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Merkel cell carcinomas are rare and aggressive tumors about which the expression of cell cycle regulatory proteins are not well known. We evaluated the clinicopathologic features of Merkel cell carcinomas and examined the expression of the cell cycle regulatory markers p27 and S-phase kinase-associated protein 2 (Skp2) and the proliferation markers Ki-67 and DNA topoisomerase II alpha (topo II alpha) in a group of these tumors. Thirty-nine cases of Merkel cell carcinoma were studied, 19 from the Mayo Clinic, Rochester, MN, and 20 from the University of Torino, Torino, Italy. Although the University of Torino patients tended to be slightly older at time of surgery compared to the Mayo Clinic patients, no clinical, pathologic, or immunohistochemical feature was statistically significantly different between the two groups. Of the 39 patients, 20 were male and 19 were female. The age at surgery averaged 72 yr. Formalin-fixed paraffin-embedded archival tissues from the 39 Merkel cell carcinomas were analyzed by immunohistochemistry for p27, Skp2, Ki-67, and topo II alpha with the avidin-biotin peroxidase system. The distribution of immunoreactivity was analyzed by quantifying the percentage of positive nuclei, which was expressed as the labeling index. There was a statistically significant inverse relationship between p27 and Skp2 (p = 0.005). Most tumors with increased levels of Skp2 were associated with reduced p27, and tumors with high levels of p27 expression were associated with reduced levels of Skp2. These results suggest that Skp2 regulates p27 expression in Merkel cell carcinomas. Tumors showing increased Skp2 expression were not always correlated with increased proliferation as evaluated by Ki-67 and topo II alpha, suggesting that Skp2 may be involved in Merkel cell tumorigenesis, but that other factors may also influence cell proliferation in these tumors.

Presentation of Case An eight-year-old girl was admitted to the hospital because of fever, cough, hemoptysis, and pulmonary consolidations. She had been well until six days before admission, when she was visiting El Salvador. A sore throat developed, with mild fever, a dry cough, and anorexia, and she began to vomit once daily. Three days before admission, she traveled by air to Boston, where she lived, and dyspnea developed. The next day, she began to cough up bright red blood and had right-sided otalgia and a sore throat; the low-grade fever persisted. The hemoptysis and dyspnea worsened, and she was . . .

Lessons Learned Percutaneous thermal ablation combined with in situ granulocyte-macrophage colony-stimulating factor cytokine therapy was technically feasible and well tolerated. No significant clinical or immunologic responses were seen. Background Melanoma tumor-derived heat-shock proteins (HSPs) and HSP-peptide complexes can elicit protective antitumor responses. The granulocyte-macrophage colony-stimulating factor (GM-CSF) chemokine can also promote uptake and processing by professional antigen presenting cells (APCs). On this basis, we designed a pilot study of percutaneous thermal ablation as a means to induce heat-shock protein vaccination plus GM-CSF to determine safety and preliminary antitumor activity of this combination. Materials and Methods This study was designed to assess overall safety of percutaneous ablation combined with GM-CSF for unresectable, metastatic melanoma including uveal and mucosal types. All patients received heat-shock therapy (42°C for 30 minutes), then received one of three treatments: (a) intralesional GM-CSF (500 mcg standard dose); (b) radiofrequency ablation (RFA) + GM-CSF; or (c) cryoablation plus GM-CSF. The primary endpoint of the study was the induction of endogenous HSP70 and melanoma-specific cytotoxic T lymphocytes (CTL). Results Nine patients (three per study arm) were enrolled. No dose-limiting toxicity was observed as specified per protocol. All patients developed progressive disease and went on to receive alternative therapy. Median overall survival (OS) was 8.2 months (95% confidence interval [CI] 2–17.2). The study was not powered to detect a difference in clinical outcome among treatment groups. Conclusion Percutaneous thermal ablation plus GM-CSF was well tolerated, technically feasible, and demonstrated an acceptable adverse event profile comparable to conventional RFA and cryoablation. While HSP70 was induced following therapy, the degree of HSP70 elevation was not associated with clinical outcome or induced CTL responses. While percutaneous thermal ablation plus GM-CSF combinations including checkpoint inhibitors could be considered in future studies, the use of GM-CSF remains experimental and for use in the context of clinical trials.

3034 Background: Unique to modern immune therapy for cancer is that early in the course of treatment, patients frequently exhibit transient tumor enlargement (pseudo-progression, pPROG) due to tumor infiltration by lymphocytes (TIL). Currently, pPROG cannot be reliably distinguished from true tumor progression (PROG). There is a need for biomarker techniques to discriminate pPROG (effect of therapy) and PROG (therapy failure). Nuclear medicine offers radiopharmaceuticals capable of imaging immune cells; images can be fused to evaluate functional and anatomic characteristics of tumors, and potentially discriminate pPROG from PROG. Methods: In our study of metastatic melanoma patients, SPECT/CT imaging with 99mTc-interleukin-2 (99mTc-IL2) was performed to visualize TIL. Images were collected before/after 12 weeks of ipilimumab (IPI) or pembrolizomab (PEMBRO) therapy. The 99mTc-IL2 tracer was synthesized by conjugating succinimidyl-6-hydrazinopyridine-3-carboxylate (HYNIC-NHS) with commercial interleukin-2 (Aldesleukin). HYNIC-IL2 was incubated with tricine, 99mTcO4- (370-740 MBq) and SnCl2. After labelling 99mTc-IL2 was purified by reverse-phase chromatography and diluted in 5% glucose with 0.1% human albumin before injection. Five patients were enrolled in this study. Two patients failed to complete the 12 week 99mTc-IL2 scan due to discontinuation of IPI after: 1) grade 3 colitis and 2) patient refusal for adverse events attributed to IPI. No adverse events attributable to the tracer infusion were reported. Results: Metastatic lesions could be visualized by the tracer. Some lesions decreased in size, while others increased. A positive correlation was found between size and 99mTc-IL2 uptake, before and after therapy, suggesting the potential discrimination of tumor PROG (no 99mTc-IL2 uptake) from pPROG (high 99mTc-IL2 uptake). Immunohistochemical staining for TIL of 99mTc-IL2 positive and negative lesions are illustrated. Conclusions: The results demonstrate feasibility of 99mTc-IL2 imaging as a clinically useful tool capable of discriminating tumor PROG from pPROG. A clinical validation study is in progress. Clinical trial information: NCT01789827.

Abstract 3840 Background: Patients with myeloproliferative neoplasms (MPN) harbor a multitude of somatic mutations involving JAK2, MPL, LNK, CBL, TET2, ASXL1, IDH1, IDH2, EZH2, DNMT3A, IKZF1 and TP53. None of these mutations have been consistently traced back to the ancestral clone and most of them are currently believed to represent secondary genetic events. The higher prevalence of IDH, LNK, IKZF1 and TP53 mutations in blast-phase MPN, as opposed to chronic-phase disease, suggests their pathogenetic contribution to leukemic transformation (Harutyunyan A, et al. N Engl J Med. 2011;364:488). We examined this possibility for TP53 mutations or its SNPs in chronic-phase PMF; TP53 SNPs involving codon 72 have been associated with increased risk in the development of several cancers. Methods: Mayo Clinic MPN database was utilized to identify adult patients (>18 years) with chronic-phase PMF. Study eligibility criteria included availability of bone marrow histology and cytogenetic information at time of referral. In addition, all patients were annotated for IDH, MPL and JAK2 mutational status. Patients with blast-phase disease at the time of their referral were excluded from the study. DNA from bone marrow or peripheral blood was extracted using conventional methods and amplified with one set of primers covering TP53 exons 4 through 9. The amplification products were then sequenced with eight primers using the Big Dye Terminator sequencing kit v1.1 (Applied Biosystems, Foster City, CA) and the ABI 3130xl Genetic Analyzer. Sequences were examined for mutations by the Sequencher software (Gene Codes, Ann Arbor, MI). Any mutation found was confirmed with a second PCR and sequencing reaction. A mutation was considered to be any sequence other than genomic reference sequence NC_000017.10 or a well documented polymorphism such as the rs1042522 in exon 4. Mutations were compared with the IARC p53 Database (http://www-p53.iarc.fr/) and/or the TP53 Mutation Database (http://p53.free.fr/index.html) to determine if the mutation had been reported before. Results I: Baseline characteristics and clinical course A total of 107 patients with chronic-phase PMF were studied. Median age at time of referral was 64 years (range 32–81) and 71% were males. DIPPS-plus risk assignment was low in 13%, intermediate-1 in 15%, intermediate-2 in 38% and high in 34%. Karyotype was normal in 70 (65%) patients, favorable in 26 (24%) and unfavorable in 11 (10%). JAK2, MPL and IDH mutations were detected in 62 (58%), 7 (7%) and 6 (6%) cases, respectively. To date, 74% of patients had died and 15% had documented leukemic transformation. Results II: TP53 mutations/polymorphisms and their clinical relevance TP53 mutations were discovered in only 4 (4%) cases: i) E204E; GAG>GAA (silent exon 6); ii) G245D; GGC>GAC (exon 7); iii) R175H; CGC>CAC (exon 5); and iv) six base insert (GGCGAG) after bp13767 (exon 6). There was no significant difference in presenting features or survival between TP53 mutated and unmutated cases. None of the four patients with TP53 mutation incurred leukemic transformation. TP53 exon 4 SNPs data for codon 72 was available on 104 patients and included 58 (56%) patients with homozygous Arg72Arg, 34 (33%) patients with heterozygous Pro72Arg and 12 (11%) patients with homozygous Pro72Pro. Allele frequencies were 0.7 for G (corresponding to arginine) and 0.3 for C (corresponding to proline), which is similar to the general population (0.65 and 0.35 respectively). There were no significant differences among the three codon 72 genotypes in terms of presenting characteristics or survival. Conclusions: TP53 mutations are infrequent in chronic phase PMF. A higher number of informative cases are needed to accurately define their phenotypic or prognostic effects. We are currently analyzing more cases in this regard. On the other hand, TP53 polymorphisms at codon 72 do not appear to influence phenotype or prognosis in chronic-phase PMF. Disclosures: No relevant conflicts of interest to declare.

Although metastases or secondary direct extension of tumor to parathyroid tissues and tumors is rare, it is known to occur. In a series of 911 papillary thyroid carcinomas, 20 involved the parathyroid by direct invasion from the main tumor with infiltrative growth, invasion of the parathyroid with an expansive growth with pseudocapsule between the carcinoma and the parathyroid, and metastatic tumor within the parathyroid gland. Of the 20 cases, 6 (30 %) had primary thyroid tumors measuring 1 cm or less and 14 (70 %) had primary tumors measuring more than 1 cm, indicating that parathyroid involvement may occur in papillary thyroid carcinomas even in the early stage of the disease. A study of 1,770 thyroid carcinomas identified 10 (6 papillary, 3 follicular, and 1 anaplastic thyroid carcinoma) with parathyroid metastases (0.5 %). Other tumors in the neck may involve the parathyroid secondarily. Hepatocellular carcinoma, breast carcinoma, and tumors from other visceral sites may occasionally metastasize to the parathyroid or even to a parathyroid adenoma.

Graves disease, an autoimmune disorder, is the most common cause of hyperthyroidism. Graves disease is associated with antibodies against the thyrotropin receptor that stimulate the receptor and promote synthesis and secretion of thyroglobulin and follicular cell proliferation. Patients present with goiter and symptoms of hyperthyroidism, including anxiety, tachycardia, palpitations, tremor, heat sensitivity, and weight loss, and may develop ophthalmopathy and dermopathy. Patients may be treated symptomatically with β-blockers and with antithyroid medications (propothiouracil and methimazole), radioactive iodine, and surgery. Complications of untreated Graves disease are thyroid storm, muscle catabolism with myopathy, and bone catabolism with osteoporosis, among others. Graves disease occurs in 1 in 2,000 people in the United States. A study from Olmstead County, Minnesota, reports an incidence of 30 cases per 100,000 person years. Graves disease is more common in women than in men. There is a marked increase risk of Graves disease in the postpartum period. In men, Graves disease occurs at an older age and frequently is more severe and associated with greater ophthalmopathy. Graves disease occasionally occurs in children and has a high concordance in identical twins. Smoking is associated with an increased risk of Graves disease and Graves ophthalmopathy. Patients have elevated serum thyroxine and low thyroid-stimulating hormone levels. There is an association with HLA-B8 and DR3, and patients may have a familial predisposition to autoimmune disease, including thyroid disease. Thyroid carcinomas occasionally occur in thyroids involved by Graves disease. In a retrospective review of 61 thyroid carcinomas with concurrent Graves disease, 58 papillary carcinomas, 1 follicular carcinoma, 1 Hurthle cell carcinoma, and 1 medullary carcinoma were identified. Most (80 %) of the tumors were 1 cm or smaller. Incidental thyroid carcinomas are less prevalent in Graves disease than in multinodular goiter.

The hyalinizing trabecular tumor—or “adenoma,” as it originally was described by Carney in 1987, can mimic medullary and papillary thyroid carcinoma. This unique tumor occurs more commonly in females and over a broad age range (27–72 years; mean, 46 years). These tumors originally were diagnosed as carcinoma, adenoma, paraganglioma, or “indeterminate.” None of the tumors in the original series metastasized during 10 years of follow-up. Additional case reports and small series followed, with a few tumors showing capsular or vascular invasion. These tumors generally are not associated with BRAF or RAS mutations, but RET alterations have been reported. Whether this is sufficient for these tumors to be regarded as variants of papillary thyroid carcinoma (PTC) has been controversial, as RET/PTC rearrangements are not specific for PTC. Some of the hyalinizing trabecular tumors with RET rearrangements were from thyroids that also had PTCs. Also, some have reported RET/PTC rearrangements in Hashimoto thyroiditis, although this is not corroborated by others.

Follicular thyroid neoplasms are solitary nodules that present as a mass. Follicular adenomas are benign, encapsulated tumors with follicular differentiation that are more common in women, usually occur in adults, and are more common in areas of iodine deficiency. Follicular adenomas measure 1–3 cm and usually are smaller than follicular carcinomas, although size may overlap. Follicular neoplasms lack cytologic features of papillary thyroid carcinoma (PTC). Malignancy in follicular neoplasms requires capsular or vascular invasion. The capsule in follicular carcinomas often is thicker and more irregular than that of adenomas. Various histologic patterns, including microfollicular, macrofollicular, normofollicular, and trabecular growth, may be seen in follicular neoplasms. Areas of papillary architecture may be seen. Follicular neoplasms may have different cytomorphologies, including mucinous, signet ring cell, and clear cell, and may have intratumoral fat. Follicular neoplasms show immunopositivity for thyroid transcription factor 1 (TTF1), thyroglobulin, and keratin and are negative for chromogranin, synaptophysin, and calcitonin. Follicular neoplasms often show RAS mutations, and a few have t(2;3)(q13;p25) involving PAX8 and peroxisome proliferator-activated receptor-γ encoding a fusion protein. Follicular adenomas show increased expression of p27 cell cycle inhibitory protein and decreased Ki67 proliferative indices (LI) compared with follicular carcinomas, and carcinomas with metastases have higher Ki67 LI levels than those without. However, in an individual lesion, these and other immunohistochemical or molecular markers cannot separate benign from malignant follicular neoplasms definitively. Cytologic specimens cannot distinguish benign from malignant follicular neoplasms, as diagnosis of malignancy requires invasive growth. Follicular adenomas are treated with lobectomy and have an excellent prognosis. Follicular carcinomas show capsular and/or vascular invasion. Vascular invasion must occur within or beyond the capsule. Tumors with capsular invasion only (no vascular invasion) have more indolent behavior than those with vascular invasion. Follicular carcinomas with focal capsular and/or vascular invasion have been designated as minimally invasive, whereas those with more extensive invasion have been characterized as widely invasive, although this classification is being used less often. Tumors with extensive vascular invasion often are referred to as angioinvasive follicular carcinomas. Unlike PTC, which has frequent lymph node metastases, follicular carcinomas usually metastasize directly to viscera. Minimally invasive follicular carcinomas have a low mortality rate (3%–5% in some studies), and those with only capsular invasion (no vascular invasion) have a particularly good prognosis. Widely invasive carcinomas are aggressive, with a long-term mortality rate of 50 %.

Medullary thyroid carcinoma (MTC) comprises 5–10 % of thyroid carcinomas. About 25 % of cases are familial; thus, patients are offered RET mutation analysis. MTC occurs in multiple endocrine neoplasia 2A (MEN2A), MEN2B, and familial MTC (FMTC), autosomal dominant disorders due to RET mutations. MEN2A and FMTC are associated with RET mutations of codons 609, 611, 618, 620, and 634. In FMTC, mutations of codons 768, 790, 791, 804, 844, and 891 are associated with less aggressive disease and a later onset. Most MEN2B RET mutations are at codon 918 (>95 %) or 883 (2–3 %). MEN2A is associated with MTC, pheochromocytoma, and parathyroid disease. MEN2B is associated with MTC, pheochromocytoma, mucocutaneous neuromas, ganglioneuromatosis, and marfanoid habitus. MTC usually occurs before pheochromocytoma in MEN2A and MEN2B, and preoperative calcitonin levels may help identify MTC and prevent a hypertensive crisis during surgery.

Poorly differentiated thyroid carcinomas are diagnostically controversial, as there is a lack of consensus regarding diagnostic criteria. Poorly differentiated thyroid carcinomas usually occur in older patients (>50 years) and are more common in Italy and Latin America (4–7 % of thyroid carcinomas) and less common in the United States. These tumors are morphologically and prognostically intermediate between well-differentiated and anaplastic thyroid carcinoma. An operational pathologic definition offered in 2007 included insular and trabecular variants, but not solid lesions or more differentiated tumors that may have a poor prognosis, such as tall cell, columnar, diffuse sclerosing, and oncocytic lesions. At a consensus conference in Turin in 2006, 12 thyroid pathologists evaluated 83 tumors without knowledge of clinical parameters and devised a diagnostic algorithm for the diagnosis of poorly differentiated thyroid carcinoma to include “(1) presence of a solid/trabecular/insular pattern of growth, (2) absence of the conventional nuclear features of papillary carcinoma, and (3) presence of at least one of the following features: convoluted nuclei; mitotic activity ≥3×10 HPF [high-power fields]; and tumor necrosis.”

Metastases to the thyroid from tumors of other sites are not uncommon in patients with disseminated cancer, as metastases are identified in approximately 25 % of autopsies in this setting. The most common primary tumors to metastasize to the thyroid are renal cell carcinoma, lung cancer, breast cancer, malignant melanoma, esophageal cancer, and gynecologic malignancies. The tumors may form a single mass or show multifocal disease. Patients may present with a mass, hoarseness, pain, or dysphagia. Squamous cell carcinoma of the head and neck may involve the thyroid secondarily by direct extension. Metastases to the thyroid generally retain the histologic features of the primary tumor, and many are known to have metastatic disease elsewhere at the time of presentation of the thyroid metastasis.

Papillary thyroid carcinoma (PTC) is the most common endocrine malignancy, accounting for 80 % of thyroid carcinomas in adults and 90 % in children. PTC is a malignant epithelial tumor showing follicular differentiation and distinctive nuclear features. Patients usually are 20–50 years old, but those of any age may be affected. PTC is more common in women than men. Most PTCs are sporadic but may occur with syndromes such as Gardner syndrome, Cowden syndrome, and ataxia telangiectasia. PTC may arise in ectopic thyroid tissue such as struma ovarii, adrenal glands, and trachea. Radiation exposure is a risk factor for PTC. Histologic variants of PTC are important to recognize prognostically and for association with other diseases. Aggressive variants include tall cell, columnar cell, solid, and the recently described hobnail variant. The cribriform-morular variant often is associated with familial adenomatous polyposis. PTCs are positive for thyroglobulin, thyroid transcription factor 1 (TTF1), and keratins and are negative for calcitonin, chromogranin, and synaptophysin. Markers useful in confirming a diagnosis of PTC are HBME-1, keratin 19, galectin-3, and CITED1. BRAF mutations occur in about 60 % of PTCs, and RET/PTC rearrangements occur in 20–30 % of adult PTCs. BRAF mutation and RET/PTC rearrangement are mutually exclusive abnormalities in PTCs. RET/PTC1 is more common in papillary microcarcinomas and PTCs with classic architectural features, whereas RET/PTC3 is more common in the solid variant. BRAF mutations occur in classic, Warthin-like, and oncocytic PTCs; microcarcinomas; and aggressive variants such as tall cell, columnar, and hobnail PTCs. Poorly differentiated and anaplastic thyroid carcinomas also may show BRAF mutation, particularly if associated with or dedifferentiated from a PTC. BRAF mutation is not common in pediatric or radiation-associated PTCs. The follicular variant of PTC (FVPTC) is associated with RAS mutations (as are follicular neoplasms), thus RAS is not useful in separating FVPTC from follicular neoplasms. PTCs usually metastasize to cervical nodes, particularly ipsilateral nodes, before spreading to the lung and other sites. Unfavorable prognostic features are older age, male sex, large tumor size, multicentricity, angiolymphatic invasion, necrosis, mitoses, extrathyroid extension, distant metastases, high grade, marked nuclear atypia, and progression to poorly or undifferentiated carcinoma. PTCs are treated by thyroidectomy and removal of involved lymph nodes. Radioactive iodine may be used to ablate any remaining tumor, including metastatic sites. Overall, PTC has an excellent prognosis, with >90 % survival, and most patients survive even with metastatic disease.

The chromaffin cells of the adrenal medulla produce catecholamines such as epinephrine. The adrenal medulla appears gray-white grossly and comprises 10 % of the gland. The medulla may be hyperplastic in adrenal medullary hyperplasia, as may be seen in multiple endocrine neoplasia (MEN) types 2A and 2B, cystic fibrosis, and Beckwith-Wiedemann syndrome, as well as sporadically. Adrenal medullary hyperplasia may have clinical and biochemical findings similar to those of pheochromocytoma. Adrenal medullary hyperplasia usually affects both adrenals, unlike most sporadic pheochromocytomas. However, bilateral pheochromocytomas occur and may arise in a background of medullary hyperplasia. Pheochromocytoma is a tumor of the neural crest–derived medulla chromaffin cells.

Adrenal cortical adenomas are benign neoplasms of adrenal cortical cells that may or may not have functional activity. Adrenal cortical adenomas usually are single unilateral tumors that are more common in females. The incidence is unclear, particularly because many are identified as incidentalomas. Nonfunctional tumors often are identified as incidentalomas or in autopsies. A nonfunctional adrenal cortical adenoma may be associated with clinical symptoms if it is associated with hemorrhage or reaches a large size, although this is uncommon. Functional tumors may be associated with cortisol production (Cushing syndrome), aldosterone production (Conn syndrome), or sex steroid–producing tumors (virilization or feminization). Feminizing or virilizing tumors are quite uncommon, and the presence of these features is concerning for malignancy. Adrenal cortical adenomas may show degenerative features, hemorrhage, and cystic change.

A variety of unusual mesenchymal tumors involve the adrenal gland primarily, such as hemangiomas, Kaposi sarcomas, angiosarcomas, and benign and malignant smooth muscle and neural tumors. Malignant melanoma is an extraordinarily rarely reported primary in the adrenal gland; most malignant melanomas involving the adrenal gland are metastatic. Rare cases of primary lymphoma of the adrenal gland also have been reported. Other unusual tumors in the adrenal gland are teratomas and adenomatoid tumors. Adenomatoid tumors usually are identified in the urogenital system but may occur at a variety of sites, including the adrenal gland. Although a variety of unusual tumors rarely may be primary to the adrenal gland, the histologic and immunophenotypic features of these tumors are characteristic of the tumor and enable their identification.

Adrenal cortical carcinomas (ACCs) are rare; account for 3 % of endocrine tumors; affect people of all ages, including children; are more common in females; and have an incidence of one per one million patient-years. Up to 49 % of ACCs are functional, with androgen secretion (virilization) and glucocorticoid secretion (Cushing syndrome) common; functional tumors are more frequent in females. ACCs may vary in size (1–30 cm), but usually are large (10–13 cm) and may show necrosis. Rarely, ACCs may be cystic. Differentiating ACC from adenoma may be very difficult; ACCs usually are larger than adenomas. Tumors ≥100 g are particularly worrisome for malignancy; however, tumors less than 100 g have metastasized, and adenomas may weigh more than 100 g. ACCs recapitulate normal cortex but show more diffuse growth and eosinophilic cytoplasm and lack the zonation of normal adrenal cortex. Histologic features of malignancy are vascular invasion, necrosis, fibrous bands, capsular invasion, increased mitotic rate, atypical mitoses, and nuclear pleomorphism.

Tumors metastatic to the adrenal gland are more common than primary adrenal tumors. Understanding the histologic spectrum of primary adrenal tumors as well as the immunophenotype enables differentiation of tumors metastatic to the adrenal gland. Adrenal cortical tumors are positive for the broad-spectrum neuroendocrine marker synaptophysin, but negative for chromogranin. This enables differentiation of adrenal cortical tumors from adrenal medullary tumors and neuroendocrine tumors metastatic to the adrenal glands. Mart-1/MelanA is very helpful in identifying adrenal cortical tumors and differentiating them from metastases. Adrenal cortical tumors show immunopositivity for Mart-1/MelanA and are negative for S100, enabling distinction from malignant melanoma.

The adrenal glands are composed of two distinct types of tissue: adrenal cortical tissue and adrenal medullary tissue. The adrenal cortex is approximately 2 mm thick and surrounds the adrenal medulla. The adrenal cortex shows zonation with the thin discontinuous zona glomerulosa most peripherally, the zona fasciculata comprising most of the cortex, and the innermost zona reticularis cells, which are adjacent to the adrenal medulla. The adrenal cortex synthesizes mineralcorticoids, glucocorticoids, and sex steroids. These steroids have been associated with different zones of the adrenal cortex, with aldosterone produced by the zona glomerulosa, cortisol produced by the zona fasciculata and somewhat by the zona reticularis, and dehydroepiandrosterone sulfate synthesized by the zona reticularis and somewhat by the zona fasciculata. This simplified characterization is proving more complex as more is learned about the adrenal cortex.

Adrenal cortical hyperplasia is characterized by an increase in cortical cells, which usually occurs bilaterally. Adrenal cortical hyperplasia generally affects both adrenal glands and may be diffuse or nodular or show features of both patterns. Adrenal glands may show hyperplasia primarily and secondarily. Primary adrenocorticotropic hormone (ACTH)-independent cortical hyperplasia is seen sporadically or in Carney complex. ACTH-dependent cortical hyperplasia occurs in congenital adrenal hyperplasia (adrenogenital syndrome), an autosomal recessive defect in an enzymatic step of steroid synthesis (most commonly 21-hydroxylase). The adrenal glands are enlarged as the result of continuous stimulation of the adrenal cortex by ACTH. Congenital adrenal hyperplasia is the most common cause of primary adrenal insufficiency in children. Secondary adrenal cortical hyperplasia is caused by pituitary ACTH adenoma, often a microadenoma, or ectopic ACTH production. The adrenal glands show a diffuse and/or micronodular pattern. These specimens, however, rarely are removed and evaluated by pathologists, because removal of the pituitary tumor is the mainstay of treatment. Other ectopic sites of ACTH production may occur and may be associated with hypercortisolism.

Hurthle cell adenomas and carcinomas are thyroid neoplasms that are composed predominantly (>75 %) or exclusively of Hurthle cells and lack cytologic features of papillary thyroid carcinoma (PTC). Hurthle cell neoplasms are classified by the World Health Organization as oncocytic variants of follicular neoplasms. Hurthle cell neoplasms present as a thyroid mass, affect women more often than men, and usually occur in adults. The mean patient age for a Hurthle cell adenoma is 45 years, which is 5–10 years younger than that for Hurthle cell carcinomas. Hurthle cell adenomas are benign and lack the capsular and/or vascular invasion seen in Hurthle cell carcinomas. Hurthle cell adenomas usually are smaller than carcinomas but may overlap in size. Hurthle cell adenomas have a lower Ki67 proliferative labeling index and less often have diffuse nuclear cyclin D1 staining compared with Hurthle cell carcinomas. However, in evaluating an individual lesion, no immunohistochemical or genetic marker can separate Hurthle cell adenoma from carcinoma definitively. Hurthle cell tumors show a low prevalence of RAS mutation or PAX8–peroxisome proliferator-activated receptor-γ translocation. Many chromosomal abnormalities have been identified, and chromosomal gains are more common than losses in both benign and malignant Hurthle cell neoplasms. Hurthle cell carcinomas tend to have more chromosome losses than adenomas, and among carcinomas, losses, particularly of chromosome 22, are more frequent in tumors associated with death from disease. GRIM-19 (gene associated with retinoic-interferon–induced mortality 19) point mutations, thought to be involved in tumorigenesis via mitochondrial metabolism and cell death, have been identified in Hurthle cell tumors and are more specific than other markers for Hurthle cell neoplasms. Unlike hyperplastic or adenomatous nodules, Hurthle cell neoplasms generally are solitary encapsulated lesions. Hurthle cell neoplasms with papillary growth are differentiated from oxyphilic PTC by the lack of characteristic nuclear features of PTC. Hurthle cell adenomas are benign, treated by lobectomy, and have an excellent prognosis. Hurthle cell carcinomas invade soft tissue and show nodal involvement more often than conventional follicular carcinomas. Hurthle cell carcinoma accounts for 2–3 % of thyroid carcinomas and 20 % of follicular carcinomas. Hurthle cell carcinomas are thought to be somewhat more aggressive than follicular carcinomas and have a 5-year survival rate of 50–60 %. Features associated with aggressive behavior include large tumor size and vascular invasion. Tumors with only capsular invasion and no vascular invasion usually behave less aggressively than those with vascular invasion.

Although ganglioneuromas are benign and easily recognizable tumors, primitive neural tumors of the adrenal gland, such as neuroblastoma, are malignant and present much more complex problems in diagnosis and classification. Ganglioneuromas may occur in a variety of sites, including the adrenal gland. They are benign neural tumors composed of ganglion cells and Schwann cells. Neuroblastomas are malignant tumors derived from primordial neural crest cells. These tumors may be identified in a variety of sites, including the adrenal gland. Neuroblastomas usually are sporadic. They are the fourth most common malignant tumor in children; most occur in children younger than 5 years, and one fifth are congenital.

Metastatic neuroendocrine neoplasms can have similar histologic appearances, and without an obvious primary, it may be difficult to determine the site of origin of the metastasis. Thyroid transcription factor-1 (TTF-1) is a nuclear protein expressed during the development of thyroid, lung, and forebrain. The clinical utility of TTF-1 to distinguishing between metastatic pulmonary and nonpulmonary well-differentiated neuroendocrine tumors (WDNET) has not been previously studied. One hundred fifty-eight primary and metastatic WDNET were evaluated for TTF-1 expression. The tumors included 20 pulmonary WDNET, including 17 typical and 3 atypical carcinoid tumors, 10 metastatic pulmonary WDNET, 26 intestinal WDNET, 24 metastatic intestinal WDNET, 3 thymic mediastinal WDNET, 30 thyroid tumors (10 medullary carcinomas, 5 follicular carcinomas, 5 follicular adenomas, 5 papillary carcinomas, and 5 anaplastic carcinomas), 10 parathyroid adenomas, 20 pituitary adenomas, 10 pancreatic WDNET, and 5 pheochromocytomas. TTF-1 expression was found in 19 of 20 (95%) pulmonary WDNET, 8 of 10 (80%) metastatic pulmonary WDNET, and in 0 of 50 (0%) intestinal WDNET. All thyroid tumors were diffusely positive for TTF-1, except for three anaplastic carcinomas. All parathyroid and pituitary adenomas, pancreatic and thymic WDNET, and pheochromocytomas were uniformly negative for TTF-1. These results indicate that TTF-1 is clinically useful in distinguishing metastatic pulmonary from metastatic WDNET of extrapulmonary origin.

We analyzed a series of adrenocortical neoplasms to compare the clinicopathologic features and the expression of insulin-like growth factor-2 (IGF-2) in adrenocortical adenomas and carcinomas. IGF-2 is a growth factor commonly expressed in many tumors including adrenal cortical and medullary neoplasms. Formalin-fixed paraffin-embedded tissues from 64 adrenocortical adenomas and 67 adrenocortical carcinomas were analyzed. The carcinomas were histologically graded from 1 to 4 based on mitotic activity and necrosis. Tumor weight, size, and follow-up information were obtained by chart review. Expression of IGF-2 was detected by immunohistochemistry with the avidin-biotin-peroxidase complex method and a monoclonal antibody against IGF-2. Adrenocortical carcinomas were larger (mean: 13.1 cm, 787 g) than adenomas (mean: 4.2 cm, 52 g) (p

In most cases, the histopathologic and cytologic distinction between Graves' disease and papillary thyroid carcinoma is relatively easy, but on occasion Graves' disease may simulate a thyroid papillary carcinoma. For example, papillary fronds with fibrovascular cores may be present in both Graves' disease and papillary carcinoma. p27kip1 (p27) is a cyclin-dependent kinase inhibitory protein that has been shown to be an independent prognostic factor in a variety of human tumors. Our previous studies of p27 expression in hyperplastic and neoplastic endocrine lesions showed that the level of p27 was quite different in these two conditions. To determine if this distinction could also be made between Graves' disease and papillary carcinoma, we analyzed expression of p27 and other cell cycle proteins in a series of cases of Graves' disease with papillary hyperplasia and a series of papillary thyroid carcinomas. Formalin-fixed paraffin-embedded tissues from 61 randomly selected patients with thyroid disease, including 29 cases of Graves' disease with papillary architectural features and 32 cases of papillary carcinoma, were analyzed for expression of p27, Ki-67, and DNA topoisomerase II alpha (topo II alpha) by immunostaining. The distribution of immunoreactivity was analyzed by quantifying the percentage of positive nuclei that was expressed as the labeling index (LI) plus or minus the standard error of the mean. The papillary hyperplasia of Graves' disease had a p27 LI of 68.2 +/- 3.1 (range, 24 to 88), whereas papillary carcinomas had a LI of 25.6 +/- 2.5 (range, 12 to 70) (P < .0001). No significant differences in Ki-67 or topo II alpha expression were identified between papillary hyperplasia in Graves' disease and papillary carcinoma. These results indicate that p27 protein expression is significantly higher in papillary hyperplasia of Graves' disease compared to papillary carcinoma, which may be diagnostically useful in difficult cases.

Making a histologic distinction between Hurthle cell adenomas and carcinomas sometimes may be difficult. We analyzed a series of Hurthle cell lesions to determine whether specific histologic features and expression of Ki67 and cyclin D1 could be useful in distinguishing Hurthle cell adenomas from carcinomas. Formalin-fixed, paraffin-embedded tissues from 128 Hurthle cell neoplasms, including 59 adenomas; 55 carcinomas; and 14 tumors classified as neoplasms of uncertain malignant behavior (UMB), which had equivocal capsular invasion but no vascular invasion, were analyzed for expression of Ki67 and cyclin D1 by immunostaining. The distribution of immunoreactivity for Ki67 with antibody MIB-1 was analyzed by quantifying the percentage of positive nuclei that was expressed as the labeling index. None of the patients with adenomas or UMB tumors developed recurrent or metastatic disease after a mean follow-up of 7.8 and 7.9 years, respectively. Of the 55 patients with Hurthle cell carcinoma, 19 were associated with metastatic disease, 13 of whom died with disease. No patient with a Hurthle cell carcinoma without vascular invasion developed metastatic disease. The mean tumor size for Hurthle cell carcinomas (4.8 cm) was significantly larger than that of Hurthle cell adenomas (3.1 cm) or UMB tumors (3.7 cm). No patient with a Hurthle cell tumor smaller than 3.5 cm developed metastatic disease, even when vascular invasion was present. The Ki67 labeling index in Hurthle cell carcinomas (10.0 +/- 1.2) was 3-fold higher than in Hurthle cell adenomas (3.2 +/- 0.3). The Ki67 labeling index in the UMB group was 5.0 +/- 0.7. Cyclin D1 showed diffuse nuclear staining in 1 of the 59 (1.7%) Hurthle cell adenomas, in 10 of the 55 (18%) Hurthle cell carcinomas, and in none of the UMB tumors. In summary, analyses of the cell cycle proteins Ki67 and cyclin D1 in Hurthle cell thyroid neoplasms indicate that these markers may assist in distinguishing some Hurthle cell carcinomas from adenomas. Among the Hurthle cell carcinomas, large tumor size and vascular invasion are associated with clinically aggressive tumors. Our study also suggests that Hurthle cell neoplasms with only equivocal capsular invasion and no vascular invasion should behave in a benign manner.

Endocrine tumors are often diagnostic challenges. Recent studies have suggested that proteins that regulate cell cycle may have diagnostic and prognostic utility in endocrine tumors. p27kip 1 (p27) is a cyclin-dependent kinase inhibitor that regulates the transition from the G1 to the S phase of the cell cycle. p27 and other cell-cycle proteins are becoming increasingly important in assessing the biologic behavior of endocrine neoplasms, classifying hyperplastic and neoplastic endocrine tissues, and in the progression of endocrine tumors. p27 appears to separate normal from neoplastic endocrine tissues and, in some cases, benign from malignant endocrine tumors. However, there is overlap in p27 expression among individual cases of benign and malignant tumors, and p27 has only limited prognostic utility in endocrine tumors compared to some epithelial tumors such as breast and prostate neoplasms. Thus, more effective molecular and cellular markers that can be used for diagnostic and prognostic purposes in endocrine pathology are needed.

Non-islet cell tumor hypoglycemia (NICTH) is uncommon. Many of the tumors associated with NICTH are mesenchymal tumors, although carcinomas are also involved in some cases. High serum levels of insulin-like growth factor II (IGF-II) have been associated with NICTH. Analysis of 4 pituitary tumors, 2 adrenocortical tumors, 42 solitary fibrous tumors, and 23 other mesenchymal tumors for IGF-II protein and mRNA showed that most mesenchymal tumors expressed IGF-II protein and mRNA, although only 4 of 48 patients had associated hypoglycemia. Tumor size was related to IGF-II production. Tumors less than 5 cm were usually negative for IGF-II mRNA, whereas 92.3% of tumors greater than 9 cm were positive for IGF-II mRNA. These results show that IGF-II mRNA and protein can be readily detected in many tumors, even when the tumors are not associated with clinical hypoglycemia. The expression and production of this growth factor cannot accurately predict patients with clinical evidence of hypoglycemia.

p27kip1 (p27) is a member of the universal cyclin-dependent kinase inhibitor (CDKI) family. p27 expression is regulated by cell contact inhibition and by specific growth factors, such as transforming growth factor (TGF)-beta. Since the cloning of the p27 gene in 1994, a host of other functions have been associated with this cell cycle protein. In addition to its role as a CDKI, p27 is a putative tumor suppressor gene, regulator of drug resistance in solid tumors, and promoter of apoptosis; acts as a safeguard against inflammatory injury; and has a role in cell differentiation. The level of p27 protein expression decreases during tumor development and progression in some epithelial, lymphoid, and endocrine tissues. This decrease occurs mainly at the post-translational level with protein degradation by the ubiquitin-proteasome pathway. A large number of studies have characterized p27 as an independent prognostic factor in various human cancers, including breast, colon, and prostate adenocarcinomas. Here we review the role of p27 in the regulation of the cell cycle and other cell functions and as a diagnostic and prognostic marker in human neoplasms. We also review studies indicating the increasingly important roles of p27, other CDKIs, and cyclins in endocrine cell hyperplasia and tumor development.

Transforming growth factor B (TGF-B) has an inhibitory effect on cell proliferation in various cells and tumors, so loss of TG-B-receptor (TGF-B-R) may lead to increase proliferative activity in these tumors. We compared the expression of TGF-B and TGF-B-Rll in a group of thyroid neoplasms from the United States, Japan, and China to determine if there were differences in the expression of this growth factor or its receptors in various tumor types from different countries. A total 108 neoplastic thyroids from the United States, 42 from Japan, and 46 from China were analyzed for TGF-B1, TGF-B3, and TGF-B-Rll by in situ hybridization with riboprobes. TGF-jB-RII expression was also examined by immunohistochemistry. TGF-B1 mRNA was expressed in all neoplastic thyroids from all three countries except for one anaplasti carcinoma (ACA). TGF-B3 expression was lowest in follicular carcinomas (FCA) from all three countries (30/42; 71%). TGF-B-RII was much lower in FCA from Japan (112; 50%) and China (6/11; 55%) compared to cases from the United States (26/29; 90%). TGF-B-RII expression in papillary carcinoma (PCA) was also lower in carcinomas from Japan (21/28; 75%) and China (23/30; 77%) compared to the United States (24/25; 96%). Most ACA from the United States (25/30; 83%) and from China (3/3; 100%) were positive for TGF-B-Rll. Immunohistochemical analysis for TGF-B-RII protein expression showed the highest levels in follicular adenomas (FA) (38/38; 100%) with decreased immunoreactivity in FCA (36142; 86%). PCA (66/83; 80%), and ACA (14/33; 42%). These findings suggest that loss of TGF-B--RII may be important in thyroid tumor progression and that environmental/geographic factors may play a role in the variable expression of TGF-B--RII in thyroid malignancy.

Recent reports indicate that papillary thyroid carcinoma with hobnail features, also designated as micropapillary variant of papillary thyroid carcinoma, is a rare but very aggressive variant of papillary thyroid carcinoma. We examined the histopathologic and immunohistochemical features of 24 cases of papillary thyroid carcinoma with hobnail/micropapillary component to determine the prognostic significance of the amount of hobnail/micropapillary features in these tumors. The patients included 18 women and 6 men. Ages ranged from 28 to 78 years (mean, 57 years). Tumor size ranged from 1 to 5.8 cm (mean, 3 cm). The average follow-up time was 106 months (range, 4-274 months). Twelve cases (50%) of papillary thyroid carcinoma showed more than 30% hobnail/micropapillary features, and all but 3 cases were associated with an aggressive behavior. During the follow-up, 6 of these patients died of disease after a mean of 44.8 months, and 3 patients remained alive with extensive disease after a mean follow-up of 32.3 months. Metastases to lymph nodes or distant organs showed a hobnail pattern of growth similar to the primary tumor. The remaining 3 patients with prominent hobnail/micropapillary features were alive with no evidence of disease after a mean follow-up of 125.3 months. The other 12 papillary thyroid carcinoma cases (50%) showed less than 30% hobnail/micropapillary features. Nine of these patients were alive without disease after a mean of 162 months, and 1 patient died of sepsis, which was not related to thyroid tumor after 155 months. Two patients in this group died of disease after 21 and 163 months, respectively. These findings confirm earlier observations that papillary thyroid carcinoma with hobnail/micropapillary features is an aggressive variant of papillary thyroid carcinoma. Tumors with more than 30% hobnail/micropapillary features were often. very aggressive, although 2 patients with tumors with 10% hobnail/micropapillary features also had poor outcomes.

The majority of locoregional recurrences in melanoma occur in the form of intradermal or subcutaneous local or in-transit metastasis. In-transit melanoma represents contamination of the lymphatic space that, if treated, can result in long-term cure in a subset of patients. The management of in-transit metastases is challenging, since the treatments and extent of disease vary greatly based on the number, depth, location, and distribution of lesions, and on their biological behavior. A number of different treatment options exist, but there is no level 1 evidence to guide clinical decision-making. Herein we present our institutional treatment algorithm, which allows for individualization based on the patient's presentation.