# In-depth Genetic and Molecular Characterization of Unilateral Coexisting Adrenal Cortical Adenoma and Carcinoma in the Context of MEN1 Syndrome

## TL;DR

This study explores the genetic differences between benign and malignant adrenal tumors in a patient with MEN1 syndrome, suggesting a possible but not proven link between them.

## Contribution

The study provides a detailed genetic comparison of coexisting benign and malignant adrenal tumors in a MEN1 patient, offering insights into their potential relationship.

## Key findings

- MEN1 loss of heterozygosity was found in the carcinoma but not the adenoma.
- Shared variants between benign and malignant tumors suggest a possible genetic link.
- Clonal evolution analysis revealed distinct mutations in the carcinoma and recurrence.

## Abstract

Adrenal lesions often occur in patients with multiple endocrine neoplasia type 1 (MEN1), mostly adrenal cortical adenomas (ACAs), although the frequency of adrenal cortical carcinomas (ACCs) is higher than in the general population. The coexistence of benign and malignant masses has seldom been documented, leaving open the question of ACC progression from benign forms. We report a comprehensive genetic characterization of three adrenal cortical tumor samples obtained from a familial MEN1 patient, operated for the rapid progression of an initially stable nonfunctional adrenal incidentaloma. Histologically, the tumor consisted of a small ACA contiguous to a large ACC, which subsequently relapsed. Exome sequencing of ACC, ACA and recurrence evidenced a MEN1 loss of heterozygosity (LOH) in ACC but not in ACA, where, however, a second hit driven by alternative mechanisms could not be excluded. The majority of the ACA variants were found to co-occurred in ACC (n = 36/42) and were benign, except for two of unknown significance in KANK1 and REN genes, described as associated with renal cancer. Among variants shared between ACC and its recurrence (n = 69), 11 were Tier III, while 2 affecting TP53 and NF1 genes were pathogenic. Bioinformatic clonal evolution analysis identified one clone − characterized by TP53 and NF1 mutations − absent in ACA but present in ACC and recurrence, as well as 2 clones shared between ACA and ACC but lost in the recurrence. In conclusion, comparative Whole Exome Sequencing (WES) analysis of three adrenal tumors in a MEN1 patient suggests a possible relationship between malignant and benign lesions occurring in MEN1 patients, without, however, demonstrating any causal adenoma-to-carcinoma progression driven by MEN1 LOH. Overall, these data further suggest an increased risk of MEN1 patients to develop adrenocortical malignancy.

The online version contains supplementary material available at 10.1007/s12022-026-09908-0.