Michaela Kuhlen*, Stefan A. Wudy, Clara Baumann, Christian Vokuhl, Michaela F. Hartmann, Marina Kunstreich, Rainer Claus and Antje Redlich
Prolonged symptom duration and the potential for gradual progression in pediatric adrenocortical tumors: observations from the MET studies
https://doi.org/10.1515/jpem-2025-0198 Received April 10, 2025; accepted June 17, 2025; published online June 30, 2025
Abstract
Objectives: To explore the clinical spectrum and symptom duration in pediatric adrenocortical tumors (pACTs), with a focus on identifying cases that may reflect gradual tumor progression.
Methods: We retrospectively analyzed data from 110 pediatric patients with pACTs enrolled in the German Pedi- atric Oncology Hematology-Malignant Endocrine Tumor (GPOH-MET) studies (1997-2022). Endocrine symptom dura- tion, histopathological classification, and clinical outcomes were assessed. Patients with symptom durations ≥2 standard
deviations (SDs) from the mean were defined as outliers and evaluated for potential progression.
Results: The cohort included 31 patients with adrenocor- tical adenomas (ACAs), 12 with tumors of uncertain malig- nant potential (ACx), and 67 with adrenocortical carcinomas (ACCs). Seven patients (6.4 %) showed markedly prolonged symptom duration, including four with ACC. One represen- tative case demonstrated a nearly 5-year course from initial androgen excess to metastatic ACC, with evolving biochem- ical features and a diagnostic urinary steroid profile indic- ative of adrenal tumor activity.
Conclusions: A small subset of pACTs may present with prolonged endocrine symptoms, possibly reflecting gradual tumor evolution. While molecular validation is lacking, these findings support the need for early recognition and further research into the natural history of pACTs.
Keywords: adrenocortical tumor; adenoma; carcinoma; sequence; children and adolescents
*Corresponding author: Michaela Kuhlen, Pediatrics and Adolescent Medicine, Faculty of Medicine, University of Augsburg, Stenglinstr. 2, D-86156 Augsburg, Germany; and Bavarian Cancer Research Center (BZKF), Augsburg, Germany, E-mail: michaela.kuhlen@uk-augsburg.de. https:// orcid.org/0000-0003-4577-0503
Stefan A. Wudy and Michaela F. Hartmann, Steroid Research & Mass Spectrometry Unit, Laboratory for Translational Hormone Analytics, Pediatric Endocrinology & Diabetology, Centre of Child and Adolescent Medicine, Justus Liebig University Giessen, Giessen, Germany. https:// orcid.org/0000-0001-7232-9532 (M.F. Hartmann)
Clara Baumann, Department of Pediatric Kidney, Liver, Metabolic and Neurological Diseases, Children’s Hospital, Hannover Medical School, Hannover, Germany
Christian Vokuhl, Section of Pediatric Pathology, Institute of Pathology, University of Bonn, Bonn, Germany. https://orcid.org/0000-0002-4138- 4536
Marina Kunstreich, Pediatrics and Adolescent Medicine, Faculty of Medicine, University of Augsburg, Augsburg, Germany; and Department of Pediatrics, Pediatric Hematology/Oncology, Otto-von-Guericke-University, Magdeburg, Germany. https://orcid.org/0000-0002-2672-4045 Rainer Claus, Bavarian Cancer Research Center (BZKF), Augsburg, Germany; and Pathology, Faculty of Medicine, University of Augsburg, Augsburg, Germany. https://orcid.org/0000-0003-2617-8766
Antje Redlich, Department of Pediatrics, Pediatric Hematology/Oncology, Otto-von-Guericke-University, Magdeburg, Germany. https://orcid.org/ 0000-0002-1732-1869
Introduction
Pediatric adrenocortical tumors (pACTs) are exceedingly rare, with an estimated incidence of 0.2-0.3 cases per million children and adolescents annually [1, 2]. These tumors pose significant challenges in diagnosis, classification, and treat- ment [3, 4].
pACTs differ markedly from their adult counterparts in both clinical behavior and molecular characteristics [5-7]. One major challenge lies in the histopathological classifica- tion. While adult ACTs are typically evaluated using the Weiss criteria [8, 9], this scoring system is not fully appli- cable to pediatric cases. As a result, pediatric-specific sys- tems, such as the Wieneke index, the Five-Item microscopic score, and the modified Reticulin Algorithm, have been developed to more accurately distinguish adrenocortical adenomas (ACAs) from adrenocortical carcinomas (ACCs), or to stratify tumors based on favorable vs. unfavorable his- tology in children and adolescents [10-13].
A subset of tumors remains difficult to classify as benign or malignant, leading to the designation of “tumors of uncertain malignant potential” (ACx). These borderline tumors may represent an intermediate stage and could potentially reflect a gradual progression from ACA to ACC in some pediatric patients.
In adult patients, there is limited evidence of a possible adenoma-carcinoma-sequence, though this progression ap- pears to be rare and remains poorly understood [14, 15]. Molecular studies in adults have shown shared genetic alterations in pathways such as Wnt/B-catenin and IGF2 between ACAs and ACCs [16], and genetic mutations in TP53, CTNNB1, and others have been implicated in tumor progression.
However, pediatric ACTs demonstrate distinct molecu- lar features [5, 7]. For example, TP53 mutations are far more common in pACTs, especially among patients with Li-Fraumeni syndrome [17], while CTNNB1 alterations are more typical of adult cases [18, 19]. These differences suggest that, even if a progression from ACA to ACC occurs in chil- dren, the underlying mechanisms may differ substantially from those in adults.
Clinically, pACTs often present with a wide spectrum of endocrine symptoms that may precede diagnosis by several months or longer [20, 21]. The variability in this pre- diagnostic interval raises important questions about tumor biology and the possibility of gradual disease evolution in select patients.
This study aims to explore the clinical characteristics and symptom duration in children and adolescents with pACTs, focusing on cases with unusually long prediagnostic intervals. Through this analysis, we seek to examine whether a prolonged course may reflect stepwise tumor progression.
Materials and methods
This study retrospectively analyzed prospectively collected clinical data from pediatric and adolescent patients (0-17 years of age) diagnosed with ACTs who were enrolled in the German Pediatric Oncology Hematology-Malignant Endo- crine Tumor (GPOH-MET) studies between 1997 and 2022.
Eligible patients had documented endocrine symptoms related to their ACT and a recorded interval between symptom onset and diagnosis. Patients without endocrine manifestations or missing data on symptom duration were excluded. Informed consent was obtained from all patients, parents, or legal guardians, as appropriate. The study pro- tocols were approved by the Ethics Committees of the
University of Luebeck (IRB 97125) and Otto-von-Guericke- University Magdeburg (IRB 174/12 and 52/22), Germany.
Endocrine symptoms were recorded from original case report forms and clinical documentation. Manifestations included virilization, Cushing syndrome, hypertension, and other hormone-related signs. For this analysis, patients with symptom duration exceeding two standard deviations (SDs) above the mean interval were classified as “outliers”, rep- resenting approximately 5% of the cohort. This threshold was selected to identify individuals with atypically pro- longed endocrine manifestations, which may indicate more gradual tumor progression.
Histopathological classification was based on reference pathology where available or on local assessment when necessary. Because patient enrollment spanned several decades, scoring systems evolved over time [8, 9]. Initially, the Weiss criteria were commonly used, but the Wieneke index later became the standard pediatric scoring system [11]. To ensure consistency, the Wieneke index [11] and the Five-Item microscopic score [12] were retrospectively calculated for all cases with sufficient histopathological data, as previously described [21].
Tumors were classified as ACA, ACx, and ACC. Particular attention was given to the group of outliers, to explore whether prolonged symptom duration was associated with more aggressive disease or clinical progression at some time.
Descriptive statistics were used to summarize de- mographic and clinical characteristics. Means and SDs were calculated for the symptom interval. Group comparisons were conducted using the chi-square test, Mann-Whitney U test, t-test, or Kruskal-Wallis test, as appropriate. Progression- free survival (PFS) was defined as the time from diagnosis to first event (nonremission, relapse, or death) and was analyzed using the Kaplan-Meier method. A p-value of <0.05 was considered statistically significant. Analyses were performed using IBM SPSS Statistics (version 29.0.0.0), and graphical displays were generated using R (version 4.3.3) and R Studio.
Results
MET cohort
A total of 110 pediatric and adolescent patients with ACTs were included in the analysis. The median age at diagnosis was 4.4 years (range 0.1-17.1 years), and the female-to-male ratio was 2.8:1. Clinical presentations varied, with viriliza- tion as the most common symptom (57.3 %, n=63), followed by Cushing syndrome (14.5 %, n=16), and a combination of both (28.2 %, n=31). Germline TP53 testing was reported in
42 patients (38 % of the total cohort). Of these, 23 patients (55 %) were identified with a tumor predisposition syn- drome, including 16 patients with pathogenic TP53 vari- ants. In 19 patients, no pathogenic germline variant was reported.
Based on histopathological classification, 31 cases were diagnosed with ACAs, 12 with ACx, and 67 with ACCs. The median interval between symptom onset and diagnosis across the cohort was 6.0 months (range 0-91.2 months). The distribution of symptom durations by tumor classification is shown in Figure 1.
Seven patients (6.4 %) were classified as outliers (mean: 6.0 months, SD: 16.8 months). These outliers included three patients with ACA and four with ACC. Detailed demographic and clinical characteristics by tumor classification and outlier status are summarized in Table 1.
Outliers were significantly older at diagnosis (median: 13.0 years) compared to the overall cohort. All seven outliers were aged ≥6.4 years, contrasting with the younger age distribution observed in ACA and ACC groups. In addition, outliers had significantly longer symptom intervals (median: 69.6 months) and were more frequently diagnosed with advanced-stage disease. Among the four ACC outliers, two presented with lymph node involvement and distant me- tastases. Ki-67 proliferation indices were elevated (30-70 %) in three of the four ACC cases, indicating high-grade malignancy.
Kaplan-Meier analysis showed significantly different outcomes by tumor classification and outlier status. At 3 years, progression-free survival (PFS) and overall survival (OS) for the total cohort were 69.5 and 78.7 %, respectively (Figure 2).
The four outlier patients with ACC were aged between 6.4 and 14.6 years (median: 9.4 years), with equal distribution by sex. Tumor volumes ranged from 120 to 1804 mL (median: 153.5 mL), with maximum diameters between 6.0 and 16.7 cm (median: 12.0 cm). Two patients presented with local inva- sion, regional lymph node metastases, and pulmonary involvement. Three patients had high Ki-67 indices (30-70 %), while one presented with a low index (2 %). Clinical outcomes varied: two patients with localized disease remained in remission at last follow-up (12.8 and 4.3 years), while the other two experienced early disease progression within 6-7 months.
Case presentation
One case had comprehensive documentation of early symptoms and urinary steroid metabotyping. The patient initially presented at 6 months of age with signs of viriliza- tion, marked by the appearance of pubic hair. By 18 months, he was referred to pediatric endocrinology due to progres- sive pubarche, penile enlargement, acne, body odor, and accelerated growth velocity with height crossing the percentiles.
Endocrinological assessment revealed elevated serum testosterone levels and suppressed gonadotropins, a constellation ruling out central precocious puberty.
Gas chromatography-mass spectrometry (GC-MS) uri- nary steroid metabotyping demonstrated significantly elevated excretion of C19 steroids, particularly the main metabolites androsterone, etiocholanolone, dehydro- epiandrosterone (DHEA), and androstenetriol-16a.
30
Median
+2 SD
Time to diagnosis in years
6
Patients
20
4.
10
2
0
0
0
2
Time to diagnosis in years
4
6
8
ACA
ACx
Diagnosis
ACC
Outlier
(A)
(B)
| ACA 28 (25.5 %) | ACx 12 (10.9 %) | ACC 63 (52.3 %) | Outliersª 7 (6.4 %) | p-Value | |
|---|---|---|---|---|---|
| Sex | 0.141 | ||||
| Female | 25 (89.3) | 9 (75.0) | 43 (68.3) | 4 (57.1) | |
| Male | 3 (10.7) | 3 (25.0) | 20 (31.7) | 3 (42.9) | |
| Age at diagnosis, years | 0.017 | ||||
| Median (range) | 3.5 (0.6-14.5) | 1.9 (0.3-13.8) | 4.4 (0.1-17.1) | 13.0 (6.4-16.0) | |
| Age groups | 0.014 | ||||
| 0-3 years | 15 (53.6) | 9 (75.0) | 28 (44.4) | 0 (0) | |
| ≥4 years | 13 (46.4) | 3 (25.0) | 35 (55.6) | 7 (100) | |
| Symptom interval, months | <0.001 | ||||
| Median (range) | 7.8 (1.2-31.2) | 4.8 (1.2-24.0) | 4.8 (0-32.4) | 69.6 (43.2-91.2) | |
| Mean (SD) | 9.6 (8.4) | 8.1 (7.2) | 6.8 (7.0) | 67.9 (15.3) | |
| Endocrine phenotype | 0.932 | ||||
| Virilization | 14 (60.7) | 8 (66.7) | 35 (55.6) | 3 (42.9) | |
| Cushing's syndrome | 4 (14.3) | 2 (16.7) | 9 (14.3) | 1 (14.3) | |
| Combined | 7 (25.0) | 2 (16.7) | 19 (30.2) | 3 (42.9) | |
| T Stage (acc. To AJCC system) | 0.002 | ||||
| T | 12 (44.4) | 2 (18.2) | 6 (10.3) | 1 (16.7) | |
| T2 | 15 (55.6) | 8 (72.7) | 28 (48.3) | 4 (66.7) | |
| T3 | 0 (0) | 0 (0) | 6 (10.3) | 0 (0) | |
| T4 | 0 (0) | 1 (9.1) | 18 (31.0) | 1 (16.7) | |
| Lymph node metastasesb | 0.185 | ||||
| NO | 27 (100) | 12 (100) | 54 (90.0) | 5 (83.3) | |
| N | 0 (0) | 0 (0) | 6 (10.0) | 1 (16.7) | |
| No data | 1 | 0 | 3 | 1 | |
| Distant metastasesb | 0.031 | ||||
| MO | 26 (100) | 12 (100) | 51 (82.3) | 5 (71.4) | |
| M | 0 (0) | 0 (0) | 11 (17.7) | 2 (28.6) | |
| No data | 2 | 0 | 1 | 0 | |
| Wieneke score | 0.001 | ||||
| <3 | 9 (90.0) | 5 (62.5) | 7 (26.9) | 3 (100) | |
| =3 | 0 (0) | 3 (37.5) | 4 (15.4) | 0 (0) | |
| >3 | 1 (10.0) | 0 (0) | 15 (57.7) | 0 (0) | |
| Five-item score | <0.001 | ||||
| ≤2 features | 25 (100) | 8 (66.7) | 6 (15.4) | 2 (100) | |
| >3 features | 0 (0) | 4 (33.3) | 33 (84.6) | 0 (0) | |
| Ki-67 index | <0.001 | ||||
| ≤15 % | 25 (96.2) | 9 (75.0) | 16 (32.7) | 3 (50.0) | |
| >15 % | 1 (3.8) | 3 (25.0) | 33 (67.3) | 3 (50.0) | |
| COG stage (for ACx/ACC) | 0.014 | ||||
| Stage I | 5 (41.7) | 10 (18.2) | 0 (0) | ||
| Stage II | 3 (25.0) | 12 (21.8) | 0 (0) | ||
| Stage III | 4 (33.3) | 22 (40.0) | 2 (50.0) | ||
| Stage IV | 0 (0) | 11 (20.0) | 2 (50.0) |
ªDefined as ≥2 standard deviations from mean interval between the onset of endocrine symptoms and diagnosis. “For ACx and ACC only; significant p-values are indicated in bold.
Additionally, excretion of 11-hydroxyandrosterone, main metabolite of the typical adrenal 11-oxygenated androgen 4-androstenedione, was clearly elevated, raising suspicion of tumorous steroid production of adrenal origin. Cortisol metabolites were within the normal range at this time, though further investigation was recommended (Table 2).
Chronological age was 1.5 years, but skeletal maturation was significantly advanced, with a metacarpal bone age of 3 years and a phalangeal bone age of 6 years. Testicular ultrasonography showed testicular volumes of 0.6 mL, respectively. The findings were interpreted as gonadotropin- independent precocious puberty, and treatment with
ACC - ACA - ACx - Outlier
ACC - ACA - ACx - Outlier
100%
100%
Progression-free survival
75%
Overall survival
75%
50%
50%
25%
25%
p<0.001
0%
p=0.003
0
5
Years after diagnosis
10
15
20
0%
0
5
Years after diagnosis
10
15
20
(a)
(b)
| Age, years | 1.5 | 5th/50th/ 95th percentile | 6.4 | 5th/50th/ 95th percentile |
|---|---|---|---|---|
| Androgen precursor and androgen metabolites | ||||
| Pregnenetriol-17a | 175 | 4/8/18 | 3,960 | 3/10/33 |
| Androsterone | 545 | 25/55/78 | 24,873 | 24/46/119 |
| Etiocholanolone | 148 | 19/45/67 | 19,694 | 20/34/113 |
| DHEA | 41 | 5/8/15 | 220,207 | 3/7/26 |
| 16a-hydroxy-DHEA | 783 | 27/60/86 | 338,176 | 27/56/118 |
| Androstenetriol-16a | 993 | 2/8/19 | 95,695 | 3/8/56 |
| Testosterone | 31 | 0/0/0 | 0 | 0/0/6 |
| -Hydroxyandrosterone | 894 | 35/82/164 | 153,143 | 52/97/185 |
| Sum C19 | 3,435 | 851,787 | ||
| Cortisol precursor and cortisol metabolites | ||||
| Tetrahydro- - | 133 | 32/48/89 | 1,509 | 22/41/137 |
| deoxycortisol | ||||
| Tetrahydrocortisone | 742 | 505/1,089/ | 5,294 | 434/1,040/ |
| 2036 | 1,648 | |||
| Tetrahydrocortisol | 444 | 214/337/591 | 1,720 | 163/312/557 |
| Allo tetrahydrocortisol | 917 | 196/502/864 | 252 | 239/461/793 |
| Cortisol | 67 | 8/20/33 | 1,084 | 18/27/48 |
| 6ß-hydroxycortisol | 194 | 16/51/106 | 7,842 | 39/86/176 |
| Sum of cortisol | 2,364 | 16,192 | ||
| metabolites | ||||
bicalutamide (nonsteroidal antiandrogen) and anastrozole (aromatase inhibitor) was initiated to mitigate further viri- lization and skeletal advancement.
At the age of 5 years and 11 months, a progression of virilization symptoms was observed, including increasing pubic hair growth and pubertal behaviors. Physical exami- nation revealed Tanner genital stage 2-3 development.
Testicular ultrasound demonstrated volumes of 1.3/1.2 mL, with no structural abnormalities. Laboratory findings showed low gonadotropins but testosterone levels in the male adult range. Treatment with leuprolide acetate (GnRH receptor agonist) was initiated, and reevaluation was rec- ommended after 6 months.
At the age of 6 years and 3 months, the patient presented to his general pediatrician with increasing abdominal girth, initially suspected to result from a gastrointestinal infection. Despite symptomatic treatment, abdominal measurements continued to increase, prompting a repeat evaluation 2 weeks later. Abdominal ultrasound identified a large intra- abdominal mass, necessitating urgent hospital admission.
Subsequent imaging revealed a 16 × 11 × 16 cm mass extending from the left upper abdomen to the lesser pelvis, with displacement to the right side (Figure 3A). Additionally, there was a tumor thrombus extending into the inferior vena cava and reaching the right atrium, intra-abdominal lymph node enlargement, as well as evidence of dissemi- nated pulmonary metastases.
GC-MS-based urinary steroid metabotyping revealed excessive levels of C19 steroids and excessive excretion of cortisol metabolites. Additionally, elevated excretion of me- tabolites of pregnenolone and tetrahydro-11-deoxycortisol further supported the diagnosis of a hormonally active ad- renal carcinoma (Table 2).
Histopathological evaluation of the tumor biopsy confirmed an ACC with a Ki-67 proliferation index of 30 % and a TP53 mutation (Figure 3B, 3C).
Next-generation sequencing of tumor tissue identified a TP53 mutation c.375G>T (p.T125=), which has been reported as a pathogenic splicing variant [22]. The high variant allele frequency (93.8 %) may indicate allelic imbalance or loss of heterozygosity (LOH) at the TP53 locus or alternatively reflect a germline variant with subsequent somatic loss of the
A
B
C
wild-type allele. Formal LOH analysis was not performed, and germline testing was not available for this patient.
Discussion
This study highlights a rare subgroup of pACTs character- ized by prolonged durations of endocrine symptoms prior to diagnosis. While most patients with pACTs present and are diagnosed within a few months, a subset of patients in our cohort (6.4 %) experienced markedly extended in- tervals - some exceeding 70 months - between the onset of clinical signs and the final diagnosis. Notably, four of these patients were ultimately diagnosed with pACC, despite symptom durations far beyond the typically rapid pro- gression observed in pACC, which is between 0.6 and 0.7 years [21, 23].
One case is particularly illustrative: a patient presented with gonadotropin-independent precocious puberty begin- ning at 6 months of age and was ultimately diagnosed with metastatic ACC nearly 5 years later. Urinary steroid profiling revealed progressive abnormalities consistent with tumorous steroidogenesis, and final histopathological ex- amination showed a high Ki-67 index and a TP53 mutation, a well-established driver in ACC pathogenesis [24].
The extended clinical course in this patient, as well as in other outliers, raises the hypothesis of a gradual evolution of tumor biology. While a histological or molecular transition from adenoma to carcinoma cannot be definitively demon- strated, the observation of slowly evolving biochemical and clinical signs, followed by late-stage aggressive disease, is suggestive of a more indolent early phase in select cases.
In adult ACTs, an adenoma-carcinoma sequence has been proposed, although such progression is considered uncom- mon [14, 25-28]. Molecular studies in adults have occasionally demonstrated overlapping mutations - particularly involving the Wnt/B-catenin and IGF2 pathways - in both benign and malignant lesions [29]. However, pediatric ACTs are molecu- larly distinct, with TP53 mutations being more prevalent and potentially driving early tumorigenesis. While conclusive evidence for a sequential transformation in pediatric ACTs is lacking, the existence of tumors with uncertain malignant potential (ACx), as well as clinical heterogeneity within ACC, supports the possibility of gradual malignant transformation in rare instances.
TP53 mutations are known to play a pivotal role in the pathogenesis of pediatric ACT and may contribute to pro- gression from benign to malignant lesions. In our patient with metastatic ACC, a somatic TP53 mutation (c.375G>T, p.T125=) was reported, which is pathogenic due to aberrant splicing as previously described [22]. The high variant allele frequency in this case may reflect loss of heterozygosity, suggesting biallelic inactivation of TP53, a potential molec- ular driver of malignant progression. While it remains speculative whether a second-hit somatic TP53 mutation could have occurred in the setting of preexisting adenoma in this patient, such mechanisms have been proposed in tumor evolution models [17, 30, 31]. These findings underline the need for comprehensive molecular studies to further eluci- date the role of sequential TP53 alterations in pediatric ACT progression.
The strong association between pediatric ACT and germline TP53 variants is well documented, with many cases fulfilling diagnostic criteria for Li-Fraumeni syndrome (LFS). Previous studies have reported germline TP53
variants in up to 50-80 % of pediatric ACT cases [24]. In our cohort, germline TP53 testing was reported in a subset of patients, but testing results were not available for the re- ported patient. The availability of germline genetic data was limited due to national legal regulations and evolving diag- nostic practice during the study period.
The presented case also underscores important diag- nostic considerations [32-34]. Despite highly abnormal uri- nary steroid profiles already evident at first endocrinological assessment, appropriate adrenal imaging was not performed. The combination of biochemical evidence of adrenal steroid excess and progressive androgenization warranted early imaging. Furthermore, the administration of GnRH agonist therapy was inappropriate in the context of continued pe- ripheral virilization. This case highlights the critical impor- tance of early, accurate diagnostic evaluation and specialized management of patients with signs of precocious puberty. Such complex cases should be referred promptly to experi- enced pediatric endocrinology centers.
Urinary steroid metabolomics proved to be a valuable tool in this case. The biochemical profile - characterized by marked elevations in C19 steroids - was already strongly suggestive of adrenal neoplasia during the early phase of disease. The sub- sequent emergence of elevated excretion of metabolites of pregnenolone and tetrahydro-11-deoxycortisol further sup- ported the diagnosis of an adrenal carcinoma. These findings emphasize the diagnostic potential of GC-MS-based urinary steroid profiling in distinguishing benign causes of precocious puberty from adrenal tumors and in raising early suspicion of malignancy [35, 36].
Despite its strengths, this study is limited by the absence of longitudinal molecular data and the availability of biochemical profiles at first presentation and at diagnosis of ACC in only a single case. Our clinical observations - particularly in patients with long-standing endocrine symptoms who later developed histologically confirmed ACC - suggest that in rare cases, a more indolent or staged tumor evolution may occur.
Future prospective studies combining serial clinical, biochemical, and molecular assessments will be essential to clarify the natural history of pACTs and to determine whether sequential malignant transformation can occur. Such insights may ultimately improve early detection, risk stratification, and therapeutic decision-making in this rare and challenging pediatric malignancy.
Conclusions
This study highlights a rare subset of pediatric adrenocor- tical tumors with unusually prolonged endocrine symptom duration prior to diagnosis. In exceptional cases, a gradual
progression from hormonally active tumor to carcinoma may occur. Although molecular confirmation is lacking, evolving clinical and biochemical features support this possibility. Urinary steroid profiling proved valuable in early detection and risk assessment. These findings under- score the need for timely evaluation and further research into tumor progression in pediatric ACTs.
Research ethics: The MET studies were approved by the Ethics Committee of the University of Luebeck (IRB 97125) and Otto-von-Guericke University Magdeburg (IRB 174/12 and 52/22), Germany.
Informed consent: Informed consent for participation in the study was obtained from all participants or, where applicable, from their parents or legal guardians. Informed consent for the publication of data was included as part of the informed consent process.
Author contributions: MiKu: Conceptualization, Methodol- ogy, Investigation, Resources, Writing-original draft, Writing-review & editing, Supervision, Project administra- tion, Funding acquisition. SAW: Investigation, Writing- review & editing. CB: Investigation, Writing-review & edit- ing. MFH: Investigation, Writing-review & editing. MaKu: Investigation, Writing-review & editing, Project adminis- tration. CV: Investigation, Writing-review & editing. RC: Methodology, Writing-original draft, Writing-review & editing. AR: Formal analysis, Resources, Data Curation, Visualization, Writing-review & editing, Project adminis- tration, Funding acquisition. All authors have accepted re- sponsibility for the entire content of this manuscript and approved its submission.
Use of Large Language Models, AI and Machine Learning Tools: To improve language ChatGPT was used.
Conflict of interest: The authors state no conflict of interest.
Research funding: The German MET studies were funded by Deutsche Kinderkrebsstiftung, grant number DKS 2014.06, DKS 2017.16, DKS 2021.11, DKS 2024.16, Mitteldeutsche Kind- erkrebsforschung, and Magdeburger Förderkreis kreb- skranker Kinder e.V.
Data availability: Not applicable.
References
1. Siegel DA, King J, Tai E, Buchanan N, Ajani UA, Li J. Cancer incidence rates and trends among children and adolescents in the United States, 2001-2009. Pediatrics 2014;134:e945-55.
2. Dall’Igna P, Virgone C, De Salvo GL, Bertorelle R, Indolfi P, De Paoli A, et al. Adrenocortical tumors in Italian children: analysis of clinical characteristics and P53 status. Data from the national registries. J Pediatr Surg 2014;49:1367-71.
3. O’Neill AF, Ribeiro RC, Pinto EM, Clay MR, Zambetti GP, Orr BA, et al. Pediatric adrenocortical carcinoma: the nuts and bolts of diagnosis and treatment and avenues for future discovery. Cancer Manage Res 2024; 16:1141-53.
4. Virgone C, Roganovic J, Vorwerk P, Redlich A, Schneider DT, Janic D, et al. Adrenocortical tumours in children and adolescents: the EXPERT/ PARTNER diagnostic and therapeutic recommendations. Pediatr Blood Cancer 2021;68:e29025.
5. Faria AM, Almeida MQ. Differences in the molecular mechanisms of adrenocortical tumorigenesis between children and adults. Mol Cell Endocrinol 2012;351:52-7.
6. Grisanti S, Cosentini D, Lagana M, Turla A, Berruti A. Different management of adrenocortical carcinoma in children compared to adults: is it time to share guidelines? Endocrine 2021;74:475-7.
7. Ghosh C, Hu J, Kebebew E. Advances in translational research of the rare cancer type adrenocortical carcinoma. Nat Rev Cancer 2023;23: 805-24.
8. Weiss LM. Comparative histologic study of 43 metastasizing and nonmetastasizing adrenocortical tumors. Am J Surg Pathol 1984;8: 163-9.
9. Weiss LM, Medeiros LJ, Vickery AL Jr. Pathologic features of prognostic significance in adrenocortical carcinoma. Am J Surg Pathol 1989;13:202-6.
10. Lopez-Nunez O, Virgone C, Kletskaya IS, Santoro L, Giuliani S, Okoye B, et al. Diagnostic utility of a modified reticulin algorithm in pediatric adrenocortical neoplasms. Am J Surg Pathol 2024;48:309-16.
11. Wieneke JA, Thompson LD, Heffess CS. Adrenal cortical neoplasms in the pediatric population: a clinicopathologic and immunophenotypic analysis of 83 patients. Am J Surg Pathol 2003;27:867-81.
12. Picard C, Orbach D, Carton M, Brugieres L, Renaudin K, Aubert S, et al. Revisiting the role of the pathological grading in pediatric adrenal cortical tumors: results from a national cohort study with pathological review. Mod Pathol 2019;32:546-59.
13. Jangir H, Ahuja I, Agarwal S, Jain V, Meena JP, Agarwala S, et al. Pediatric adrenocortical neoplasms: a study comparing three histopathological scoring systems. Endocr Pathol 2023;34:213-23.
14. Belmihoub I, Silvera S, Sibony M, Dousset B, Legmann P, Bertagna X, et al. From benign adrenal incidentaloma to adrenocortical carcinoma: an exceptional random event. Eur J Endocrinol 2017;176:K15-9.
15. Reimondo G, Muller A, Ingargiola E, Puglisi S, Terzolo M. Is follow-up of adrenal incidentalomas always mandatory? Endocrinol Metab 2020;35: 26-35.
16. Heaton JH, Wood MA, Kim AC, Lima LO, Barlaskar FM, Almeida MQ, et al. Progression to adrenocortical tumorigenesis in mice and humans through insulin-like growth factor 2 and beta-catenin. Am J Pathol 2012; 181:1017-33.
17. Pinto EM, Chen X, Easton J, Finkelstein D, Liu Z, Pounds S, et al. Genomic landscape of paediatric adrenocortical tumours. Nat Commun 2015;6: 6302.
18. Crona J, Beuschlein F. Adrenocortical carcinoma - towards genomics guided clinical care. Nat Rev Endocrinol 2019;15:548-60.
19. Zheng S, Cherniack AD, Dewal N, Moffitt RA, Danilova L, Murray BA, et al. Comprehensive pan-genomic characterization of adrenocortical carcinoma. Cancer Cell 2016;30:363.
20. Kunstreich M, Dunstheimer D, Mier P, Holterhus PM, Wudy SA, Huebner A, et al. The endocrine phenotype induced by pediatric adrenocortical tumors is age- and sex-dependent. J Clin Endocrinol Metab 2024;109:2053-60.
21. Kuhlen M, Kunstreich M, Wudy SA, Holterhus PM, Lessel L, Schneider DT, et al. Outcome for pediatric adreno-cortical tumors is best predicted by the COG stage and five-item microscopic score- report from the German MET studies. Cancers 2022;15. https://doi.org/ 10.3390/cancers15010225.
22. Carbonnier V, Leroy B, Rosenberg S, Soussi T. Comprehensive assessment of TP53 loss of function using multiple combinatorial mutagenesis libraries. Sci Rep 2020;10:20368.
23. Kuhlen M, Kunstreich M, Lessel L, Wudy SA, Holterhus P-M, Vokuhl C, et al. Refractory and relapsed paediatric ACC in the MET studies - a challenging situation necessitating novel diagnostic and therapeutic concepts. EJC Paediatr Oncol 2023;1. https://doi.org/10.1016/j.ejcped. 2023.100015.
24. Wasserman JD, Novokmet A, Eichler-Jonsson C, Ribeiro RC, Rodriguez- Galindo C, Zambetti GP, et al. Prevalence and functional consequence of TP53 mutations in pediatric adrenocortical carcinoma: a children’s oncology group study. J Clin Oncol 2015;33:602-9.
25. Gharib E, Robichaud GA. From crypts to cancer: a holistic perspective on colorectal carcinogenesis and therapeutic strategies. Int J Mol Sci 2024;25. https://doi.org/10.3390/ijms25179463.
26. Thuzar M, Perry-Keene DA, d’Emden MC, Duncan EL. An adrenocortical carcinoma evolving from A small adrenal incidentaloma after years of latency. AACE Clin Case Rep 2018;4:65-9.
27. Fassnacht M, Arlt W, Bancos I, Dralle H, Newell-Price J, Sahdev A, et al. Management of adrenal incidentalomas: European society of endocrinology clinical practice guideline in collaboration with the European network for the study of adrenal tumors. Eur J Endocrinol 2016;175:G1-34.
28. Fassnacht M, Tsagarakis S, Terzolo M, Tabarin A, Sahdev A, Newell- Price J, et al. European Society of endocrinology clinical practice guidelines on the management of adrenal incidentalomas, in collaboration with the European network for the study of adrenal tumors. Eur J Endocrinol 2023;189:G1-42.
29. Berthon A, Sahut-Barnola I, Lambert-Langlais S, de Joussineau C, Damon-Soubeyrand C, Louiset E, et al. Constitutive beta-catenin activation induces adrenal hyperplasia and promotes adrenal cancer development. Hum Mol Genet 2010;19:1561-76.
30. Knudson AG Jr. Mutation and cancer: statistical study of retinoblastoma. Proc Natl Acad Sci U S A 1971;68:820-3.
31. Bougeard G, Renaux-Petel M, Flaman JM, Charbonnier C, Fermey P, Belotti M, et al. Revisiting Li-Fraumeni syndrome from TP53 mutation carriers. J Clin Oncol 2015;33:2345-52.
32. Mohnike K, Palm K, Richter-Unruh A. Aktualisierte Handlungsempfehlung nach der Leitlinie Pubertas praecox. Monatsschr Kinderheilkd 2021;169:1171-3.
33. diabetologie DGfKu, e.V. D. S1-Leitlinie - Pubertas praecox. AWMF Leitlinie. 2019; Version 1.0(AWMF-Register-Nummer Nr. 174-015).
34. Carel JC, Leger J. Clinical practice. Precocious puberty. N Engl J Med 2008;358:2366-77.
35. Hartmann M, Pons-Kühnemann J, Kunstreich M, Redlich A, Vorwerk P, Kuhlen M, et al. Detection and differentiation of adrenocortical tumors (ACTs) in children by gas chromatography- mass spectrometry (GC-MS) based urinary steroid metabotyping. Hormone Res Paediatr 2024;97: 1-736. Abstr FC8.2.
36. Wudy SA, Schuler G, Sanchez-Guijo A, Hartmann MF. The art of measuring steroids: principles and practice of current hormonal steroid analysis. J Steroid Biochem Mol Biol 2018;179:88-103.