JJCO
Japanese Journal of Clinical Oncology
Cancer Genetics Report
Novel Germ Line Mutation p53-P177R in Adult Adrenocortical Carcinoma Producing Neuron-specific Enolase as a Possible Marker
Hisamitsu Ide1, Yuichi Terado2, Shino Tokiwa1, Kojiro Nishio1, Keisuke Saito1, Shuji Isotani1, Yutaka Kamiyama 1, Satoru Muto1, Tetsuo Imamura3 and Shigeo Horie 1,*
1Department of Urology, Teikyo University School of Medicine, 2Department of Pathology, Kyorin University School of Medicine and 3Department of Surgical Pathology, Teikyo University School of Medicine, Tokyo, Japan
*For reprints and all correspondence: Shigeo Horie, Department of Urology, Teikyo University School of Medicine, Kaga 2-11-1, Itabashi, Tokyo, Japan. E-mail: shorie@med.teikyo-u.ac.jp
Received November 29, 2009; accepted February 23, 2010
Adrenocortical cancer (ACC) is a rare and aggressive endocrine tumor. The patient presented with a large retroperitoneum tumor and lung metastases. Removal of the adrenocortical tumor with part of the transverse colon and tail of the pancreas, spleen and kidney was suc- cessfully performed following chemotherapy. Levels of serum neuron-specific enolase (NSE) were found to be markedly high before surgery and may be clinically useful markers for moni- toring tumor status during management. Immunohistochemical studies showed that the cancer cells were positive for NSE and overexpression of p53. We identified a novel germ line variant of the 177 mutant (Pro to Arg; P177R) of p53 by genomic sequencing. The genetic and biochemical data presented in this case confirm the importance of screening for p53 status in ACC with inherited cancer syndrome.
Key words: adernocortical carcinoma - p53 - mutation - neuron-specific enolase
INTRODUCTION
Adrenocortical cancer (ACC) is a rare malignancy, account- ing in large studies for 0.02% of all cancers deaths (1). At the time of presentation, the median tumor size in adults is ~10 cm, and 30-40% of patients have clear evidence of metastatic disease (1-3). Complete surgical resection is the treatment of choice, but it remains a crucial problem that many patients present with locally advanced or metastatic disease. Chemotherapeutic agents consisting of etoposide, doxorubicin and cisplatin with mitotane have shown favor- able results, and the FIRM-ACT study (First International Randomized trial in locally advanced and Metastatic Adenocortical Carcinoma Treatment) is currently underway (2). However, the prognosis of patients with inoperable or metastatic disease is dismal, with an estimated 5-year survi- val rate of close to 0% (3).
ACC is a component of Li-Fraumeni syndrome, an inher- ited cancer syndrome consisting primary of soft-tissue sarco- mas, and brain and breast cancers, as well as a wide variety of other malignant tumors (4). Germ line p53 hotspot mutations strongly predispose carriers to cancer in both chil- dren and young adults. p53 gene mutation causes inacti- vation or dominant-negative effects on p53 function, which negatively control cell growth and viability. The high fre- quency of mutations at codons 175, 245, 248, 273 and 282 has led to these areas being referred to as hotspots (4,5).
We report here a 31-year-old patient with ACC associated with a novel germ line mutation of p53 resulting in an amino acid change of proline to arginine at codon 177 (p.P177R). We found that serum levels of neuron-specific enolase (NSE) may be a potential marker of adrenocortical tumors for detection of recurrence and monitoring of tumor status after chemotherapy.
CASE REPORT AND GENETIC ANALYSIS
A 31-year-old woman was referred from another hospital with a chief complaint of left abdominal pain. On computed tomography (CT), a large adrenal mass (20 × 13 × 13 cm) was seen as an enhanced cystic tumor with necrotic lesions on the left kidney (Fig. 1A and B). She had no past history but family history; i.e. both of her parents died from cancer. Unfortunately, there were no remaining records of her parents’ cancer deaths, as they died over 20 yeas earlier, and her relatives could provide no further information about her parents’ history. Imaging data suggested that the ACC adhered tightly to the transverse colon, pancreas and left kidney (Fig. 1A and B). Chest CT revealed two small nodules (about 1 cm) in the lung (Fig. 1C). Laboratory tests showed high serum levels of cortisol (22.6 µg/dl), lactate dehydrogenase (2227 IU), alkaline phosphatase (439 IU) and NSE (280 ng/ml). Serum aldosterone, catecholamine,
A
2006
B
=
A
C
D
300
Surgery
250
NSE (ng/ml)
200
150
100
50
Chemotherapy
0
2006.10.24
2006.11.15
2006.12.4
2007.1.29
2007.2.16
2007.3.26
2007.5.10
2007.6.4
2007.6.30
2007.8.9
2007.9.6
testosterone, 17-ketosteroids and dihydroepiandosterone levels were within normal ranges.
Given the tumor size, abdominal pain and patient prefer- ences, she was scheduled for open radical nephrectomy with removal of the ACC, transverse colon and tail of the pan- creas and spleen. The large tumor was successfully removed intact without any rupture and measured 20 x 13 x 8 cm. Macroscopically, the specimen was an encapsulated mass surrounded by a thin rim of yellow tissue. A cut section showed rough and yellowish tissue interspersed with brown areas of hemorrhage and necrosis (Fig. 3C). Owing to pul- monary involvement, four cycles of systemic chemotherapy were planned, in accordance with the EDP scheme (etopo- side 100 mg/m2, on days 5-7, doxorubicin 20 mg/m2, on days 1 and 8, and cisplatin 40 mg/ m2, on days 1 and 9, every 4 weeks) (6). Oral mitotane was given concomitantly with chemotherapy and between cycles, at a starting dose of 1 g/day, increasing to 4 g/day. To prevent adrenal insuffi- ciency, hydrocortisone at a daily dose of 37.5 mg was given. The patient received two cycles of chemotherapy and CT scans showed regression of pulmonary metastases (Fig. 1C and D). The patient underwent surgical resection of pulmon- ary metastases following two more courses of chemotherapy. After tumor removal, serum NSE levels were rapidly nor- malized within weeks. However, new pulmonary metastases appeared at 4 months after pulmonary resection. Serum NSE levels were again elevated when recurrence and metastasis were detected (Fig. 2). The patient refused to undergo further chemotherapy and died 6 months later.
Histologically, tumor cells had foamy clear cytoplasm or eosinophilic cytoplasm, and proliferated in solid or trabecu- lar nests with capillary networks. They occasionally had unusual, giant nuclei and frequent mitosis. Tumor cells showed clear vascular permeation in the primary and pul- monary region (Fig. 3A and B). There was little of the normal rim of the adrenal gland in the background, and the tumor was diagnosed as cortical carcinoma derived from the left adrenal gland. On immunohistochemical study, cancer cells stained positive for p53 (Fig. 3D) and NSE (Fig. 3F), but negative for chromogranin A (Fig. 3E). p53 protein was strongly expressed and accumulated within the nucleus (Fig. 3D). The patient was referred for genetic evaluation of the adrenal tumors. She provided written informed consent and the genetic audit adhered to the guidelines and principles of the Declaration of Helsinki. Somatic and germ line sequence analysis of the coding region of p53 identified a missense mutation in the L2 loop of the DNA-binding domain (7), predicting the p.P177R variant (Mitsubishi Chemical Medience Corp., Tokyo, Japan) (Fig. 4).
DISCUSSION
ACC patients can present with symptoms of a specific hor- monal syndrome or can present with non-specific symptoms
A
B
×200
×200
C
D
×200
E
F
×200
×200
resulting from an abdominal mass. The present patient had non-specific abdominal pain on the left side. Although her blood tests showed cortisol hypersecretion, she had no hor- monal oversecretion syndromes such as Cushing syndrome, virilization and hyperaldosteronism. Glucocorticoids and/or androgens are the steroids most frequently oversecreted, whereas hypersecretion of aldosterone or estradiol is rare (2,3,8). A large cohort study of ACC patients has recently demonstrated poor prognosis associated with cortisol- secreting tumors (8). The immunosuppressive effects of excess cortisol were suggested to favor tumor development and metastases. In this case, high serum levels of NSE were also detected at diagnosis and decreased significantly after surgery. NSE levels then rapidly increased with tumor pro- gression at metastatic sites. Although NSE is considered to be a marker for neuroendocrine tissues, ACC is extensively positive for NSE on immunohistochemical analysis (9).
Serum NSE levels may thus be a useful ACC marker during therapeutic intervention.
This is the first report of a missense mutation at codon 177 occurring as a germ line p53 abnormality. This codon lies within a highly conserved region of the gene, and this region is a frequent site for both acquired and inherited mis- sense mutations (3-5). Most germ line p53 mutations have been found in families with strong histories of cancer. Indeed, both of her parents died from cancer, which suggests Li-Fraumeni syndrome. Wild-type p53 has been demon- strated to induce apoptosis within the context of DNA damage; loss of wild-type p53 is thought to result in abroga- tion of apoptosis in DNA-damaged cells, leading to propa- gation of DNA lesions that could result in neoplastic transformation (10).
The p53 mutation in this study was located in the L2 loop of the DNA-binding domain and is a unique germ line
Codon no.
175 Arg
176 177 Cys Pro/Arg
178 His
179
His
CGCT G CC CC CAC CAT G
Peripheral blood cells
Codon no.
175 Arg
176 Cys
177 Pro/Arg
178 His
179
His
C GC TG CCCCCACCAT G
Cancer tissues
mutation. It has also been described in sporadic malignan- cies in the International Agency for Research on Cancer (IARC) TP53 mutation database (http://www-p53.iarc.fr/).
According to the database, this mutation leads to non- functional transactivation of p53. Despite the lack of infor- mation about the oncogenic activity of this mutation in ACC, the present findings are important and may aid in devising management strategies for Li-Fraumeni patients. Because of the consequences of germ line p53 mutations among these individuals and their relatives, genetic testing is important for risk assessment in adrenocarcinoma.
Conflict of interest statement
None declared.
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