Received: 30 December 2016
WILEY
Journal of SURGICAL ONCOLOGY
Diagnostic and prognostic role of SF1, IGF2, Ki67, p53, adiponectin, and leptin receptors in human adrenal cortical tumors
Anna Babińska1 iD | Rafał Pęksa2 Piotr Wiśniewski1
Renata Świątkowska-Stodulska1
Krzysztof Sworczak1
1 Department of Endocrinology and Internal Medicine, Medical University of Gdansk, Gdansk, Poland
2 Department of Pathology, Medical University of Gdansk, Gdansk, Poland
Correspondence
Anna Babińska MD, Department of Endocrinology and Internal Medicine, Medical University of Gdansk, ul. Dębinki 7, 80-288 Gdańsk, Poland. Email: a.mail@wp.pl
Background: The authors have examined the immunohistochemical expression of several proteins and their relationship with adrenal cortical carcinoma (ACC) diagnosis and progression. Materials and Methods: A total of 83 patients with benign and malignant adrenal cortex tumors operated on in a single center were included in the study. Expression of the following proteins was examined: steroidogenic factor 1 (SF1), insulin growth factor 2 (IGF2), Ki67, p53, as well as adiponectin (Adipo R1, Adipo R2), and leptin (Ob-R) receptors.
Results: Multivariate analysis revealed that the expression of SF1, IGF2, and Adipo R1 and R2 receptors was associated with ACC diagnosis. An acknowledged proliferation marker Ki67 was related with the size of ACC and was an independent ACC diagnosis marker. The authors also assessed the relationship between immunohistochemical parameters and overall survival (OS) and disease progression. Only high IGF2 expression was associated with longer OS (P = 0.025). The most significant one for the prognosis of ACC patients was tumor resectability of the primary tumor. More favorable prognosis was found for young men (P = 0.033).
Conclusions: The presented data indicate that immunohistochemical assessment (of IGF2, SF1, Adipo R1, and R2 receptors’ expression) may be useful in making the diagnosis of uncertain ACC cases.
KEYWORDS
adiponectin and leptin receptors, adrenal tumors, IGF2, Ki 67, p53, SF1
1 INTRODUCTION
Adrenal cortical carcinoma (ACC) is a neoplasm with poor prognosis that is diagnosed in 0.5-2 cases per million per year.1-3 The neoplasm metastasizes early, most commonly to the liver, lungs, and bones, which worsens the prognosis. The prevalence of adrenocortical cancer among incidentally diagnosed tumors is 2-12%.2,3
Weiss criteria are universally applied in differentiating between benign and malignant adrenal cortex tumors, however, this classification does not encompass all cases.4 Sometimes differentiating between adrenal cortex cancer (ACC) and adenoma (ACA) is difficult. ACC risk in tumors up to 4 cm in diameter is 2%, in tumors measuring 4-6 cm, 6%, and in tumors larger than 6 cm, 25% are primary malignant neoplasms
of adrenal cortex.2-4 Weiss criteria are useful in diagnosing ACC, however, they may be ambiguous, if there is no local invasion by the neoplasm or distant metastases.4 What is applied in these cases are other proliferation markers, such as Ki67, p53, as well as IGF2, and SF1. Some of them serve an important role in assessing progression of the adrenal neoplasm. However, research reports may be contradictory.1,5-9
The role of adipokines in the development of human endocrine neoplasms has not been elucidated. There are few studies where expression of adiponectin and leptin receptors in adrenal gland neoplasms in human were investigated. However, the relationship between hormonal activity of adipose tissue and tumorigenesis of adrenal tumors seems significant.10,11
Reports on adiponectin and leptin receptors in neoplasms not associated with obesity11 and the fact that at least some ACC patients are hypercortesolemic as well as have increased BMI, led the authors to examine the presence of Adipo R1 and Adipo R2 or leptin receptors
[Correction added on 5 July 2017, after first online publication: Reference 9 was updated.]
and their expression in adrenal tumor tissue. We also decided to assess whether they constitute a prognostic factors in ACC.
In our study, the usefulness of immunohistochemical expression of SF1, IGF2, Ki67, p53, Adipo R1, and R2, as well as leptin Ob-R was examined in differentiating between benign and malignant tumors. In ACC patients, a relationship was investigated between expression of these proteins and clinical data: tumor size, relapse-free survival (RFS), and overall survival (OS). The authors of the study analyzed cancer tissue specimens of patients operated in a single hospital. The tumor size, RFS, and OS were all assessed based on retrospective data patients’ clinical characteristics. An attempt was made at an assessment of the role of various immunohistochemical parameters assessed in ACC diagnosis and of its course in patients undergoing surgery in a single hospital.
2 MATERIALS AND METHODS
The study included 83 patients diagnosed with an adrenal tumor. All of them had been hospitalized in the Department of Endocrinology and Internal Medicine of the Medical University of Gdańsk between 1995 and 2014. Patients were aged 23-92 (mean age 52.5 years).
The study material comprised tissue specimens of resected adrenal tumors; there were 63 cases of an adrenal cortex adenoma (ACA) and nodular hyperplasia (ACH), and 20 cases of adrenal cortex cancers (ACC).
The histopathological diagnosis is difficult at times and does not allow to clearly differentiate between ACC and ACA. In the present study, patients were selected, whose histopathological diagnosis was certain and who were followed-up for 5-20 years. Patients with benign tumors included here are a mere fraction of all adrenal tumor patients of our Department (in total 1870 patients with adrenal tumors are followed-up), but this group is representative and includes individuals who have not had a recurrence of the neoplasm.
The histological type of the tumor was determined according to the 2004 World Health Organization classification (Pathology and Genetics of Tumors of Endocrine Organs, Lyon, 2004). All adrenal cortex tumors were assessed by two independent pathologists.
We assessed immunohistochemical staining for acknowledged parameters, that is, Ki67, p53, SF1, IGF2, as well as so far unexamined adipokine antibodies Adipo R1, R2, and leptin Ob-R in malignant and benign adrenal cortex tumors.
Tumor tissue was preserved according to standard procedures (fixed for approximately 48 h in 10% formaldehyde solution, later dehydrated using appropriate alcohol, and xylene solutions, and, finally, embedded in low melting point paraffin). Tissue specimens of analyzed cases were re- assessed in routinely prepared hematoxin-eozin (H&E) stains to verify the histopathological diagnosis. From the studied specimens fragments most representative for neoplasm were chosen; there were neither necrotic lesions nor thermal damage areas in these fragments.
Selected specimens along with respective paraffin blocks were used to map tumor areas extracted for tissue microarrays. This was done using 1.5-mm diameter needles. Tumor cores were inserted in pre-prepared “recipient” paraffin blocks that contained no tissue. The complete tissue microarrays were created using Manual tissue arrayer
I by Beecher Instruments (MTAI, K7 BioSystems). At least three cores (biopsies) of neoplastic tissue were removed. This way, at least ten microarrays were acquired. Additionally, in every newly created recipient block, cores of palatine tonsil and stomach wall were inserted, which served as internal control and facilitated orientation among cores acquired from different specimens within one block. This orientation method allowed for localizing a specific core of a given tumor specimen.
2.1 | Preparation of specimens
Immunochistochemical stains were made with microtome sections of 4 um thickness. They were placed on Superfrost PLUS slides (by Surgipath) and later incubated overnight at 37ºC.
Antibodies used for detection along with the applied methodology of immunohistochemical stains are presented in Table 1.
2.2 | Assessment of immunohistochemical reactivity and statistical analysis
Antigen expression was assessed in three samples acquired from the same tumor. The assessment comprised the percentage of cells with positive reactivity (0-100%) as well as the intensity of reactivity (0-3), and was expressed as their product (H-score). For each tumor, three scores were calculated, however, the highest of these was considered final.
H-score values were classified as follows: 0-100 denoted lack or low antigen expression, 101-200-moderate antigen expression, 201- 300-high antigen expression. Ki67 expression was quantified in so- called “hot spots” as percentage of 100-500 cells (Table 2).
2.3 | Statistical analysis
Standard descriptive statistics were calculated. Differences between groups were determined using linear regression with robust standard errors. Correlations were assessed using Spearman’s method. To assess the relationship between antigen expression and ACC diagnosis, probability logistic regression was applied. Kaplan-Meier method was used to generate functions of survival, median, 1-year and 5-year survival. The relationship between OS, RFS, and clinical data was assessed using Cox proportional hazard regression. RFS is defined as the time of diagnosis to development of first evidence of clinical or radiographic disease recurrence (local, regional, or distant). In some analyses, several quantitative variables (eg tumor size) were categorized using median values as threshold. A value of P < 0.050 was considered statistically significant. All calculations were performed using a PC computer and STATA v13.1 statistical software package (StataCorp LP, TX).
3 | RESULTS
3.1 | Results of differentiation between malignant and benign adrenal cortex tumors
The relationship between expression of antigens and the odds ratio of an ACC diagnosis is shown in Table 3.
| Target | Catalog number | Dilution | Epitope retrieval | Incubation time | Control tissue | Metod of evaluation | Location reaction |
|---|---|---|---|---|---|---|---|
| SF-1 | ab58077 | 1:100 | PTlink DAKO | night | colon | Semi-quantitative | nuclear |
| IGF 2 | ab170304 | 1:200 | PTlink DAKO | night | placenta | Semi-quantitative | cytoplasmic |
| Adipo R1 | ab126611 | 1:50 | PTlink DAKO | 60' | endometrium | Semi-quantitative | cytoplasmic |
| Adipo R2 | LS-B9345 | 1:50 | PTlink DAKO | night | small intestine | Semi-quantitative | cytoplasmic |
| Leptin Ob- R | ab2139 | 1:10 | PTlink DAKO | 60' | placenta | Semi-quantitative | cytoplasmic |
| p53 | REF. IR616 | Autostainer | PTlink DAKO | 20' | stomach | Semi-quantitative | nuclear |
| Ki67 | REF. IR629 | Autostainer | PTlink DAKO | 20' | lymph node | quantitative | nuclear |
Adipo R1, adiponectin receptor 1; Adipo R2, adiponectin receptor 2; Ob- R, leptin receptor; SF1, steroidogenic factor 1; IGF2, insulin growth factor 2.
In a univariate model, higher Ki67, Adipo R1, and R2, leptin Ob .- R receptors’ expression was associated with higher odds ratio of ACC diagnosis. In the multivariate model, a statistically significant relation- ship was found for SF1, IGF2, and Adipo R1 and R2 receptors. A one unit increase in H-score was associated with a, respectively, 14%, 22%, 23%, 36% higher odds ratio of an ACC diagnosis adjusted for age, gender, tumor size, and hormonal activity.
The observed differences between crude and adjusted OR indicated confounding. For all examined antigens, the main con- founder was tumor size. Excluding this variable from the analysis led to overestimation of the influence of Ki67, p53, and underestimation of the influence of SF1, IGF2, and Adipo R1, R2, and leptin Ob .- R receptors on the odds ratio of ACC diagnosis.
Authors of the study demonstrated that acknowledged prolifera- tion markers Ki67 and p53 correlate mainly with tumor size and not ACC diagnosis. Obviously, ACC are usually large tumors with a dynamic growth potential, however, in the case of unclear diagnoses immunohistochemical assessment with Ki67 and p53, which corre- lates with tumor size, may not be helpful in making a histopathological diagnosis and must be considered cautiously.
3.2 | Assessment of overall and relapse-free survival
Clinical characteristics of patients with ACC are shown in Table 4.
A total of 20 ACC patients were followed-up for a median of 22.5 months. There were 15 deaths.
| Antigen | Cortical adenoma | Cortical carcinoma | Cortical nodular hyperplasia |
|---|---|---|---|
| Ki67 | 0 (0-2) | 1 (0-11) | 0 (0-1) |
| AdpoR1 | 20 (0-100) | 100 (100-100) | 0 (0-100) |
| AdpoR2 | 100 (100-135) | 100 (100-200) | 100 (100-120) |
| SF1 | 182.5 (100-270) | 215 (175-285) | 170 (90-270) |
| IGF2 | 100 (0-110) | 100 (50-100) | 0 (0-100) |
| LPT Ob .- R | 100 (0-135) | 100 (50-175) | 20 (0-100) |
| p53 | 0.0 (0.0-15.0) | 0.5 (0.0-12.5) | 0.0 (0.0-10.0) |
Data are: median H-score (25th-75th percentile).
All-cause median survival was 1.75 years, with non-resectable tumor cases having shorter survival (5.0 years for resectable and 0.3 years for non-resectable, P < 0.0001; Fig. 1).
One-year survival rate was 86.7% for patients with a resectable tumor, and the maximum observed survival for patients with a non- resectable tumor was 10 months. Five-year survival rate was 40% for patients with a resectable tumor. There was no association between tumor size and 5-year survival for patients with a resectable tumor (37.5% for <10 cm, 42.2% for ≥10 cm; P = 0.83).
We compared the outcomes for patients operated before 2006 and after 2006. The former had a median OS of 15 months and the latter of 60 months, however, the difference between survival functions of these two groups was not statistically significant.
3.3 | Analysis of survival data
A relationship between clinical data and OS was assessed and the results are shown in Table 5. There was a relationship between survival and patients’ age and gender, however, it had a complex nature, which resulted from an interaction between these variables. Survival was significantly higher in young men as compared to all other patients (Fig. 1). Survival was unfavorably influenced by non-radical surgical treatment (HR = 43.6; P= 0.006). No relationship was found between OS and primary tumor size, hormonal activity, and treatment with Mitotane.
| Antigen | Crude OR | Adjustedª OR |
|---|---|---|
| Ki67% | 1.332 ** (1.057-1.678) | 0.811 (0.455-1.446) |
| SF1 | 1.004 (0.999-1.010) | 1.014 ** (1.000-1.029) |
| IGF2 | 1.006 (0.999-1.014) | 1.022 ** (1.003-1.042) |
| P53 | 1.018 (0.999-1.037) | 0.994 (0.958-1.031) |
| Adipo R1 | 1.013* (1.005-1,021) | 1.023 ** (1.003-1.044) |
| Adipo R2 | 1.017* (1.005-1.030) | 1.036 ** (1.005-1.069) |
| Leptin Ob .- R | 1.008 ** (1.001-1.015) | 1.017 (0.998-1.035) |
Data are: odds ratio (95% confidence interval).
ªadjusted for: age, gender, tumor size, hormonal overproduction.
*significance with 0.001 ≤ P < 0.010.
** significance with 0.010 ≤ P < 0.050.
|
Journal of SURGICAL ONCOLOGY
| Total number of patients, n | 20 |
|---|---|
| Age [y], mean + SD | 51.8 ±15.6 |
| Male, n (%) | 8 (40%) |
| Female, n (%) | 12 (60%) |
| Primary tumor size (cm), mean ± SD | 12.5 ±9.1 |
| Hormonal overproduction | 16 (80%) |
| Incomplete resection, n (%) | 5 (25%) |
| Mitotane treatment, n (%) | 15 (75%) |
3.4 | Immunohistochemical parameters and overall survival in ACC
The influence of immunohistochemical parameters on OS was assessed.
The results were presented in Table 5. Of all examined parameters, only IGF2 expression was significantly associated with OS. Higher expression of this receptor was associated with longer OS (HR = 0.97; P = 0.025, Fig. 1).
3.4.1 | Analysis of relapse data
The analysis included only 15 ACC patients, who underwent radical resection. A total of 12 relapses were observed. Median RFS time was 1.25 years (Fig. 1).
One and five-year RFS were 60% and 13%, respectively.
There was no association between tumor size and 1-year RFS (75% for <10 cm, 43% for ≥ 10 cm; P = 0.31).
3.5 | Clinical data and recurrences
Group consisted of 15 patients with total resection of ACC (7 male- 47%; 6 female- 53%). Primary tumor size was 11,5 ± 9,7 cm and hormonal overproduction was found in 12 cases (80%). The 13 (87%) of the patients went through Mitotane treatment.
A relationship between clinical data and relapse-free survival was assessed. Due to the very small variance, the “treatment with Mitotane” variable was removed from the multivariate regression model. The relationship between RFS and age as well as gender was analogos to that for OS. RFS was significantly higher in young men as compared to other patients (HR = 1.93-1.05-3.54-for interaction
A
B
1.00
radical resection
-
non-radical resect.
0.50
LO
0
0.00
0
24
48
72
96
120
144
months
0
24
48
72
96
120
144
months
F, 40 y.
M, 40 y.
F, 60 y.
M, 60 y.
C
D
1.00
1
IGF2 H-score=50
IGF2 H-score=150
0.50
5
0
0.00
0
24
48
72
96
120
144
0
24
48
72
96
120
144
months
months
| Clinical factor | Hazard ratio (95%CI) |
|---|---|
| Age [y] | 0.94 (0.88-1.02) |
| Male | 1.16 (0.23-5.87) |
| Male* age interaction | 1.40* (1.12-1.76) |
| Primary tumor size (cm) | 1.10 (0.99-1.22) |
| Hormonal overproduction | 0.16 (0.02-1.40) |
| Incomplete resection | 85.5* (4.24-1723.6) |
| Mitotane treatment | 0.09 (0.01-1.86) |
| Ki67 | 1.02ª (0.90-1.16) |
| AdpoR1 | 0.99ª (0.98-1.01) |
| AdpoR2 | 0.99ª (0.98-1.01) |
| SF1 | 1.00ª (0.99-1.01) |
| IGF2 | 0.97 ª, ** (0.94-0.99) |
| LPT Ob .- R | 1.00ª (0.99-1.02) |
| p53 | 1.00ª (0.98-1.02) |
ªAdjusted for age, gender, tumor size, hormone overproduction, type of resection and mitotane treatment.
*Significance with 0.001 ≤ P < 0.010.
** Significance with 0.010 ≤ P <0.050.
factor male by age). There was no relationship between RFS and primary tumor size or hormonal activity of the tumor.
3.6 | Immunohistochemical parameters and ACC relapse
The influence of immunohistochemical parameters on RFS was assessed. There were no statistically significant relationships between examined immunohistochemical parameters and RFS.
4 | DISCUSSION
4.1 | The role of immunohistochemistry in the diagnosis of ACC
Three histolopathological scoring systems are acknowledged in the differentiation of benign and malignant tumors of the adrenal cortex: the Hough system criteria, the van Slooten criteria, and Weiss criteria. The latter were adopted in 1984 and eventually modified in 2002.12 Weiss criteria are the current standard of practice in establishing the diagnosis of ACC. Despite widely accepted and acknowledged ACC diagnosis criteria, diagnostic errors do take place. A large-scale audit of cases in Germany revealed a high histopathological misclassification rate of 13%.13
The authors of the current study have attempted to assess several immunohistochemical parameters that influence cell proliferation and assessed their applicability in establishing the diagnosis and clinical course of ACC.
According to some authors, complementing the histopathological examination with an immunohistochemical staining for Ki67 aides in
establishing the diagnosis of ACC,14,15 while p53 may be a recommended marker of higher malignancy.14,16 Also, high Ki67 expression seems to be present in patients with metastasizing ACC with poor prognosis.1,16
Results of the current study indicated that high Ki67 expression in adrenal tumor tissue was associated with the diagnosis of ACC and can be recognized as a marker differentiating between benign and malignant adrenal cortex tumors. The odds ratio of an ACC diagnosis increased 0.29 times for every percentage point of Ki67 increase (P=0.015). However, the authors found that Ki67 is not an independent factor in the diagnosis of ACC. The relationship between ACC diagnosis and Ki67 results from the influence of this proliferation marker on the adrenal tumor size.
Physiologically p53 inhibits cell replication and allows for the repair of damaged DNA strand fragments. If the damage of the genetic material is too extensive, the p53 gene initiates apoptosis. The loss of the suppressor function of the p53 gene due to its mutation is the most common molecular abnormality in human malignancies.1,16 Immuno- histochemical expression of the p53 protein has been extensively studied, also in ACC. Contrary to previous reports,16 p53 expression was not related to ACC diagnosis in the current study.
Since authors showed that Ki67 and p53 immunohistochemical assessment correlates mainly with adrenal tumor size, applying these markers when making the diagnosis of ACC or ACA must be cautious.
SF1 plays a pivotal role in the development of steroidogenic tissues and is important in the regulation of steroid biosynthesis. SF1 protein assessed immunohistochemically has a considerable value as a marker of tumor origin.1,17-18 SF1 protein is present in all tumors derived from the adrenal cortex. There are several reports concerning the role of SF1 in differentiating between ACC and ACA.1,17-18
In multivariate analysis-adjusting for patients’ age and gender as well as tumor’s hormonal activity-the expression of this protein was significantly higher in ACC as compared to benign adrenal cortex tumors analyzed in the study presented by the authors here, and can serve to differentiate between benign and malignant adrenal cortex tumors (P = 0.05).
Genetic modification of chromosome 11p15 locus results in excessive IGF2 expression in adrenal cortex and is specific for ACC and not for ACA.1
A signal from the IGF2 receptor plays a role in ACC tumorigenesis. In the results obtained here, high IGF2 protein expression was associated with a higher probability of ACC diagnosis. IGF2 seems to be an independent differentiation marker between ACC and benign adrenal cortex tumors.
Furthermore, authors of the study analyzed the immunohisto- chemical expression of adipokine Adipo R1 and R2, as well as leptin Ob .- R receptors, whose relationship with the development of obesity- related neoplasms was stated.10
There is strong evidence in literature for the undeniable relationship between obesity and many neoplasms-the influence of obesity was proven for breast, endometrial, colon, and esophageal cancer. Recently, more and more attention has been paid to the influence of adipokines on neoformation in neoplasms without concomitant obesity, for example, advanced stage lung cancer,
melanoma, or thyroid neoplasms.10-11,19 A link between adipokines and endocrine neoplasms has been sought; for instance in thyroid neoplasms adiponectin receptors’ expression has been demon- strated.19 ACC does not usually present with obesity, however, among ACC patients half exhibit hormonal activity-most frequently Cushing’s syndrome or subclinical hypercortisolemia (SCS), both of which may lead to BMI increase.3,16
So far, research on receptors in adrenal tumors has not been extensive. In solitary reports, their presence has been confirmed in adrenal tissue.10,11,20
Authors of this study found a statistically significant relationship between the expression of Adipo R1 and Adipo R2 receptors and ACC diagnosis. It seems that higher adipokine receptor expression in malignant adrenal tumors can be explained by the down-regulation mechanism present and studied in epithelial breast cancer as well as Barrett’s adenocarcinoma. 10-11 It might be tentatively speculated that the low adiponectine serum level, which can be related to a pro- neoplastic influence, results in an increased Adipo R1 and R2 receptor expression in the adrenal tumor tissue, which is evident in their higher expression in ACC.
The degree of leptin receptor expression, after adjusting for age, gender, tumor size, and its hormonal activity, had no statistical influence on ACC diagnosis. The mechanism of leptin action in human neoplasms is unclear. It is believed that leptin activates various intracellular signaling pathways;21 it also has direct autocrine and paracrine effects that are elicited without binding to its receptor via unclear mechanisms.22
Authors of the present study may recommend IGF2 and SF1 assessment as auxiliary markers in making the diagnosis of ACC to complement Weiss criteria. If the immunohistochemical assessment including IGF2, SF1, and adiponectin and leptin receptors becomes part of the adrenal tumor work-up, prognostic information may be acquired, that may facilitate therapeutic decisions of a given ACC patient. A more exact histopathological diagnosis allows for consecutive therapeutic step: Mitotane treatment or considering adjuvant radiotherapy of the location of the resected adrenal tumor, which improves prognosis in some ACC patients.
Complementing the histopathological assessment of adrenal tumors with two more antibodies, that is, SF1 and IGF2, at least in uncertain cases, would increase the cost of current work-up by 36 dollars.
4.2 | The role of clinical and immunohistochemical parameters in overall and relapse-free survival in ACC
In the current study, the authors showed that the most important factor influencing survival of ACC patients is the resectability of the primary tumor. There was no statistically significant relationship between the size of the primary tumor, its hormonal activity, Mitotane treatment, and RFS, as well as OS. It was also recorded that patients’ age and gender influence OS in ACC: it was longer in younger men as compared to other patients (HR = 43.6; P = 0.006).
Studies by other authors also indicate that surgical treatment is a significant factor that improves prognosis of ACC patients.2,3 The recommended approach is open adrenalectomy.3,23 Some authors favor laparoscopic surgery in tumors smaller than 10 cm.23 All authors agree that successful surgery improves prognosis of ACC patients.2,23
Even after a radical surgery the ACC relapse risk is high. Complementary treatment with Mitotane improves outcomes in ACC,3,24,25 however, it is not certain whether all patients benefit from this therapy.3,24 Our data showed no prognosis improvement in patients with ACC: neither for overall nor for RFS.
In reports by many authors, various immunohistochemical markers have been assessed in the context of ACC biology and clinical course. Sbiera et al17 found positive SF1 immunohistochemical staining in 98% of ACC cases; high expression of this protein was present in 30% of ACC cases. Higher SF1 expression correlated with poorer prognosis. Authors found that SF1 expression is an indepen- dent prognostic factor in ACC patients.17 In our study, we did not find such a relationship between RFS or OS and the expression of SF1 in analyzed ACC tissue specimens. This marker was only useful in differentiating between ACC and benign adrenal cortex tumors. It should be taken into consideration that SF1 action in adrenal cortex cells depends on the activity and concentration of its repressors, that is, Dax-1 and COUP-TF, as well as its post-translational modifications and the availability of its activating ligands.5 It is possible that these mechanisms may account for the lack of influence on OS and RFS of ACC patients in our study.
It was found in vitro that the IGF2 gene induces neoplastic cell proliferation in ACC via IGF1 receptor, which points at a role of the IGF-system in adrenocortical carcinogenesis.15 For that reason, IGF2 expression may be associated with a very malignant ACC phenotype.15 This relationship has been applied in novel antineoplastic therapy.26
It is unclear whether an increase in IGF2 expression modifies ACC biology. In a report by Guillard-Bataille et al,8 the authors compared the phenotype, clinical, biological, and molecular characteristics of ACC with low and high IGF2 gene expression and found no statistically significant differences in the clinical course, hormonal activity, tumor size, and the biology of metastasis.
In our study, we assessed the influence of immunohistochemical parameters on OS and disease progression. Of all examined parameters only IGF2 protein expression was associated significantly with OS. It was found that its high expression is associated with longer OS (P = 0.025). It seems that the explanation of this observation lies in the fact that the IGF2 gene significantly reduces the growth of neoplastic cells (>50%) by blocking their development in the G1 phase and promoting their apoptosis.8 Possibly high IGF2 gene expression, present in the majority of ACCs, is lost early or during tumorigenesis. It is possible that in ACC cases with low IGF2 protein expression other signals influence the tumor growth. This can have an impact on varied outcomes of applied therapy types.8 It seems that IGF2 is not a prognostic factor of ACC progression or metastasis.8
It can be supposed that tumor morphology is the most important factor influencing the prognosis.2,6,9,14,16 The authors of a recent publication believe that the mitotic index is the most important independent prognostic factor in multivariate analysis.6
ACKNOWLEDGMENT
This research did not receive any specific grant from any funding agency in the public, commercia or not-for-profit sector. The authors declare that they have no compating interests. All authors approved the final manuscript.
CONSENT
Written informed consent was obtained from the patients for publication of this report and any accompanying images.
AUTHORS’ CONTRIBUTIONS
AB contributed to planning and conducting the study, collecting, and interpreting data, and drafting the manuscript. RP performed histological and immunohistochemical analysis. RSS collecting date. PW performed the statistical analysis. KS approved the final draft submitted.
DISCLOSURE
The authors have nothing to disclose.
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How to cite this article: Babińska A, Pęksa R, Wiśniewski P, Świątkowska-Stodulska R, Sworczak K. Diagnostic and prognostic role of SF1, IGF2, Ki67, p53, adiponectin, and leptin receptors in human adrenal cortical tumors. J Surg Oncol. 2017;1-7. https://doi.org/10.1002/jso.24665