Impact of standardised reporting in adrenocortical carcinoma: a single centre clinicopathological review A Advani, 1,2 S Vaikkakara, 1 M S Gill, 3 C S Arun, 1 S H Pearce, 1 S G Ball, 1 R A James, 1 T W J Lennard, 4 R D Bliss, 4 R Quinton, 1 S J Johnson 3 1 Department of Endocrinology, The Newcastle upon Tyne NHS University Hospital Foundation Trust, Newcastle upon Tyne, UK; 2 Keenan Research Centre of the Li Ka Shing Knowledge Institute, St Michael’s Hospital, and University of Toronto, Ontario, Canada; 3 Department of Cellular Pathology, The Newcastle upon Tyne NHS University Hospital Foundation Trust, Newcastle upon Tyne, UK; 4 Department of Surgery, The Newcastle upon Tyne NHS University Hospital Foundation Trust, Newcastle upon Tyne, UK Correspondence to: Dr Sarah J Johnson, Department of Cellular Pathology, The Newcastle upon Tyne NHS University Hospital Foundation Trust, Newcastle upon Tyne NE1 4LP, UK; sarah.johnson8@nuth. nhs.uk Accepted 8 May 2008 Published Online First 2 June 2008 ABSTRACT Aims: Structured multicentre efforts are needed if the prognosis of adrenocortical carcinoma (ACC) is to be improved. Data collection may be enhanced through standardised histopathological reporting using criteria such as the recently published Royal College of Pathologists’ (UK) minimum dataset (MDS). This study aimed to perform a clinicopathological review of the adult patients treated at the Royal Victoria Infirmary, Newcastle upon Tyne, in the 10 years preceding the MDS. Methods: Case records were examined for all patients diagnosed with ACC between 1996 and 2006. Pathology was reviewed and compared with the Royal College of Pathologists’ MDS along with the original reports. A systematic evaluation of Ki-67 immunolabelling was also performed. Results: Eleven patients with ACC were diagnosed and treated. Histopathological reporting according to the MDS identified more features of malignancy than in the original reports (8.5¡1.2 versus 5.1¡0.8, p,0.02). The median number of microscopic criteria of malignancy was 7 (range 5–10), with >5 features occurring in all cases. The most commonly observed features of malignancy were diffuse architecture, ,25% clear cells, confluent necrosis, abnormal mitoses and mitotic count >6 per 50 high- power fields. Capsular invasion and >8 MDS criteria of malignancy were associated with a worse outcome (each p,0.01). Median Ki-67 index was 19.0% (range 3.7– 44.1%) and was not apparently related to survival. Conclusions: Standardised criteria for histopathological reporting of ACC will improve the accuracy of data for cancer registration and may also assist in individual patient stratification. An elevated Ki-67 index is a feature of ACC, although it does not appear to predict individual patient survival. Adrenocortical carcinoma (ACC) is a highly aggressive malignancy. Metastatic spread is com- mon at presentation (21–52%) and almost invari- able on follow up. 1–4 All current medical and surgical treatments carry poor results. For instance, the average survival after diagnosis is only 10–22 months 4–6 and 5-year survival rates vary between 16% and 38% (see review 7 ). One of the major restrictions to improving the treatment for ACC is the infrequency of its occurrence, with an incidence of 1–2 per million population per year. 89 Thus, even single tertiary care centres may see and treat only one or two patients each year. Accordingly, multicentre collaborations are essential if the prognosis is to be improved. One of the major limitations in this regard has been the lack of standardised data collection between centres. The histological diagnosis of malignancy in resected adrenocortical neoplasms can be proble- matic and various combinations of criteria have been proposed. 10–13 In 2006, the Royal College of Pathologists (UK) ((RCPath(UK)) produced a minimum dataset (MDS) for histopathology reports of ACC, based mainly on the Weiss criteria. 14 The MDS also includes comment on involvement of versus clear surgical margins (ie, apparent completeness of resection) and, by encouraging accurate diagnosis and SNOMED coding, it should improve data accuracy for cancer registration. The value of these histological fea- tures in predicting outcome and guiding adjuvant therapy has yet to be appraised. Several groups have demonstrated the apparent role of Ki-67 (MIB-1 clone) immunostaining in differentiating benign from malignant adrenocortical neoplasms 15– 18 and in predicting outcome in malignancy. 19 Nevertheless, a Ki-67 index is not a criterion included in the current MDS. This clinicopathological review aimed to retro- spectively test the completeness and accuracy of pathological reporting of features listed in the MDS, and to assess the performance of these features and the Ki-67 index in predicting survival for patients with ACC at one centre over 10 years. METHODS Histopathology records were interrogated to find all patients who attended the Royal Victoria Infirmary, Newcastle upon Tyne, UK, and who had a diagnosis of ACC made between 1996 and 2006. Patient clinical records were reviewed for age, sex, mode of presentation, pre- and postoperative biochemical and imaging evaluation, and treat- ment and outcome. Staging of disease was based on the McFarlane/ Sullivan classification: 20 stage I, tumour ,5 cm with negative nodes, no local invasion and no metastases; stage II, tumour .5 cm with negative nodes, no local invasion and no metastases; stage III, tumour with positive nodes or local invasion; and stage IV, tumour with positive nodes and local invasion or distant metastases. Stage of disease was based on imaging, intraoperative and pathological findings. Serum cortisol and testosterone (T) were mea- sured using a competitive chemiluminescence immunoassay (Advia Centaur System, Bayer Diagnostics, Newbury, UK). Follicle stimulating hormone (FSH) and luteinising hormone (LH) were measured by a two-site sandwich chemilu- minescence immunoassay (Advia). Urine cortisol was determined by competitive radioimmunoassay Original article J Clin Pathol 2008;61:939–944. doi:10.1136/jcp.2008.057067 939