Adrenal tumors autonomously producing cortisol cause Cushing's syndrome1,2,3,4. We performed exome sequencing of 25 tumor-normal pairs and identified 2 subgroups. Eight tumors (including three carcinomas) had many somatic copy number variants (CNVs) with frequent deletion of CDC42 and CDKN2A, amplification of 5q31.2 and protein-altering mutations in TP53 and RB1. Seventeen tumors (all adenomas) had no somatic CNVs or TP53 or RB1 mutations. Six of these had known gain-of-function mutations in CTNNB1 (β-catenin)5,6 or GNAS (Gαs)7,8. Six others had somatic mutations in PRKACA (protein kinase A (PKA) catalytic subunit) resulting in a p.Leu206Arg substitution. Further sequencing identified this mutation in 13 of 63 tumors (35% of adenomas with overt Cushing's syndrome). PRKACA, GNAS and CTNNB1 mutations were mutually exclusive. Leu206 directly interacts with the regulatory subunit of PKA, PRKAR1A9,10. Leu206Arg PRKACA loses PRKAR1A binding, increasing the phosphorylation of downstream targets. PKA activity induces cortisol production and cell proliferation11,12,13,14,15, providing a mechanism for tumor development. These findings define distinct mechanisms underlying adrenal cortisol-producing tumors.
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This work was supported in part by the US National Institutes of Health (NIH) Centers for Mendelian Genomics (5U54HG006504). G.G. is supported by the Agency for Science, Technology and Research of Singapore. T.C. is a Damon Runyon Clinical Investigator supported in part by the Damon Runyon Cancer Research Foundation. R.P.L. is an investigator of the Howard Hughes Medical Institute.
The authors declare no competing financial interests.
Integrated supplementary information
Frequency of gains (red) and losses (blue) plotted across genome.
Left, deletions in blue. Right, amplifications in red. The green line signifies the threshold for significance, q = 0.25.
Both wild-type (A) and mutant (C) alleles are detected in the tumor, as shown in the position highlighted.
Representative images of PRKACA-mutant tumor and wild-type tumor (no mutation in PRKACA, CTNNB1 or GNAS) stained for CREB phosphorylated at Ser133. Intense nuclear-specific staining is observed in the majority of the nuclei in the mutant tumor (a) but not in the wild-type tumor (b). Scale bars represent 60 μm.
All tumors reviewed with PRKACA mutations (n = 6) were well-defined, solitary adrenal cortical nodules with well-differentiated morphology. The majority of these tumors had low-grade nuclei (5/6), and none of the tumors showed fibrosis, necrosis, mitosis and hemorrhage, consistent with benign adenomas. (a) 2.6-cm cortisol-secreting adrenal cortical adenoma showing a bright yellow and brown cut surface that corresponds to its cellular composition as shown in b. The ruler is in centimeters and millimeters. (b) The tumor comprises lipid-rich clear cells (filled arrow) and oncocytic cells (open arrow) with granular eosinophilic cytoplasm. The scale bar represents 60 μm.
Supplementary Figure 6 Model for cortisol-producing adrenal tumor formation due to gain-of-function mutation in PRKACA.
(a) In quiescent adrenal fasciculata cells, protein kinase A exists as an inactive tetramer, with the catalytic subunits bound to a dimer of regulatory subunits. (b) ACTH binds to its receptor, melanocortin receptor 2, which stimulates adenylyl cyclase via Gas, leading to an increase in intracellular cAMP levels. cAMP binds to the regulatory subunits, causing the release of the catalytic subunits and downstream signaling, which leads to cell proliferation and cortisol production. (c) The mutant catalytic subunits are not bound by the regulatory subunit and are thus constitutively active in the absence of external stimuli. The resulting uncontrolled cell proliferation and cortisol production lead to the formation of a cortisol-producing adrenal tumor. MC2, melanocortin receptor 2; AC, adenylyl cyclase; R, regulatory subunit; C, catalytic subunit.
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Goh, G., Scholl, U., Healy, J. et al. Recurrent activating mutation in PRKACA in cortisol-producing adrenal tumors. Nat Genet 46, 613–617 (2014). https://doi.org/10.1038/ng.2956
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