Wecan VI .SINCE 1925*
CASE REPORT WITH REVIEW OF LITERATURE
A case of mineralocorticoid intermediate-producing sarcomatoid adrenal cortical carcinoma: case report and review of literature
Maki Kanzawa1),2) (D, Miki Watanabe3), Masaaki Yamamoto4) (D, Tomoko Nishigaki4), Masaki Suzuki4),
Hidenori Fukuoka3) (D, Tomoaki Terakawa5), Katsumi Shigemura5), Hiroki Shimada6),
Yasuhiro Nakamura6), Wataru Ogawa4) and Tomoo Itoh2)
1) Department of Diagnostic Pathology, Kobe City Nishi-Kobe Medical Center, Kobe, Japan
2) Department of Diagnostic Pathology, Kobe University Hospital, Kobe, Japan
3) Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Hospital, Kobe, Japan
4) Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
5) Division of Urology, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan
6) Division of Pathology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
Abstract. Sarcomatoid adrenal cortical carcinoma (SACC) is an extremely rare histological subtype accounting for only 0.2% of all adrenal cortical carcinomas. Most reported cases of SACC are nonfunctional, showing a biphasic histological pattern with both epithelial adrenocortical carcinoma and sarcomatous components, which are often associated with poor prognosis. Herein, we report a unique case of SACC with characteristics distinct from those previously documented. A 66- year-old man presented with uncontrolled hypertension, night sweats, exertional dyspnea, and palpitations. Imaging revealed an 11 cm mass in the left adrenal gland. Laboratory results indicated hypokalemia with suppressed plasma renin and aldosterone levels and the presence of mineralocorticoid intermediates, notably elevated deoxycorticosterone (DOC), detected via LC-MS/MS. The patient underwent a left adrenalectomy. Histologically, the tumor consisted solely of spindle cells without the typical adrenocortical carcinoma components. Immunohistochemical analysis demonstrated partial positivity for steroidogenic enzymes, including 3ß-hydroxysteroid dehydrogenase, cytochrome P450 family 21 subfamily A member 2 (CYP21A2) and cytochrome P450 family 11 subfamily B member 1 (CYP11B1). This finding was consistent with RNA expression analysis, supporting the synthesis of mineralocorticoid intermediates within the tumor. However, the discrepancy between the measured steroid intermediate metabolites and enzyme expression patterns in the tumor, as indicated by immunostaining and mRNA levels, suggests that the steroid production pathway in this tumor remains partially unclear. Two years postoperatively, the patient has remained free from recurrence or metastasis. This case holds particular value, as it is the first report to describe hormone production in a SACC composed solely of spindle cells.
Key words: Sarcomatoid adrenal cortical carcinoma, Mineralocorticoid intermediate, 11-Deoxycorticosterone, Steroidogenic factor-1, Spindle cells
Introduction
Adrenal cortical carcinoma (ACC) is a rare malig- nancy with a five-year survival rate of less than 60% [1]. ACC exhibits various histological subtypes, with the “conventional” subtype accounting for 97% of patients,
Submitted Dec. 19, 2024; Accepted May 9, 2025 as EJ24-0687 Released online in J-STAGE as advance publication Jun. 18, 2025 Correspondence to: Masaaki Yamamoto, MD, PHD, Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki, Chuo, Kobe, 650-0017, Japan.
E-mail: yamamasa@med.kobe-u.ac.jp
whereas rarer subtypes such as myxoid (0.8%), onco- cytic (2%), and sarcomatoid variants (0.2%) are far less common [2].
Among ACCs, 67.5% exhibited hormone-secreting properties. Specifically, 24.5% were cortisol-secreting, 13% were androgen-secreting, and 28% were secreting both androgen and cortisol [3]. Mineralocorticoid- secreting ACCs are rare, representing only 2% of all patients, with 11-deoxycorticosterone (DOC)-producing ACCs being even rarer, reported in only 9 out of 807 patients with ACC (1%) [3]. However, detailed histologi- cal descriptions of these patients are limited.
Sarcomatoid ACC (SACC) is an extremely rare
CC
7
=
BY NC ND
histological subtype, typically characterized by a bipha- sic pattern of epithelial adrenocortical carcinoma and sarcomatous components. However, in certain cases, such as the current case, the tumor may consist entirely of spindle cells lacking conventional adrenocortical car- cinoma features. SACC is often clinically nonfunctional, with few cases that are secreting hormones, likely due to sarcomatous transformation, which reduces the steroido- genic capacity of the tumor [4].
Here, we report the first case of mineralocorticoid intermediate-producing SACC confirmed using immuno- histochemistry and steroid profile analyses, offering novel insights into the histopathological and functional characteristics of this rare ACC variant.
Materials and Methods
Immunohistochemical analysis
We performed staining for steroidogenic acute regula- tory protein (StAR) and steroid synthase enzymes, including 3ß-hydroxysteroid dehydrogenase (3ßHSD), cytochrome P450 family 11 subfamily A member 1 (CYP11A1), cytochrome P450 family 21 subfamily A member 2 (CYP21A2), cytochrome P450 family 11 sub- family B member 1 (CYP11B1), and cytochrome P450 family 11 subfamily B member 2 (CYP11B2). Antibody details are provided in Supplementary Table 1.
RNA extraction and real-time PCR
RNA was extracted from tissue randomly dissected from the tumor’s paraffin block using the RNeasy FFPE Kit (QIAGEN). cDNA was synthesized from 1 µg of purified RNA using the ReverTra Ace qPCR RT Master Mix with gDNA Remover (TOYOBO) in a Takara PCR Thermal Cycler Dice Touch (TAKARA). qPCR was performed in 10 uL reactions using either the THUNDERBIRD Probe qPCR Mix (TOYOBO) for CYP11B1, CYP11B2, CYP17A1, and HSD3B2 or the THUNDERBIRD NEXT SYBR qPCR Mix (TOYOBO) for other targets on a QuantStudio 3 system (Applied Biosystems). The nucleotide sequences of the primers are provided in Supplementary Table 2.
Electron microscopy
Ultrastructural analysis was performed using formalin- fixed, paraffin-embedded (FFPE) sample. FFPE blocks were deparaffinized using xylene and rehydrated through a graded ethanol series. The samples were then post-fixed with 1% osmium tetroxide, dehydrated in ethanol, and embedded in epoxy resin. Ultrathin sections (70 nm) were cut using an ultramicrotome and stained with uranyl acetate and lead citrate. Electron micrographs were obtained using a HT7800 transmission electron microscope.
Case Presentation
The patient was a 66-year-old man with a history of hypertension which had been well-controlled with 1-2 antihypertensive drugs since the age of 50 years. His medical history included hyperuricemia, dyslipidemia, reflux esophagitis, inguinal hernia, and cataracts. Since age 65, the patient has experienced worsening blood pressure control, night sweats, shortness of breath during exertion, and palpitations. A computed tomography (CT) scan was performed as screening to investigate these symptoms and revealed a large tumor in the left adrenal gland; hence, he was referred to our department.
On physical examination, the patient’s height was 162.6 cm, weight was 76.8 kg (BMI 28.9 kg/m2), blood pressure was 140/76 mmHg, pulse was 98 beats per minute, and body temperature was 36.7℃. The patient had hypertension and mild bilateral leg edema but with no signs of excess cortisol or androgenization. Upon admission, the antihypertensive regimen of the patient included Benidipine Hydrochloride 8 mg, Sacubitril Valsartan Sodium Hydrate 200 mg, Esaxerenone 5 mg, Doxazosin Mesylate 8 mg, and Potassium Chloride 191 mEq. Despite significant potassium supplementa- tion, the patient exhibited hypokalemia (K 2.8 mmol/L) with suppression of both the active renin concentration (ARC) and plasma aldosterone concentration (PAC) (ARC 0.99 pg/mL, PAC 5.2 pg/mL). No prior intake of medication that could cause pseudoaldosteronism was reported. Blood tests showed an ACTH level of 35.0 pg/mL and a cortisol level of 7.5 µg/dL, suggesting the absence of autonomous cortisol secretion. Addition- ally, dehydroepiandrosterone sulfate (DHEA-S) levels were 598 µg/dL, with no noted elevation. Plasma-free metanephrine and normetanephrine levels were within normal ranges. Blood test results are summarized in Table 1.
Given the patient’s hypertension, hypokalemia, and low renin and aldosterone levels, we considered the possibility of mineralocorticoid intermediate-producing tumors. Plasma steroid hormone levels were measured using LC-MS/MS by Aska Pharma Medical Co., Ltd. (Tokyo, Japan). The results revealed that preoperative levels of progesterone, deoxycorticosterone (DOC), cor- ticosterone, and 11-dehydrocorticosterone were elevated above the reference range (Table 2). DOC levels were approximately 187 times the preoperative upper limit of the reference range. Based on these findings and the patient’s clinical characteristics, the tumor was suspected to be producing mineralocorticoid intermediates.
Contrast-enhanced CT showed an 11 cm tumor in the left adrenal gland with nearly absent contrast enhance- ment (Fig. 1a, b). An 18F-FDG-PET-CT scan showed
| Hematological and Biochemical findings | Endocrinological findings | Normal range | ||
|---|---|---|---|---|
| white blood cell (/mL) | 5,200 | ACTH (pg/mL) | 35.0 | 7.7-63.1 |
| Hb (g/dL) | 12.6 | Cortisol (mg/dL) | 7.5 | 5.9-17.0 |
| Ht (%) | 36.2 | ARC (pg/mL) | 0.99 | 2.21-39.49 |
| Plt (/mL) | 216 × 103 | PAC (pg/mL) | 5.2 | 3.0-82.1 |
| APTT (sec) | 27.9 | MN (pg/mL) | 32.0 | <130 |
| PT-INR | 1.09 | NMN (pg/mL) | 105.0 | <506 |
| D-dimer (mg/mL) | 0.8 | DHEA-S (ng/ml) | 598 | 240-2,440 |
| TP (g/dL) | 6.5 | |||
| Alb (g/dL) | 3.2 | |||
| AST (U/L) | 19 | |||
| ALT (U/L) | 19 | |||
| y-GTP (U/L) | 18 | |||
| ALP (U/L) | 79 | |||
| LDH (U/L) | 236 | |||
| CK (U/L) | 386 | |||
| BUN (mmol/L) | 10.0 | |||
| Cr (mg/dL) | 0.62 | |||
| eGFR (mL/min/1.73 m2) | 98.3 | |||
| Na (mmol/L) | 144 | |||
| K (mmol/L) | 2.8 | |||
| Cl (mmol/L) | 101 | |||
| Glucose (mg/dL) | 135 | |||
| HbA1c (%) | 6.3 | |||
ARC: active renin concentration, PAC: plasma aldosterone concentration, MN: plasma-free metanephrine, NMN: plasma- free normetanephrine, DHEA-S: dehydroepiandrosterone sulfate
high FDG accumulation in the left adrenal tumor without abnormal accumulation in other organs (Fig. 1c). Based on the clinical diagnosis of an adrenal tumor-producing mineralocorticoid intermediate, surgery was promptly performed.
The resected tumor was 11 cm in diameter and located adjacent to the left kidney; however, it was not directly connected (Fig. 2a). Grossly, it appeared as a yellow solid mass with hemorrhage (Fig. 2b). Despite sampling 18 parts of the tumor (Fig. 2c), no conventional adreno- cortical carcinomatous or heterologous components were observed. The tumor showed a dense proliferation of atypical spindle cells with highly polymorphic, irregu- larly shaped nuclei and eosinophilic cytoplasm, which appeared to be an undifferentiated sarcoma (Fig. 3). Mitosis was relatively low (2 per 2 mm2), necrosis was absent, and the Ki-67 labeling index was 7.5%. Although the tumor was within the adrenal gland, a small amount of residual adrenocortical tissue was observed surround-
ing the tumor margins with an unclear adrenocortical ori- gin based on hematoxylin and eosin (HE) staining.
Immunohistochemical analyses were performed to exclude metastatic carcinoma, sarcoma, and mesothelioma. Most cells were negative for steroidogenic factor-1 (SF-1), except in a few cells (Fig. 3). Calretinin expression was focally positive, whereas that of Wilms’ tumor protein 1 (WT-1) was negative. Other adrenocortical markers, such as inhibin and melan-A, were negative. Imaging studies did not identify any organs other than the adrenal gland as a potential primary site, and AE1/3 and CAM5.2 were negative, ruling out metastatic carcinoma. Various sarcomas, including liposarcoma, epithelioid sarcoma, leiomyosarcoma, rhabdomyosarcoma, gastroin- testinal stromal tumor, malignant peripheral nerve sheath tumor, and mesothelioma, were excluded based on the negative results for markers including S100, murine dou- ble minute 2 (MDM2), cytokeratins (AE1/3 CAM5.2), CD34, desmin, myogenin, CD117 (c-kit) and podoplanin
| Before surgery | After surgery | Reference range | |
|---|---|---|---|
| P5ª (ng/ml) | 1.17 | 0.16 | 0.17-1.50 |
| P4b (ng/ml) | 2.41 | 0.03 | 0.03-0.17 |
| DOCe (ng/ml) | 20.59 | 0.01 | 0.01-0.11 |
| Bd (ng/ml) | 11.2 | 1.73 | 0.39-7.19 |
| Ae (ng/ml) | 3.32 | 0.64 | 0.15-2.16 |
| 17-OHP5f (pg/mL) | 711.4 | 590.6 | 222.1-2,887.5 |
| 17-OHP4% (pg/mL) | 1,036.8 | 650.1 | 114.7-1,982.3 |
| 21-DOFh (pg/mL) | 0.0 | 0.0 | ND |
| 11-DOFi (ng/ml) | 2.88 | 0.26 | 0.05-0.85 |
| Fi (ng/ml) | 93.18 | 132.19 | 31.72-278.10 |
| Ek (ng/ml) | 17.46 | 19.23 | 7.56-60.86 |
| DHEAl (ng/mL) | 1.03 | 1.04 | 1.12-7.38 |
| A-dione™ (pg/mL) | 573.6 | 496.2 | 310.5-1,006.8 |
| 45A-diol" (pg/mL) | 620.7 | 972.5 | 431.3-2,018.3 |
| T° (ng/ml) | 2.73 | 4.70 | 2.19-9.00 |
| DHTP (pg/mL) | 257.9 | 349.3 | 148.8-846.4 |
a: Pregnenolone, b: Progesterone, c: 11-Deoxycorticosterone, d: Corticosterone, c: 11- Dehydrocorticosterone, f: 17-Hydroxypregnenolone, 8: 17-Hydroxyprogesterone, h: 21-Deoxycortisol, i: 11-Deoxycortisol, j: Cortisol, k: Cortisone, 1: Dehydroepiandrosterone, ™: Androstenedione, n: Androstenediol, º: Testosterone, P: Dihydrotestosterone, ND: not determined Reference ranges were provided by Aska Pharma Medical.
a
b
C
(D2-40). Despite weak SF-1 expression, other carcino- mas, sarcomas, and mesotheliomas were excluded based on immunohistochemical results. Considering the clini- cal presentation of intermediate mineralocorticoid production, the patient was diagnosed with SACC. Angioinvasion and invasion of the surrounding tissues were not observed. The Weiss criteria were counted as three points: a decrease in clear cells, diffuse architec- ture, and profound nuclear atypia.
To support the diagnosis of mineralocorticoid intermediate-producing SACC, immunohistochemical
analysis was performed on five selected slides. Markers included SF-1, StAR, and steroid synthases, includ- ing 3ßHSD, CYP11A1, CYP21A2, CYP11B1 and CYP11B2. The tumor cells showed partial positivity for 3฿HSD, CYP21A2 and CYP11B1, but the positive cells differed for each marker. All sections were negative for StAR, CYP11A1, and CYP11B2 (Fig. 3). To investigate molecules involved in steroid synthesis and metabolism- related genes at the RNA level, RNA was extracted from the tumor paraffin block and analyzed by qPCR. Most targets were detectable; however, CYP17A1 and
a
b
C
10
1
5
16
11
6
12
2
7
17
13
14
8
3
18
15
9
4
10
Section
Positive control
1
3
7
13
17
HE
SF-1
StAR
CYP11A1
3ß-HSD
CYP21A2
CYP11B1
CYP11B2
CYP11B2 were not expressed at the RNA level (Fig. 4).
To further assess the steroidogenic potential, electron microscopy revealed an absence of lipid droplets com- pared to background adrenal cortical cell, but abundant mitochondria with tubulovesicular cristae, which is help- ful only to characterize a lesion as derived from steroido- genic lineage [5] and small amounts of endoplasmic reticulum (ER) (Fig. 5).
Following surgery, the patient’s blood pressure decreased rapidly, and potassium levels normalized. Sup- pression of both ARC and PAC was resolved. The preop- erative and postoperative dynamics of potassium levels, renin-aldosterone activity, and medication adjustments are provided in Table 3. Postoperative plasma steroid hormone levels demonstrated that all elevated mineralo- corticoid intermediates had returned to normal (Table 2).
10000
mRNA/ RPL13A
1000
100
10
1
0.1
ND
ND
NR5A1
STAR
CYP11A1
CYP17A1
HSD3B2
CYP21A2
CYP11B1
CYP11B2
| Before surgery | After surgery | |
|---|---|---|
| K (mmol/L) | 2.8 | 4.4 |
| ARC (pg/mL) | 0.99 | 21.56 |
| PAC (pg/mL) | 5.2 | 36.5 |
| Medication | ||
| Potassium Chloride (mEq) | 191 | |
| Benidipine (mg) | 8 | |
| Doxazosin (mg) | 8 | |
| Sacubitril/Valsartan (mg) | 200 | |
| Spironolactone (mg) | 100 | |
| Azosemide (mg) | 15 | |
| Indapamide (mg) | 1 | |
| Amlodipine (mg) | 10 |
a
b
n
*
Based on the ENS@T staging system, the patient was classified as Stage II, with a tumor size of 11 cm, no evidence of invasion into surrounding tissues, and no lymph node or distant metastases [6]. According to the S-GRAS scoring system, the patient scored 2 points owing to being over 50 years old and exhibiting hormone secretion symptoms. The patient was classified as ENS@T Stage II, with a Ki-67 index of 6% (below the 10% threshold for higher recurrence risk) and achieved complete surgical resection (R0). These factors do not contribute additional points to the S-GRAS scoring system, thus indicating a relatively low risk of recurrence [7].
Given these considerations, adjuvant therapy with mitotane was not initiated. Instead, the patient was placed under careful postoperative follow-up with imag- ing studies every 3 months to monitor for recurrence. This approach was chosen based on the patient’s clinical profile and current recommendations for low-risk cases.
Two years postoperatively, the patient has remained free from any signs of recurrence or metastasis.
Discussion
Here, we report a case of mineralocorticoid intermediate-producing SACC that was identified based on clinical data and confirmed by immunohistochemistry and steroid profiling (Graphical Abstract).
Patients with SACC were extremely rare, and to date, a search for case reports of histologically confirmed SACC has identified 26 patients aside from our patient (Table 4) [4, 8-30]. Reported patients with SACC were characterized by patient ages ranging from 23 to 79 years, with 14 of the 26 patients being women. The tumors were large (median size: 12.75 cm, interquartile range (IQR) 10.5-15.0), survival duration was short (median: 4.25 months, IQR 2.75-7.25), and there was a high incidence of metastasis (20/26 patients), indicating a poor prognosis. Histologically, 23 of the 26 patients exhibited a biphasic pattern consisting of epithelial adrenocortical carcinoma and sarcomatous components, commonly referred to as carcinosarcoma. The remaining three patients did not specify whether a biphasic pattern
| Case | Age | Sex | Symptoms | Endocrine Dysfunction | Tumor Location | Tumor Size (cm) | Monophasic or Biphasic | Histological Features of Sarcomatoid Component | Weiss criteria | SF-1 IHC | Metastases/ Recurrence | Prognosis | Reference |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Case | 46 | M | Abdominal distention | No | R | 14 | NA | Sarcomatoid | NA | NA | Right atrium | 6 months DOD | Okazumi (1987) [5] |
| Case 2 | 68 | F | Abdominal discomfort | No | R | 11 | Biphasic | Spindle cells | 4 | NA | Lung, liver, abdomen, vertebra | 6 months DOD | Collina (1989) [6] |
| Case 3 | 42 | F | Left upper abdominal pain, fullness, satiety | No | L | 19× 14×12 | Biphasic | Rhabdomyosarcoma | NA | NA | Lungs | 7 months DOD | Decorato (1990) [7] |
| Case 4 | 29 | F | Hirsutism, amenorrhea, weight loss | virilization | L | 12.5 | Biphasic | Rhabdomyosarcoma | NA | NA | Rapid local and metastatic recurrence | 8 months DOD | Fischler (1992) [8] |
| Case 5 | 79 | F | Severe hypertension, hypokalemia | Hyperaldosteronism | R | 9 | Biphasic | Osteogenic and chondroid differentiation | NA | NA | Liver and bone | 4 months DOD | Barksdale (1993) [9] |
| Case 6 | 61 | M | Right flank pain radiating to back and iliac crest | Slightly elevated 24-hour urine VMA | R | 12 | Biphasic | Spindle cells | Renal vein and liver | 2 days DOD | Lee (1997) [10] | ||
| Case 7 | 31 | M | Asthenia, left upper abdominal pain | No | L | 12 × 7 × 5.5 | Biphasic | Spindle cells | 8 | NA | Locoregional recurrence | 3 months DOD | Sturm (2008) [11] |
| Case 8 | 75 | F | Left abdominal pain | No | L | 15× 10×9 | Biphasic | Spindle cells | NA | NA | Liver | 12 months DOD | Coli (2010) [12] |
| Case 9 | 45 | M | Pain, Weight loss | No | L | 17× 6×6 | Biphasic | Rhabdomyosarcoma | NA | NA | Liver | 3 months DOD | Sasaki (2010) [13] |
| Case 10 | 72 | M | Right flank pain, low fever, palpable mass | No | R | 13 × 9 | Biphasic | Pleomorphic | NA | NA | Lungs | 6 months DOD | Yan (2012) [14] |
| Case 11 | 23 | F | Occasional finding | No | L | 14 | Biphasic | Osteosarcoma | 7 | NA | Bone, lung, liver, lymph nodes and cerebellum | 14 months DOD | Bertolini (2011) [15] |
| Case 12 | 45 | M | Abdominal bloating, back pain | No | L | 24 | Biphasic | Rhabdomyosarcoma | NA | NA | Retroabdominal lymph nodes, lung, and brain | 11 months DOD | Thway (2012) [16] |
| Case 13 | 48 | F | Abdominal pain, weight loss | R | 14.9 × 13.3×9.0 | Biphasic | Spindle cells | NA | NA | Lung and Liver | Alive at 7 months | Kao (2013) [17] | |
| Case 14 | 62 | F | Abdominal pain, weight loss, weakness | No | R | 4.9 × 3.3 | Biphasic | Spindle cells | NA | NA | Left adrenal and para- aortic lymph node | 3 months DOD | Shaikh (2014) [18] |
| Case | Age | Sex | Symptoms | Endocrine Dysfunction | Tumor Location | Tumor Size (cm) | Monophasic or Biphasic | Histological Features of Sarcomatoid Component | Weiss criteria | SF-1 IHC | Metastases/ Recurrence | Prognosis | Reference |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Case 15 | 58 | M | pain | No | R | 12 × 6 × 5 | Biphasic | Spindle cells | NA | NA | No | Alive at 7 months | Mark (2014) [4] |
| Case 16 | 63 | F | Pain, Weight loss | No | L | 8 | Biphasic | Spindle cells | NA | NA | No | Alive at 1 months | Wei (2015) [19] |
| Case 17 | 69 | F | Abdominal pain | Adrenal cortex hypofunction | Bilateral | 5.5 × 3×3(R) 7 × 3.5×2(L) | Biphasic | Spindle cells | NA | negative | Liver and abdominal lymph nodes | 1 months DOD | Ishikawa (2016) [20] |
| Case 18 | 53 | F | Abdominal and flank pain, weight loss | No | Bilateral | 9 × 6.5×4(R) 8 × 6 ×3.5 (L) | Biphasic | Spindle cells | NA | NA | No | 2 months DOD | Turhan (2016) [21] |
| Case 19 | 55 | M | Abdominal pain | No | L | 16 | Biphasic | Spindle cells | 9 | NA | Abdominal | 4 months DOD | Papathomas (2016) [22] |
| Case 20 | 70 | F | Abdominal pain | No | R | 15 | Biphasic | Osteosarcoma | 8 | NA | Liver, Lung and Bone | 8 months DOD | Papathomas (2016) [22] |
| Case 21 | 52 | M | Abdominal pain | No | R | 24 | Biphasic | Spindle cells | 5 | NA | Liver, Pleura | 4.5 months DOD | Papathomas (2016) [22] |
| Case 22 | 53 | M | Hypertension, diabetes mellitus type II, and hyperlipidemia | No | R | 13 × 8 × 6.5 | Biphasic | Spindle cells | 5 | Strong (epithelioid), Weak (sarcomatoid) | Liver | Alive at 6 months | Saeger (2017) [23] |
| Case 23 | 51 | M | Nonspecific | NA | R | 15 | Biphasic | Spindle cells | 6 | NA | Liver, Lung | 1.7 months DOD | Sung (2017) [24] |
| Case 24 | 27 | F | Right flank pain, moderate weight loss | No | R | 125 x 9 x 75 | Biphasic | Spindle cells | 6 | NA | No | Alive at 6 months | Sabrine (2020) [25] |
| Case 25 | 53 | M | Abdominal pain | No | R | 5.5 × 5.3×7.2 | NA | Pleomorphic | NA | NA | No | 6 months DOD | Zhang (2022 ) [26] |
| Case 26 | 78 | F | Fatigue and shoulder pain | NA | R | 27x 17×12 | Biphasic | Spindle cells | NA | NA | No | 7 days DOD | Branham (2022) [27] |
| Current Case | 66 | M | Leg edema, worsening hypertension | Mineralocorticoid intermediates | L | 11 | Monophasic | Spindle cells | 3 | Scantly positive | No | Alive at 2 years |
M:male, F: female, NA: not associated, R: right, L: left, DOD: dead of disease, IHC: immunohistochemistry
IHC-
IHC +
Cholesterol
mRNA -
mRNA +
StAR -
StAR +
Steroid profile : before surgery→after surgery
Cholesterol
CYP11A1 -
11A1 +
Pregnenolone 1.17→0.16 ng/ml
CYP17A1 -
17-OH-pregnenolone
36HSD+
HSD3B2+
17A1-
36HSD +
HSD3B2+
Progesterone 2.41→0.03 ng/ml
17-OH-progesterone 1.03→0.65 ng/ml
CYP21A2+
CYP21A2+
11-Deoxycorticosterone 20.59→0.01 ng/ml
11-Deoxycortisol 2.88→0.26 ng/ml
CYP11B1+
B2-
CYP11B1+
B2-
CYP11B1 +
CYP11B1+
3฿HSD
CYP21A2
Corticosterone 11.2→1.73 ng/mL
Cortisol
CYP11B2-
CYP11B2-
Aldosterone
-
Graphical Abstract
was present. In this case, multiple slides from 18 sections were examined to identify the conventional adrenocorti- cal carcinoma components; however, none were identi- fied. Therefore, the diagnosis was monophasic SACC, consisting entirely of spindle cells. SF-1 is considered the most reliable biomarker for confirming adrenal corti- cal origin when the specimen is properly fixed [31]. In this case, the large tumor required an extended fixation time, possibly leading to reduced staining due to over- fixation. A few reported cases included SF-1 staining, with one report indicating weak positivity in the sarco- matous component [26]. In our patient, SF-1 expression was weak, consistent with previous reports, suggesting that low SF-1 expression may be associated with sarco- matous changes and reduced steroidogenic capacity. Fur- thermore, studies have correlated high SF-1 expression with increased mitotic activity and tumor stage but not hormone functionality [32]. However, further accumula- tion of cases is required to clarify the relationship between SF-1 negativity and tumor functionality.
In patients with SACC composed entirely of spin- dle cells, the main histological challenge is distinguish- ing it from retroperitoneal sarcoma and metastases of carcinomas to other organs [33]. Several possible tumor types were considered, including retroperitoneal liposarcoma, epithelioid sarcoma, rhabdomyosarcoma, leiomyosarcoma, mesothelioma, and metastatic carci- noma. These were excluded based on the absence of MDM2 amplification in fluorescence in situ hybridiza- tion, negative staining for epithelial markers (AE1/3, CAM5.2), striated muscle markers (Myo-D1, Myf-4), smooth muscle markers (desmin, a-SMA), and mesothe-
lial markers (Calretinin, WT-1), as well as the absence of a primary site and negative results for AE1/3 and CAM5.2. Given the clinical presentation of mineralocor- ticoid excess, the tumor was diagnosed as a SACC com- posed of pure spindle cells.
As described in Table 4, SACC is typically nonfunc- tional, with local symptoms and pain being predominant. Only four patients presented with endocrine dysfunction, including virilization, hyperaldosteronism, slightly ele- vated 24-h vanillylmandelic acid (VMA), and adrenal cortical hypofunction. This suggests that the production of androstenedione, aldosterone, and VMA is based on clinical symptoms and blood tests. Another case pre- sented with hypokalemia, although no hormone produc- tion was evident [20]. To date, no patients with DOC production, such as the current case, have been reported. Immunohistochemistry of steroid synthases revealed that expression of certain enzymes particularly required for DOC production (CYP21A2 and 3ßHSD) was detected in localized areas, although their distribution did not align. This discrepancy could be attributed to disorga- nized steroidogenesis within the tumor. The absence of expected synthetic enzymes, StAR, CYP11A1, and CYP17A1 in IHC suggests several possibilities: (1) the hormone produced by the tumor may be present in minute quantities, thus rendering it undetectable by IHC; (2) enzyme overfixation may have compromised detec- tion; (3) disorganized steroidogenesis throughout the tumor may have resulted in non-expression in the ana- lyzed sections; or (4) rapid hormone transport into the bloodstream, facilitated by abundant intervening blood vessels, may have prevented its retention within tumor cells.
In the analysis of mRNA expression in the tumor, the expression levels of all molecules were low, likely due to RNA degradation and fragmentation from formalin fixation. As a result, quantitative evaluation of mRNA expression was challenging. However, qualitatively, most molecules showed detectable expression, whereas CYP17A1 and CYP11B2 were not expressed at all, which was consistent with the clinical phenotype.
Electron microscopy revealed the presence of mito- chondria with tubulovesicular cristae and ER in the tumor cells, further indicating the potential for steroid synthesis.
SACC carries a poor prognosis, as evidenced by a short median survival duration and a high incidence of metastasis across reported cases. However, the correla- tion between histological subtype and prognosis remains unclear. Criteria such as those of Weiss et al. for adreno- cortical tumors emphasize factors such as necrosis, increased mitotic figures, angioinvasion, and a high Ki-67 labeling index rather than sarcomatoid histology [33, 34]. According to the WHO 2022 guidelines, incom- plete resection and dissemination are associated with poor prognosis. In this case, resection was complete, no angioinvasion was observed, and both the Ki-67 labeling index and mitotic count were relatively low, indicating the absence of poor prognostic factors. The patient remains alive two years post-surgery without signs of metastasis or recurrence and has not received any post- operative treatment.
In conclusion, we report a case of a mineralocorticoid intermediate-producing SACC composed entirely of spindle cells. To date, no previous reports have addressed hormone production in SACC, which consists solely of spindle cells making this case particularly valuable. However, discrepancies between various tests related to hormone production suggest that the mechanisms of hor- mone synthesis in this tumor remain unclear. Further investigation of more cases is necessary to better under-
stand these mechanisms.
Declarations
Author contributions
Pathological diagnosis: M.K., Y.N., and T.I., RNA expression analysis: H.S. and M.S. Immunohistochemical analysis: M.K. and Y.N. Clinical diagnosis/treatment including surgery: M.W., T.N., T.T., K.S. and M.Y., Literature and data collection and review: M.K., M.S., and M.Y .; Writing - original draft preparation: M.K. and M.W .; Writing - review and editing: M.Y., H.F., and W.O .; Supervision: M.Y. All authors reviewed and approved the final version of the manuscript for publication.
Acknowledgments
We would like to thank Editage (www.editage.com) for the English language editing.
Funding
This study was partially supported by the Japan Society for the Promotion of Science (KAKENHI, grant number 23K08008 (MY)).
Disclosure
H.F. is a member of Endocrine Journal’s Editorial Board.
Ethics declarations
The analysis of mRNA expression in tumor tissue was conducted in compliance with the provisions of the Declaration of Helsinki and approved by the Ethics Committee of Kobe University Graduate School of Medicine (Approval #1646).
Consent for publication
Informed consent for publication of all data obtained from the patient.
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