Stojadinovic et al identified a number of histomorphological and molecular features that are associated with metastasis from an adrenocortical carcinoma. These can help identify patients who may benefit from more aggressive management and monitoring. The authors are from Memorial Sloan-Kettering Cancer Center, Walter Reed Army Medical Center (Washington, D.C.) and Singapore Management University.
Parameters:
(1) tumor necrosis
(2) atypical mitoses
(3) mitotic rate per 50 high powered microscopic fields (hpf)
(4) sinusoidal invasion
(5) morphologic index (see below)
(6) unfavorable molecular markers (see below)
|
Parameter |
Finding |
Points |
|---|---|---|
|
tumor necrosis |
absent |
0 |
|
|
present |
1 |
|
atypical mitoses |
absent |
0 |
|
|
present |
1 |
|
mitotic rate |
<= 5 in 50 high powered fields |
0 |
|
|
> 5 in 50 hpf |
1 |
|
sinusoidal invasion |
absent |
0 |
|
|
present |
1 |
|
morphologic index |
<= 5 |
0 |
|
|
> 5 |
1 |
|
unfavorable molecular markers |
<= 2 |
0 |
|
|
> 2 |
1 |
where:
• Tumor necrosis, atypical mitoses, mitotic rate and sinusoidal invasion are 4 of the 12 elements of the morphologic index.
Interpretation:
• minimum number of risk factors: 0
• maximum number of risk factors: 6
• The more risk factors that are present the greater the risk of having a metastasis from an adrenocortical carcinoma.
• An adrenal cortical tumor that scored 0 in all of these indices would be an adenoma, which would have no risk of metastasis.
Components of the Morphologic Index:
(1) tumor necrosis
(2) atypical mitoses
(3) mitotic rate in 50 high powered fields
(4) sinusoidal invasion
(5) tumor weight
(6) venous invasion
(7) capsular invasion
(8) invasion of adjacent organs
(9) nuclear grade
(10) architecture
(11) clear cytoplasm
(12) resection margin
|
Parameter |
Finding |
Points |
|---|---|---|
|
tumor necrosis |
absent |
0 |
|
|
present |
1 |
|
atypical mitoses |
absent |
0 |
|
|
present |
1 |
|
mitotic rate |
<= 5 in 50 high powered fields |
0 |
|
|
> 5 in 50 hpf |
1 |
|
sinusoidal invasion |
absent |
0 |
|
|
present |
1 |
|
tumor weight |
<= 250 grams |
0 |
|
|
> 250 grams |
1 |
|
venous invasion |
absent |
0 |
|
|
present |
1 |
|
capsular invasion |
absent |
0 |
|
|
present |
1 |
|
invasion of adjacent organs |
absent |
0 |
|
|
present |
1 |
|
nuclear grade |
Grade I or Grade II |
0 |
|
|
Grade III or Grade IV |
1 |
|
architecture |
nondiffuse |
0 |
|
|
diffuse |
1 |
|
clear cytoplasm |
> 25% |
0 |
|
|
<= 25% |
1 |
|
resection margin |
negative |
0 |
|
|
close, positive or unknown |
1 |
where:
• A diffuse architecture is present if > 33% of the tumor consists of sheets of tumor cells without a characteristic pattern.
• Venous or sinusoidal invasion is present if a vein or sinusoid within or external to the adrenal gland contains tumor cells within the lumen and adherent to the wall.
morphologic index =
= SUM(points for the 12 gross and microscopic features)
Unfavorable molecular markers:
(1) Ki-67
(2) p-21
(3) p-27
(4) mdm-2
|
Parameter |
Finding |
Points |
|---|---|---|
|
Ki-67 |
<= 5% nuclei stained |
0 |
|
|
> 5% nuclei stained |
1 |
|
p-21 |
<= 10% nuclei stained |
0 |
|
|
> 10% nuclei stained |
1 |
|
p-27 |
<= 30% nuclei stained |
0 |
|
|
> 30% nuclei stained |
1 |
|
mdm-2 |
<= 50% nuclei stained |
1 |
|
|
> 50% nuclei stained |
0 |
number of unfavorable molecular markers =
= SUM(points for the 4 marker studies)
Specialty: Hematology Oncology, Surgery, general, Endocrinology
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