (n) and percentage); bPercentages of characteristics are only based on the available data, but the percentages of the missing data apply to all 733 patients, so these percentages are in parentheses.
(12-19 years) (P<0.001), while no significant difference was noted between age groups 4-11.9 and 12-19 years (Fig. 2). To exclude any bias between stage distribution and age- dependent OS, we compared the OS of children in every particular tumor stage in dependency of the age, as depicted in Fig. 3. Interestingly, a better OS was noted for all tumor
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age <4 years (n = 339)
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Age (adults)* < 50 years
age 12-19 years (n = 69)
Age (adults)* > 50 years
| Age/years | 0 | 1 | 2 | 5 | 10 |
|---|---|---|---|---|---|
| <4 | 339 | 292 | 261 | 173 | 88 |
| 4-11.9 | 136 | 109 | 79 | 47 | 17 |
| 12-19 | 69 | 56 | 43 | 26 | 14 |
Figure 2 Kaplan-Meier curve depicting overall survival (patients n = 544) according to the age groups (age < 4 years n = 339; 4 -< 12 years n = 136; 12 -< 20 years n = 69). Percentage of survived patients (y-axis) at the respective point in time in years (x-axis), differentiated according to three pediatric age groups. P < 0.0000005 *** (Tarone), the log-rank test showed <4 vs 4 -< 12 years: P = 0.000000 *** , <4 vs 12 -< 20 years: P= 0.000004 *** , and 4 -< 12 vs 12 -< 20 years P = 0.39. *Additional Insertion of the Kaplan-Meier curve depicting disease-specific survival of adult patients with ACC (n = 400; time since diagnosis: 0-120 months) for a direct comparison of data of children to adults (curves inserted and modified from Elhassan et al. S-GRAS score for prognostic classification of adrenocortical carcinoma: an international, multicenter ENSAT study, 2021; Fig. 2).
stages in younger children (<4 years), in particular for stage 1 (P=0.001) and stage 2 (P=0.02). Stage 4 is associated with very poor prognosis for all patients, even though there is a slightly better prognosis for children < 4 years (see Fig. 3).
Evaluation of pS-GRAS criteria in pACC
First, we analyzed each single factor of the pS-GRAS- score via a univariate survival analysis. In the Kaplan-Meier curve of the univariate survival analysis, all available data on each prognostic factor (e.g.age, tumor stage, etc.) of the 733 patients were considered and analyzed (see Fig. 5B, C, D, E and F). Univariate survival analysis clarified a strong association of all evaluated variables with overall
| Clinical characteristics | Patients, n | Age, years (mean (s.D.)) | P |
|---|---|---|---|
| Hormone activity | 0.00071 | ||
| No | 67 | 7.4 (6.3) | |
| Mixed | 164 | 4.3 (4.7) | |
| Androgen | 285 | 3.8 (3.6) | |
| Glucocorticoid | 54 | 7.6 (6.1) | |
| Stage | <0.000005 | ||
| I | 157 | 2.9 (3.2) | |
| II | 119 | 3.7 (4.2) | |
| II | 86 | 5.7 (5.4) | |
| IV | 61 | 7.3 (5.0) | |
| p53/TPS | 0.0067 | ||
| No | 106 | 6.0 (5.7) | |
| Yes | 136 | 3.8 (4.3) | |
| Resection status | 0.0070 | ||
| R0 | 142 | 3.5 (3.6) | |
| RX | 555 | 4.9 (4.9) | |
| R1 | 4 | 4.8 (3.2) | |
| R2 | 8 | 6.5 (2.8) | |
| Chemotherapy | <0.000005 | ||
| No | 273 | 3.8 (4.6) | |
| Yes | 119 | 6.2 (4.6) | |
| Rate of mitosisª | 0.88 | ||
| Low | 155 | 4.6 (5.0) | |
| Moderate | 68 | 4.2 (4.1) | |
| High | 6 | 4.8 (5.3) |
aRate of mitosis: low = < 2/10 HPF, moderate ⇒2-10/10 HPF, high= >10/ HPF (although the classification into low, intermediate, and high is mostly done, the exact subdivision of mitosis rate into HPF was often missing).
survival (see Fig. 5B, C, D, E and F). Unlike in adults, age is an important prognostic factor of the scoring with a significant better outcome for children < 4 years. The analysis once again confirmed that an age < 4 years at diagnosis was a favorable factor regarding survival (Fig. 3B; P < 0.0001, 2-year survival 90 vs 58%). We showed strong correlation of survival to the tumor stage, R0 resection, and Ki67/mitose index (see Fig. 5C, D and E). Furthermore, virilization alone correlated with a better survival (P=0.03) (see Fig. 5F).
In 135 of the 733 patients,all characteristics required for the adjusted pS-GRAS score were available (see Table 2). By analyzing only those 135 patients regarding the univariate survival analysis, results remained similar: for stage: I (n=89) 133 months (95% CI: 2.8-332), II (n=29) 72 months (95% CI: 30-269), and III/IV (n=16) 17 months (95% CI: 1.4-107); for mitosis/Ki67: low (n=65) 133 months (95% CI: 2.1-304), moderate (n=39) 76 months (95% CI: 12.3-278), and high (n=31) 40 months (95% CI: 2.3-334); for resection: RO (n=46) 58 months (95% CI: 4.1-252), RX (n=87) 120 months (95% CI: 2.3-333), and >RO (n=2) 19 months (95% CI: 18-20); for age: < 4 years (n=86) 128 months (95% CI: 2.8-282) and age > 4 years (n=49) 46 months (95% CI: 2.5-328); and for hormone activity: only androgen (n=69) 112 months (95% CI: 2.5-283) and others (n=66) 79 months (95% CI: 2.7-338, data are not shown). OS Kaplan-Meier curves for pS-GRAS score analysis and its components as univariate analysis are illustrated in Fig. 5A, B, C, D, E and F. A favorable prognosis was noted in patients with a lower score compared to higher scores. The pS-GRAS score correlated with clinical outcome; median OS was 133 months (95% CI: 36-283) in group 1 (n=49), 110 months
A
Stage 1 (n=29)
B
Stage 2 (n=48)
C
Stage 3 (n=41)
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Stage 4 (n=16)
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age < 4y (n = 25) age 4 to 19y (n = 4)
age < 4y (n = 34) age 4 to 19y (n = 14)
Time from diagnosis [years]
Age(V4)<4 4c=Age(V4)<20
Time from diagnosis [years]
Age(V4)<4 4 ⇐ Age(V4)<20
Time from diagnosis [years]
| Age/years | 0 | 1 | 2 | 5 | 10 |
|---|---|---|---|---|---|
| <4 | 25 | 25 | 23 | 14 | 6 |
| 4-19 | 4 | 3 | 3 | 3 | 1 |
| Age/years | 0 | 1 | 2 | 5 | 10 |
|---|---|---|---|---|---|
| <4 | 34 | 32 | 32 | 28 | 23 |
| 4-19 | 14 | 13 | 11 | 8 | 5 |
| Age/years | 0 | 1 | 2 | 5 | 10 |
|---|---|---|---|---|---|
| <4 | 19 | 15 | 15 | 14 | 14 |
| 4-19 | 22 | 20 | 14 | 10 | 9 |
| Age/years | 0 | 1 | 2 | 5 | 10 |
|---|---|---|---|---|---|
| <4 | 7 | 6 | 3 | 1 | 1 |
| 4-19 | 9 | 6 | 2 | 0 | 0 |
Figure 3 Kaplan-Meier curves depicting overall survival (patients n = 134) according to age groups (age < 4 years; 4 -< 12 years; 12 -< 20 years): (A) tumor stage 1 (age < 4 n = 25, age > 4 n = 4; log-rank test: P = 0.00091 *** ); (B) tumor stage 2 (age < 4 n = 34, age > 4 n = 14; log-rank test: P = 0.021*); (C) tumor stage 3 (age < 4 n = 19, age > 4 n = 22; log-rank test: P = 0.12); (D) tumor stage 4 (age < 4 n = 7, age > 4 n = 9; log-rank test: P = 0.092).
Age in years
n = 157
n = 119
n = 86
n = 61
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Stage
(95% CI: 2.9-314) in group 2 (n=57), 49 months (95% CI: 5.8-278) in group 3 (n=18), and 16 months (95% CI: 2.4- 267) in group 4; (n=11) P<0.05). The difference in OS was significant for all groups (group 1 vs 2 P=0.0004, group 2 vs 3 P=0.018, group 3 vs 4 P= 0.04; see Fig. 5A). In addition, we performed an multivariate analysis according to Cox to discriminate the effect of the 5 S-GRAS groups: we could show that resection and hormone activity did not link with an additional significance, whereas tumor stage, age, and mitosis rate were able to increase the significance niveau (for details see Fig. 5).
Patients treated with chemotherapy were often in a higher pS-GRAS group (P<0.005), which is in accordance with the current recommendation of COG providing the application of chemotherapy in advanced tumor stages (53). Tumors that are associated with TP53-related cancer syndromes seem to have a slightly higher scoring, whereas sex had no remarkable prognostic value.
Discussion
pACCs are rare, and standardized treatment protocols and prognostic scores are not yet established. However, it has been shown that adult scores (Weiss, Hough, Van Slooten) have no reliable predictive value, especially in younger children as it leads to an overestimation of malignancy
(12, 54, 55, 56). The Wieneke Index - a modified histopathologic score for pACC - classifies adrenocortical tumors into three prognostic groups (benign, malignant, and of undetermined malignant potential) on the basis of pathologic criteria. The score has been reported to be more reproducible, accurate, and reliable for children (13, 27, 30). Although the Wieneke score is widely recognized, the number of criteria to be considered by pathologists may render the Wieneke pathological stratification less applicable to the clinical context and observer-dependent (55). In order to focus on the most predictive microscopic criteria, Picard et al. recently described the five-item microscopic score integrating adrenal capsular invasion, venous invasion, confluent necrosis, mitotic count > 15/20 HPF, and Ki67 ≥ 15% (57). The ENSAT staging system - initially established for adult patients - and especially the staging system of COG, firstly described by Sandrini and later modified, are widely used for the classification of pACC (14, 15, 21). Nevertheless, these staging systems alone are insufficient to provide the prognosis and therapeutic needs accurately. Therefore, a new multi-parameter scoring system including clinical, pathological, and molecular genetic prognostic markers has been recently established by ENSAT for the adult cohort, so-called S-GRAS score, and appears to have superior predictive value (17, 18, 19).
Regarding pediatric data, in our recently published systematic review (9), we could confirm that younger patients (especially <4 years) present with a different hormone profile and have a more favorable outcome than older pediatric patients. In the current analysis based on the data of individual patients, we could demonstrate that patients with younger age more often presented with hormoneactive tumors - predominantly only androgen- or mixed-producing tumors - had lower tumor stages, were more frequently associated with TP53-related cancer syndromes/p53, received less often chemotherapy, and showed a better survival rate. Of note, these age-related differences in risk constellation appear to be more impressive between the subgroup with age <4 years and all other subgroups (4-10 years, 10-14 years, >14 years) than between children (>4 years) and even adults (7). We have shown that children < 4 years of age have better OS, regardless of tumor stage. Nevertheless, it has to be noticed that stage 4 generally has a poor prognosis regardless of age. The hypothesis of a different pathogenesis of early childhood ACC and a biological similarity of tumors in older patients seems to be supported by our data (11, 12). Several authors state the hypothesis of fetal zone-derived tumorigenesis in early childhood - as this development pathway is known from other pediatric tumors of
A
pS-GRAS score (n=135)
Survival probability [%]
100
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pS-GRAS 0 - 2 (n= 49)
Time from diagnosis [years]
PS-GRAS 3 - 4 (n = 56)
5 (n = 18)
PS-GRAS 6 - 9 (n = 11)
| group/years | 0 | 1 | 2 | 5 | 10 |
|---|---|---|---|---|---|
| 0-2 | 49 | 48 | 48 | 37 | 26 |
| 3-4 | 56 | 50 | 43 | 33 | 27 |
| 5 | 18 | 16 | 11 | 7 | 4 |
| 6-9 | 11 | 7 | 3 | 1 | 1 |
C Tumor stage (n=313)
Survival probability [%]
100
90
1
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70
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Stage I (n = 113)
Time from diagnosis [years]
II = 87)
Stage III (n = 69)
Stage IV (n = 44)
| Stage/years | 0 | 1 | 2 | 5 | 10 |
|---|---|---|---|---|---|
| 1 | 113 | 102 | 92 | 57 | 20 |
| 2 | 87 | 75 | 70 | 53 | 33 |
| 3 | 69 | 55 | 41 | 27 | 24 |
| 4 | 44 | 35 | 19 | 8 | 2 |
B Age at diagnosis (n=544)
Survival probability [%]
100
90
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70
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20
10
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2
4
6
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10
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age < 4y (n =339) age 4 to 19y (n = 205)
Time from diagnosis [years]
| age/years | 0 | 1 | 2 | 5 | 10 |
|---|---|---|---|---|---|
| <4 | 339 | 292 | 261 | 173 | 88 |
| 4-19 | 205 | 165 | 122 | 73 | 31 |
D Ki67 Index / Rate of Mitosis (n=267)
Survival probability [%]
100
90
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70
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50
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30
20
10
0
2
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8
10
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Ki67 0-9%, low (n = 146)
Time from diagnosis [years]
Ki67 10-19%, intermediate (n = 65)
Ki67 >19%, high (n = 56)
| Ki67/years | 0 | 1 | 2 | 5 | 10 |
|---|---|---|---|---|---|
| 0-9% | 146 | 133 | 121 | 93 | 49 |
| 10-19% | 65 | 60 | 51 | 33 | 14 |
| >19% | 56 | 44 | 33 | 16 | 10 |
E Resection status (n=544)
100
Survival probability [%]
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R0 (n=123) RX (n=409)
Time from diagnosis [years]
R1 (n=4)
R2 (n=8)
| resection/years | 0 | 1 | 2 | 5 | 10 |
|---|---|---|---|---|---|
| R0 | 123 | 111 | 95 | 61 | 32 |
| RX | 409 | 338 | 285 | 185 | 87 |
| R1 | 4 | 3 | r2 | 0 | 0 |
| R2 | 8 | 5 | 1 | 0 | 0 |
F Hormone status (n=424)
Survival probability [%]
100
90
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70
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50
40
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androgen production (n=218)
cortisone / mixed / no hormone production (n=208)
| Hormon activity/years | 0 | 1 | 2 | 5 | 10 |
| None/others | 208 | 166 | 134 | 83 | 47 |
| androgene | 218 | 185 | 162 | 99 | 54 |
Figure 5 Kaplan-Meier curves depicting score analysis of overall survival of pACC patients (n = 135) according to pS-GRAS score grouping: (A) pS-GRAS groups (1: 0-2, 2: 3-4, 3: 5, 4: 6-9) and univariate analysis of each pS-GRAS component of all patients, in which
Figure 5 (Continued)
parameters were available, (B) age at diagnosis (<4 years n = 339, ≥4 years n = 205, log-rank test P < 0.0000005 *** ), (C) tumor stage (I n = 113, II n = 87, III n = 69, IV n = 44; P < 0.0000005*** (Test of Tarone). Log-rank test: stage: I vs II P = 0.0028** I vs III < P = 0.000000***, I vs IV P = 0.000000***; II vs III P = 0.00014***; II vs IV P = 0.000000***, III vs IV P = 0.012*), (D) Ki67 proliferation index/rate of mitosis (0-9%/low n = 146, 10-19%/moderate n = 65, >19%/high n = 56, log-rank tests: low vs moderate 0.021*, low vs high 0.000055 *** , moderate vs high 0.11), (E) resection status (R0 n = 123 RX n = 409, R1 n = 4, R2 n = 8; P = 0.000089 *** (Test of Tarone; log-rank tests: R0 vs RX P = 0.40; R0 vs R1 P = 0.000000***, R0 vs R2 P = 0.000000***; RX vs R1 P = 0.000015***; RX vs R2 P = 0.000000 *** , R1 vs R2 P = 0.97), (F) hormone status (androgen production = 218, and cortisone/mixed/no hormone production n = 208, log-rank test P = 0.034*). In addition, by analyzing only the 135 patients, which fulfilled all pS-GRAS criteria, results remained similar (P-values are given for stage: I vs II 0.039*, I vs III <0.0000005 ***; for mitosis/Ki67: low vs moderate 0.15, low vs high 0.0042**, moderate vs high 0.14, for resection: RO vs >R0/RX . 0.017*fora: <4 vs >4y/o 0.000003, for hormone activity: androgen vs others 0.062, data are not shown).
the adrenal gland (9, 11, 12, 58). Dehner et al. found cytomorphologic correlates pointing in this direction as pediatric adrenocortical tumors resemble cell formations of the fetal adrenal cortex (12). Furthermore, there are findings about the correlation of gene expression profiles of children ACT with those present in the fetal adrenal (11). For example, overexpression of IGF2 - as found in 80% of pACC - is assumed to be responsible for the phenotype of the fetal adrenal cortex. P53 mutation - more frequently in pACC compared to adult tumors - leads to a deficient apoptosis, which is the signaling pathway responsible for fetal cortical involution. This may be one explanation for the tendency of biological regression of early childhood pACC rather than progression to a malignancy despite the presence of atypical, malignant features (11, 12, 14, 59).
In addition to the age factor, several other predictive factors such as resection status, tumor stage, hormonal activity, and Ki67/mitosis rate correlated strongly with OS, as shown by univariate analysis in this study. Surgical tumor resection is the essential therapeutic approach for pACC and the predictive value of resection status is well established, as microscopic or macroscopic tumor residuals significantly worsen the clinical outcome (53, 60). Furthermore, the tumor staging system - established for pACC - has high predictive value as higher stages represent advanced tumor stages (21). Regarding hormone activity, androgen production alone seems to be associated with better OS (14). Although the association between pathological criteria and clinical behavior in pACC is not as established as in adults, recent publications show that the Ki67 factor predicts biological behavior very accurately and that a higher Ki67 rate correlates with worse outcomes and a higher risk of recurrence (61, 62).
By comparing the multinational cohort to the Brazilian cohort, the Brazilian cohort had a decreased part of non-hormone active and only glucocorticoid-producing tumors. Furthermore, Brazilian patients were significantly
younger, showed a higher proportion of stage I, a slightly better OS, and more TP53-related cancer syndrome- associated tumors as previously described (9). We suspect some bias of our results regarding prognosis: due to the higher frequency of the germline mutation at codon 337 in the TP53 gene in southern Brazil, there probably are regular screening investigations in affected families with the possibility of earlier detection of the pACC tumor (2).
Evaluation of the prognostic performance of pediatric S-GRAS score
In adaption to the publication of a very large multicentric, collaborative study on behalf of ENSAT regarding S-GRAS score for prognostic classification of ACC in the adult setting (17), a central objective of our retrospective analysis was to evaluate the prognostic performance of the modified pediatric S-GRAS score for pACC. Because of incomplete, heterogeneous data on current pACC cases from the literature, only a minority of the 733 recruited patients were included in the scoring analysis. Nevertheless - as our results demonstrate - pS-GRAS score seems to have high predictive value in pACC patients. We could show a significantly favorable prognosis in patients with a lower scoring compared to higher scoring groups. In detail, the univariate analysis shows a strong association of all evaluated variables with OS. To the best of the authors’ knowledge, this is the first score taking clinical factors as age and hormone activity at diagnosis into consideration. In comparison to genetic investigations, the data of pS-GRAS are simply available for pACC patients (17). One step toward validation may be the prospective evaluation in an international and more homogeneous clinical study context. In the long term, it will be desirable to develop a combined scoring system including histopathological, clinical, and molecular data - as it has already been shown for other pediatric tumors such as neuroblastoma.
This approach would allow risk stratification, therapy adjustment very early after diagnosis, and additional minimal residual disease-monitoring due to specific molecular markers (e.g. liquid biopsies).
This study still has many limitations, as all studies were performed retrospectively, which may have led to selection bias. The majority of the studies included a low number of patients and there was a heterogeneity of patient cohorts, therapy approaches, and a diversity of reporting accuracy. We also know that because of the low incidence of pACC we had to select patients over a large time period (1986-2021) for recruiting a sufficiently large cohort and we had to set the age cutoff at 21 years. Due to the heterogeneity of literature, patient data from different staging systems were used. Additionally, criteria of the staging systems changed over time with regard to stages III and IV, so there may be minor bias in the advanced stages. Furthermore, the number of cases considered for each factor ranged from 267 for Ki67/ mitosis rate to 544 for age and R status, so the results of these univariate analyses cannot be compared without restriction. For retrospective analysis of pS-GRAS score, only few patients with all available data on each prognostic factor were eligible - mostly because of the low number of patients with available data on Ki67/mitosis rate. Brazilian patients with the TP53 germline mutation were not analyzed separately, although pathogenesis and prognosis may differ from those of other patients. It should also be noted that important surgical prognostic factors, e.g. tumor spillage and capsular rupture during surgery, which are known to worsen outcome (57), were only indirectly considered in the current scoring system as surgical complications increase tumor stage to at least stage II (21). Furthermore, the methods for mitosis rate analysis differ between the reported cases.
Nevertheless, we showed in a retrospective heterogeneous patient cohort that the combination of clinical and histopathological criteria seems to have a good predictive value and may therefore serve as a helpful tool for risk stratification in future studies. The next step will be the prospective evaluation of pS-GRAS in an international context to establish a valuable risk stratification as a base for further clinical studies.
Supplementary materials
This is linked to the online version of the paper at https://doi.org/10.1530/ EJE-22-0173.
Declaration of interest
M Fassnacht is on the editorial board of EJE. He was not involved in the review or editorial process for this paper, on which he is listed as an author. The other authors have nothing to disclose.
Funding
This work was supported by a research grant IZKF training grant awarded to M R (project number: Z-02CSP/23).
Acknowledgments
This work was supported by a research grant from the Tour of Hope Foundation. We would like to thank the Parents Initiative Group for Children with
References
1 Kerkhofs TM, Ettaieb MH, Verhoeven RH, Kaspers GJ, Tissing WJ, Loeffen J, Van den Heuvel-Eibrink MM, De Krijger RR & Haak HR. Adrenocortical carcinoma in children: first population-based clinicopathological study with long-term follow-up. Oncology Reports 2014 32 2836-2844. (https://doi.org/10.3892/or.2014.3506)
2 Ribeiro RC, Sandrini F, Figueiredo B, Zambetti GP, Michalkiewicz E, Lafferty AR, DeLacerda L, Rabin M, Cadwell C, Sampaio G et al. An inherited p53 mutation that contributes in a tissue-specific manner to pediatric adrenal cortical carcinoma. PNAS 2001 98 9330-9335. (https://doi.org/10.1073/pnas.161479898)
3 Pinto EM, Billerbeck AE, Villares MC, Domenice S, Mendonça BB & Latronico AC. Founder effect for the highly prevalent R337H mutation of tumor suppressor p53 in Brazilian patients with adrenocortical tumors. Arquivos Brasileiros de Endocrinologia e Metabologia 2004 48 647-650. (https://doi.org/10.1590/s0004-27302004000500009)
4 Bougeard G, Renaux-Petel M, Flaman JM, Charbonnier C, Fermey P, Belotti M, Gauthier-Villars M, Stoppa-Lyonnet D, Consolino E, Brugières L et al. Revisiting Li-Fraumeni syndrome from TP53 mutation carriers. Journal of Clinical Oncology 2015 33 2345-2352. (https://doi.org/10.1200/JCO.2014.59.5728)
5 Peixoto Lira RC, Fedatto PF, Marco Antonio DS, Leal LF, Martinelli CE, de Castro M, Tucci S, Neder L, Ramalho L, Seidinger AL et al. IGF2 and IGF1R in pediatric adrenocortical tumors: roles in metastasis and steroidogenesis. Endocrine-Related Cancer 2016 23 481-493. (https:// doi.org/10.1530/ERC-15-0426)
6 Almeida MQ, Fragoso MCBV, Lotfi CFP, Santos MG, Nishi MY, Costa MHS, Lerario AM, Maciel CC, Mattos GE, Jorge AAL et al. Expression of insulin-like growth factor-II and its receptor in pediatric and adult adrenocortical tumors. Journal of Clinical Endocrinology and Metabolism 2008 93 3524-3531. (https://doi.org/10.1210/jc.2008-0065)
7 Wang Z, Liu G, Sun H, Li K, Dong K, Ma Y & Zheng S. Clinical characteristics and prognosis of adrenocortical tumors in children. Pediatric Surgery International 2019 35 365-371. (https://doi. org/10.1007/s00383-018-4409-z)
8 Zambaiti E, Duci M, De Corti F, Gamba P, Dall’Igna P, Ghidini F & Virgone C. Clinical prognostic factors in pediatric adrenocortical tumors: a meta-analysis. Pediatric Blood and Cancer 2021 68 e28836. (https://doi.org/10.1002/pbc.28836)
9 Riedmeier M, Decarolis B, Haubitz I, Muller S, Uttinger K, Borner K, Reibetanz J, Wiegering A, Hartel C, Schlegel PG et al. Adrenocortical carcinoma in childhood: a systematic review. Cancers 2021 13 5266. (https://doi.org/10.3390/cancers13215266)
10 Mendonca BB, Lucon AM, Menezes CA, Saldanha LB, Latronico AC, Zerbini C, Madureira G, Domenice S, Albergaria MA & Camargo MH. Clinical, hormonal and pathological findings in a comparative study of adrenocortical neoplasms in childhood and adulthood. Journal of Urology 1995 154 2004-2009. (https://doi.org/10.1016/S0022- 5347(01)66673-4)
11 Lalli E & Figueiredo BC. Pediatric adrenocortical tumors: what they can tell us on adrenal development and comparison with adult adrenal tumors. Frontiers in Endocrinology 2015 6 23. (https://doi. org/10.3389/fendo.2015.00023)
12 Dehner LP & Hill DA. Adrenal cortical neoplasms in children: why so many carcinomas and yet so many survivors? Pediatric and Developmental Pathology 2009 12 284-291. (https://doi. org/10.2350/08-06-0489.1)
13 Wieneke JA, Thompson LD & Heffess CS. Adrenal cortical neoplasms in the pediatric population: a clinicopathologic and immunophenotypic analysis of 83 patients. American Journal of Surgical Pathology 2003 27 867-881. (https://doi. org/10.1097/00000478-200307000-00001)
14 Michalkiewicz E, Sandrini R, Figueiredo B, Miranda EC, Caran E, Oliveira-Filho AG, Marques R, Pianovski MA, Lacerda L, Cristofani LM et al. Clinical and outcome characteristics of children with adrenocortical tumors: a report from the International Pediatric Adrenocortical Tumor Registry. Journal of Clinical Oncology 2004 22 838-845. (https://doi.org/10.1200/JCO.2004.08.085)
15 Fassnacht M, Wittekind C & Allolio B. Current TNM classification systems for adrenocortical carcinoma. Der Pathologe 2010 31 374-378. (https://doi.org/10.1007/s00292-010-1306-1)
16 Fassnacht M, Johanssen S, Quinkler M, Bucsky P, Willenberg HS, Beuschlein F, Terzolo M, Mueller HH, Hahner S, Allolio B et al. Limited prognostic value of the 2004 International Union against cancer staging classification for adrenocortical carcinoma: proposal for a revised TNM classification. Cancer 2009 115 243-250. (https://doi. org/10.1002/cncr.24030)
17 Elhassan YS, Altieri B, Berhane S, Cosentini D, Calabrese A, Haissaguerre M, Kastelan D, Fragoso MCBV, Bertherat J, Al Ghuzlan A et al. S-GRAS score for prognostic classification of adrenocortical carcinoma: an international, multicenter ENSAT study. European Journal of Endocrinology 2021 186 25-36. (https://doi.org/10.1530/EJE- 21-0510)
18 Lippert J, Appenzeller S, Liang R, Sbiera S, Kircher S, Altieri B, Nanda I, Weigand I, Gehrig A, Steinhauer S et al. Targeted molecular analysis in adrenocortical carcinomas: a strategy toward improved personalized prognostication. Journal of Clinical Endocrinology and Metabolism 2018 103 4511-4523. (https://doi.org/10.1210/jc.2018- 01348)
19 Libé R, Borget I, Ronchi CL, Zaggia B, Kroiss M, Kerkhofs T, Bertherat J, Volante M, Quinkler M, Chabre O et al. Prognostic factors in stage III-IV adrenocortical carcinomas (ACC): an European Network for the study of adrenal tumor (ENSAT) study. Annals of Oncology 2015 26 2119-2125. (https://doi.org/10.1093/annonc/mdv329)
20 Buccheri S, Sodeck GH & Capodanno D. Statistical primer: methodology and reporting of meta-analyses. European Journal of Cardio-Thoracic Surgery 2018 53 708-713. (https://doi.org/10.1093/ ejcts/ezy004)
21 Sandrini R, Ribeiro RC & DeLacerda L. Childhood adrenocortical tumors. Journal of Clinical Endocrinology and Metabolism 1997 82 2027-2031. (https://doi.org/10.1210/jcem.82.7.4057)
22 Letouze E, Rosati R, Komechen H, Doghman M, Marisa L, Fluck C, de Krijger RR, van Noesel MM, Mas JC, Pianovski MA et al. SNP array profiling of childhood adrenocortical tumors reveals distinct pathways of tumorigenesis and highlights candidate driver genes. Journal of Clinical Endocrinology and Metabolism 2012 97 E1284-E1293. (https:// doi.org/10.1210/jc.2012-1184)
23 Jehangir S, Nanjundaiah P, Sigamani E, Burad D, Manipadam MT, Lea V, Ly T & Holland AJA. Pathological prognostication of paediatric adrenocortical tumours: is a gold standard emerging? Pediatric Blood and Cancer 2019 66 e27567. (https://doi.org/10.1002/pbc.27567)
24 McDonnell CM & Zacharin MR. Adrenal cortical tumours: 25 years’ experience at the Royal Children’s Hospital, Melbourne. Journal of Paediatrics and Child Health 2003 39 682-685. (https://doi. org/10.1046/j.1440-1754.2003.00268.x)
25 Barbosa AS, Giacaglia LR, Martin RM, Mendonca BB & Lin CJ. Assessment of the role of transcript for GATA-4 as a marker of unfavorable outcome in human adrenocortical neoplasms. BMC Endocrine Disorders 2004 4 3. (https://doi.org/10.1186/1472-6823-4-3)
26 Bergada I, Venara M, Maglio S, Ciaccio M, Diez B, Bergada C & Chemes H. Functional adrenal cortical tumors in pediatric patients: a clinicopathologic and immunohistochemical study of a long term follow-up series. Cancer 1996 77 771-777. (https://doi.org/10.1002/ (SICI) 1097-0142(19960215)77:4<771:AID-CNCR24>3.0.CO;2-X)
27 Chatterjee G, DasGupta S, Mukherjee G, Sengupta M, Roy P, Arun I, Datta C, Mishra PK, Banerjee S & Chatterjee U. Usefulness of Wieneke criteria in assessing morphologic characteristics of adrenocortical tumors in children. Pediatric Surgery International 2015 31 563-571. (https://doi.org/10.1007/s00383-015-3708-x)
28 Cho MJ, Kim DY, Kim SC, Kim TH & Kim IK. Adrenocortical tumors in children 18 years old and younger. Journal of the Korean Surgical Society 2012 82 246-250. (https://doi.org/10.4174/jkss.2012.82.4.246)
29 Damiani D, Della Manna T, Aquino LG, Dichtchekenian V, Avancini V, Alves F, Longatto Filho A, Kanamura CT & Setian N. Proliferating cell nuclear antigen immunoreaction in adrenal tumors. Tumori 1995 81 273-277. (https://doi.org/10.1177/030089169508100412)
30 Das S, Sengupta M, Islam N, Roy P, Datta C, Mishra PK, Banerjee S, Chaudhuri MK & Chatterjee U. Weineke criteria, Ki-67 index and p53 status to study pediatric adrenocortical tumors: is there a correlation? Journal of Pediatric Surgery 2016 51 1795-1800. (https:// doi.org/10.1016/j.jpedsurg.2016.07.014)
31 Doghman-Bouguerra M, Finetti P, Durand N, Parise IZS, Sbiera S, Cantini G, Canu L, Hescot S, Figueiredo MMO, Komechen H et al. Cancer-testis antigen FATE1 expression in adrenocortical tumors is associated with a pervasive autoimmune response and is a marker of malignancy in adult, but not children, ACC. Cancers 2020 12 689. (https://doi.org/10.3390/cancers12030689)
32 Federici S, Galli G, Ceccarelli PL, Ferrari M, Cicognani A, Cacciari E & Domini R. Adrenocortical tumors in children: a report of 12 cases. European Journal of Pediatric Surgery 1994 4 21-25. (https://doi. org/10.1055/s-2008-1066060)
33 Gonc EN, Ozon ZA, Cakir MD, Alikasifoglu A & Kandemir N. Need for comprehensive hormonal workup in the management of adrenocortical tumors in children. Journal of Clinical Research in Pediatric Endocrinology 2014 6 68-73. (https://doi.org/10.4274/ Jcrpe.1351)
34 Guntiboina VA, Sengupta M, Islam N, Barman S, Biswas SK, Chatterjee U, Mishra PK, Roy P, Mallick MG & Datta C. Diagnostic and prognostic utility of SF1, IGF2 and p57 immunoexpression in pediatric adrenal cortical tumors. Journal of Pediatric Surgery 2019 54 1906-1912. (https://doi.org/10.1016/j.jpedsurg.2018.12.002)
35 Latronico AC, Pinto EM, Domenice S, Fragoso MC, Martin RM, Zerbini MC, Lucon AM & Mendonca BB. An inherited mutation outside the highly conserved DNA-binding domain of the p53 tumor suppressor protein in children and adults with sporadic adrenocortical tumors. Journal of Clinical Endocrinology and Metabolism 2001 86 4970-4973. (https://doi.org/10.1210/jcem.86.10.7957)
36 Leal LF, Mermejo LM, Ramalho LZ, Martinelli CE, Jr, Yunes JA, Seidinger AL, Mastellaro MJ, Cardinalli IA, Brandalise SR, Moreira AC et al. Wnt/beta-catenin pathway deregulation in childhood adrenocortical tumors. Journal of Clinical Endocrinology and Metabolism 2011 96 3106-3114. (https://doi.org/10.1210/jc.2011-0363)
37 Loncarevic IF, Hering A, Posorski N, Linden T, Hoyer H & Bucsky P. Number of genomic imbalances correlates with the overall survival for adrenocortical cancer in childhood. Pediatric Blood and Cancer 2008 51 356-362. (https://doi.org/10.1002/pbc.21603)
38 Mayer SK, Oligny LL, Deal C, Yazbeck S, Gagné N & Blanchard H. Childhood adrenocortical tumors: case series and reevaluation of prognosis - a 24-year experience. Journal of Pediatric Surgery 1997 32 911-915. (https://doi.org/10.1016/s0022-3468(97)90649-7)
39 Michalkiewicz EL, Sandrini R, Bugg MF, Cristofani L, Caran E, Cardoso AM, de Lacerda L & Ribeiro RC. Clinical characteristics of small functioning adrenocortical tumors in children. Medical and Pediatric Oncology 1997 28 175-178. (https://doi.org/10.1002/ (sici)1096-911x(199703)28:3<175:aid-mpo3>3.0.co;2-g)
40 Mishra A, Agarwal G, Misra AK, Agarwal A & Mishra SK. Functioning adrenal tumours in children and adolescents: an institutional experience. ANZ Journal of Surgery 2001 71 103-107. (https://doi. org/10.1046/j.1440-1622.2001.02045.x)
41 Mittal R, Ramadan DG, Khalifa NM, Khalifa SO, Mazidi Z & Zaki M. Adrenocortical tumors in children: a Kuwait experience. Gulf Journal of Oncology 2012 12 38-46.
42 Narasimhan KL, Samujh R, Bhansali A, Marwaha RK, Chowdhary SK, Radotra BD & Rao KL. Adrenocortical tumors in childhood. Pediatric Surgery International 2003 19 432-435. (https://doi.org/10.1007/ s00383-002-0727-1)
43 Panamonta O, Areemit S, Srinakarin J, Siritunyaporn S & Tuksapun S. Adrenocortical tumors in children. Journal of the Medical Association of Thailand 2001 84 188-194.
44 Parise IZS, Parise GA, Noronha L, Surakhy M, Woiski TD, Silva DB, Costa TEB, Del-Valle MHCP, Komechen H, Rosati R et al. The prognostic role of CD8(+) T lymphocytes in childhood adrenocortical carcinomas compared to Ki-67, PD-1, PD-L1, and the Weiss score. Cancers 2019 11 1730. (https://doi.org/10.3390/cancers11111730)
45 Sakoda A, Mushtaq I, Levitt G & Sebire NJ. Clinical and histopathological features of adrenocortical neoplasms in children: retrospective review from a single specialist center. Journal of Pediatric Surgery 2014 49 410-415. (https://doi.org/10.1016/j. jpedsurg.2013.09.008)
46 Stewart JN, Flageole H & Kavan P. A surgical approach to adrenocortical tumors in children: the mainstay of treatment. Journal of Pediatric Surgery 2004 39 759-763. (https://doi.org/10.1016/j. jpedsurg.2004.01.029)
47 Wang J, Qi F, Zhang P, Xu Z, Zheng Y, Cai H, Yu B, Xu T, Li X & Zou Q. Clinical characteristics and genetic testing of an atypical familial von Hippel-Lindauzon renal cell carcinoma. Annals of Translational Medicine 2019 7 677. (https://doi.org/10.21037/atm.2019.10.09)
48 Wu X, Xu J, Wang J, Gu W & Zou C. Childhood adrenocortical tumor: a clinical and immunohistochemical study of 13 cases. Medicine 2019 98 e17921. (https://doi.org/10.1097/MD.0000000000017921)
49 Zancanella P, Pianovski MA, Oliveira BH, Ferman S, Piovezan GC, Lichtvan LL, Voss SZ, Stinghen ST, Callefe LG, Parise GA et al. Mitotane associated with cisplatin, etoposide, and doxorubicin in advanced childhood adrenocortical carcinoma: mitotane monitoring and tumor regression. Journal of Pediatric Hematology/Oncology 2006 28 513-524. (https://doi.org/10.1097/01.mph.0000212965.52759.1c)
50 Zerbini C, Kozakewich HPW, Weinberg DS, Mundt DJ, Edwards JA & Lack EE. Adrenocortical neoplasms in childhood and adolescence: analysis of prognostic factors including DNA content. Endocrine Pathology 1992 3 116-128. (https://doi.org/10.1007/BF02921352)
51 Mattone MC, Gil S, Costanzo M, Galluzzo Mutti ML, Casanovas A, Zaidman V, Lazzati JM, Ciaccio M, Belgorosky A & Guercio G. Pediatric adrenocortical tumors cohort characteristics and long-term follow-up at a single Argentinian tertiary center. Journal of Pediatric Endocrinology and Metabolism 2022 35 19-27. (https://doi.org/10.1515/ jpem-2021-0392)
52 Cordeiro AM, Da Graca Bicalho M, Marques-Pereira R, Franca PP, Moraes MM, Rezende GYT, Nesi-Franca S, Sandrini R & De Lacerda L.
Allelic frequencies of HLA-A, HLA-B and HLA-DRB1 genes in patients with adrenocortical tumor carriers of the germline mutation R337H in the TP53 gene. Endocrine Reviews 2012 33.
53 Rodriguez-Galindo C, Krailo MD, Pinto EM, Pashankar F, Weldon CB, Huang L, Caran EM, Hicks J, McCarville MB, Malkin D et al. Treatment of pediatric adrenocortical carcinoma with surgery, retroperitoneal lymph node dissection, and chemotherapy: the Children’s Oncology Group ARAR0332 protocol. Journal of Clinical Oncology 2021 39 2463-2473. (https://doi.org/10.1200/JCO.20.02871)
54 Ribeiro RC, Sandrini Neto RS, Schell MJ, Lacerda L, Sambaio GA & Cat I. Adrenocortical carcinoma in children: a study of 40 cases. Journal of Clinical Oncology 1990 8 67-74. (https://doi.org/10.1200/ JCO.1990.8.1.67)
55 Virgone C, Roganovic J, Vorwerk P, Redlich A, Schneider DT, Janic D, Bien E, Lopez-Almaraz R, Godzinski J, Osterlundh G et al. Adrenocortical tumours in children and adolescents: the EXPERT/ PARTNER diagnostic and therapeutic recommendations. Pediatric Blood and Cancer 2021 68 (Supplement 4) e29025. (https://doi. org/10.1002/pbc.29025)
56 Cagle PT, Hough AJ, Pysher TJ, Page DL, Johnson EH, Kirkland RT, Holcombe JH & Hawkins EP. Comparison of adrenal cortical tumors in children and adults. Cancer 1986 57 2235-2237. (https://doi.org/10.1002/1097-0142(19860601)57:11<2235:aid- cncr2820571127>3.0.co;2-o)
57 Picard C, Orbach D, Carton M, Brugieres L, Renaudin K, Aubert S, Berrebi D, Galmiche L, Dujardin F, Leblond P et al. Revisiting the role of the pathological grading in pediatric adrenal cortical tumors: results from a national cohort study with pathological review. Modern Pathology 2019 32 546-559. (https://doi.org/10.1038/s41379- 018-0174-8)
58 Blavier L, Yang RM & DeClerck YA. The tumor microenvironment in neuroblastoma: new players, new mechanisms of interaction and new perspectives. Cancers 2020 12 2912. (https://doi.org/10.3390/ cancers12102912)
59 Lane DP. Cancer. p53, guardian of the genome. Nature 1992 358 15-16. (https://doi.org/10.1038/358015a0)
60 Gulack BC, Rialon KL, Englum BR, Kim J, Talbot LJ, Adibe OO, Rice HE & Tracy ET. Factors associated with survival in pediatric adrenocortical carcinoma: an analysis of the National Cancer Data Base (NCDB). Journal of Pediatric Surgery 2016 51 172-177. (https://doi.org/10.1016/j. jpedsurg.2015.10.039)
61 Martins-Filho SN, Almeida MQ, Soares I, Wakamatsu A, Alves VAF, Fragoso MCBV & Zerbini MCN. Clinical impact of pathological features including the Ki-67 labeling index on diagnosis and prognosis of adult and pediatric adrenocortical tumors. Endocrine Pathology 2021 32 288-300. (https://doi.org/10.1007/s12022-020-09654-x)
62 Pinto EM, Rodriguez-Galindo C, Pounds SB, Wang L, Clay MR, Neale G, Garfinkle EAR, Lam CG, Levy CF, Pappo AS et al. Identification of clinical and biologic correlates associated with outcome in children with adrenocortical tumors without germline TP53 mutations: ASt Jude Adrenocortical Tumor Registry and Children’s Oncology Group study. Journal of Clinical Oncology 2017 35 3956-3963. (https://doi.org/10.1200/JCO.2017.74.2460)