, Volume 65, Issue 3, pp 683–691 | Cite as

H-score of 11β-hydroxylase and aldosterone synthase in the histopathological diagnosis of adrenocortical tumors

  • Yi Yang
  • Ming Xiao
  • Ying Song
  • Yi Tang
  • Ting Luo
  • Shumin Yang
  • Wenwen He
  • Qingfeng Cheng
  • Linqiang Ma
  • Yao Zhang
  • Yunfeng He
  • Youde Cao
  • Jun Yang
  • Bin Peng
  • Jinbo HuEmail author
  • Qifu LiEmail author
Original Article



To assess the diagnostic performance of the H-score of 11β-hydroxylase (CYP11B1) and aldosterone synthase (CYP11B2) in the histopathological diagnosis of adrenocortical tumors (ACT).


We retrospectively evaluated 199 cases of ACT, of which 85 were diagnosed as aldosterone-producing adenoma (APA), 66 as cortisol-producing adenoma (CPA), 9 as aldosterone–cortisol co-secreting adenoma, 30 as nonhyperfunctioning adenoma, and 9 as adrenocortical carcinoma (ACC). Immunohistochemical staining was performed using anti-CYP11B1 and anti-CYP11B2 monoclonal antibodies. The staining was quantified by the McCarty’s H-score system. The diagnostic performance was assessed by the receiver operating characteristic curve (ROC).


The H-score of CYP11B1 is highest in the CPA group and lowest in the ACC group. The H-score of CYP11B2 in the APA group is significantly higher than other ACT groups. The area under ROC (AUC) of an increased H-score of CYP11B2 (>65) for the diagnosis of APA was 0.971 (95%CI 0.937–0.990). The AUC of an increased H-score of CYP11B1 (>204) for the diagnosis of CPA was 0.725 (95%CI 0.658–0.786). The AUC of a decreased H-score of CYP11B1 (<85) for the diagnosis of ACC was 0.960 (95%CI 0.923–0.983).


H-score of CYP11B1 and CYP11B2 are reliable tools for the histopathological subtyping of functional benign ACT and may offer some value in the histopathological diagnosis of malignant ACT.


Adrenocortical Tumors 11β-hydroxylase Aldosterone synthase H-score Histopathological diagnosis 



The authors thank Laboratory of Endocrine and Laboratory of Lipid & Glucose Metabolism, the First Affiliated Hospital of Chongqing Medical University. The authors also thank Chuan Peng, Rufei Gao, and Xiaoqiu Xiao (from Laboratory of Lipid & Glucose Metabolism, the First Affiliated Hospital of Chongqing Medical University) for suggestions of study design and revision.


This study was funded by National Key Clinical Specialties Construction Program of China to the Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University; and the National Natural Science Foundation of China (81670785) to Q.L.; and the National Natural Science Foundation of China (81800701) to Y.S.; and the Fundamental Science & Advanced Technology Research of Chongqing (Major Project, cstc2015jcyjBX0096) to Q.L.; and Chongqing Science and Technology Committee Innovation Project (Technology Development and Application of Precision Medicine, cstc2016shms-ztzx1003) to Q.L.; and the Joint Medical Research Project of Chongqing Science and Technology Commission and Chongqing Health and Family Planning Commission (Youth Project, 2018QNXM001) to J.H.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethics approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

A written informed consent was obtained from each participant enrolled.

Supplementary material

12020_2019_2022_MOESM1_ESM.doc (670 kb)
Supplementary Information


  1. 1.
    G.E. Lattin Jr, E.D. Sturgill, C.A. Tujo, J. Marko, K.W. Sanchez-Maldonado, W.D. Craig, E.E. Lack, From the radiologic pathology archives: Adrenal tumors and tumor-like conditions in the adult: radiologic-pathologic correlation. Radiographics 34(3), 805–829 (2014)CrossRefGoogle Scholar
  2. 2.
    C. Mattsson, W.F. Young Jr, Primary aldosteronism: diagnostic and treatment strategies. Nat. Clin. Pract. Nephrol. 2(4), 198–208 (2006). quiz, 191 p following 230CrossRefGoogle Scholar
  3. 3.
    A. Lacroix, R.A. Feelders, C.A. Stratakis, L.K. Nieman, Cushing’s syndrome. Lancet 386(9996), 913–927 (2015)CrossRefGoogle Scholar
  4. 4.
    S. Monticone, F. D’Ascenzo, C. Moretti, T.A. Williams, F. Veglio, F. Gaita, P. Mulatero, Cardiovascular events and target organ damage in primary aldosteronism compared with essential hypertension: a systematic review and meta-analysis. Lancet Diabetes Endocrinol. 6(1), 41–50 (2018)CrossRefGoogle Scholar
  5. 5.
    G.P. Rossi, L.A. Sechi, G. Giacchetti, V. Ronconi, P. Strazzullo, J.W. Funder, Primary aldosteronism: cardiovascular, renal and metabolic implications. Trends Endocrinol. Metab. 19(3), 88–90 (2008)CrossRefGoogle Scholar
  6. 6.
    T. Else, A.C. Kim, A. Sabolch, V.M. Raymond, A. Kandathil, E.M. Caoili, S. Jolly, B.S. Miller, T.J. Giordano, G.D. Hammer, Adrenocortical carcinoma. Endocr. Rev. 35(2), 282–326 (2014)CrossRefGoogle Scholar
  7. 7.
    D.W. Nelson, S.C. Chang, B.C. Bandera, T.D. Fischer, R. Wollman, M. Goldfarb, Adjuvant radiation is associated with improved survival for select patients with non-metastatic adrenocortical carcinoma. Ann. Surg. Oncol. 25(7), 2060–2066 (2018)CrossRefGoogle Scholar
  8. 8.
    D.E. Hansel, V.E. Reuter, Adrenal pathology in the adult: a urological pathologist’s perspective. Adv. Anat. Pathol. 23(5), 273–284 (2016)CrossRefGoogle Scholar
  9. 9.
    O. Mete, S.L. Asa, T.J. Giordano, M. Papotti, H. Sasano, M. Volante, Immunohistochemical biomarkers of adrenal cortical neoplasms. Endocr. Pathol. 29(2), 137–149 (2018)CrossRefGoogle Scholar
  10. 10.
    T. Kawamoto, Y. Mitsuuchi, K. Toda, K. Miyahara, Y. Yokoyama, K. Nakao, K. Hosoda, Y. Yamamoto, H. Imura, Y. Shizuta, Cloning of cDNA and genomic DNA for human cytochrome P-45011 beta. FEBS Lett. 269(2), 345–349 (1990)CrossRefGoogle Scholar
  11. 11.
    E. Mornet, J. Dupont, A. Vitek, P.C. White, Characterization of two genes encoding human steroid 11 beta-hydroxylase (P-450(11) beta). J. Biol. Chem. 264(35), 20961–20967 (1989)Google Scholar
  12. 12.
    T. Ogishima, H. Shibata, H. Shimada, F. Mitani, H. Suzuki, T. Saruta, Y. Ishimura, Aldosterone synthase cytochrome P-450 expressed in the adrenals of patients with primary aldosteronism. J. Biol. Chem. 266(17), 10731–10734 (1991)Google Scholar
  13. 13.
    F. Gioco, T.M. Seccia, E.P. Gomez-Sanchez, G.P. Rossi, C.E. Gomez-Sanchez, Adrenal histopathology in primary aldosteronism: is it time for a change? Hypertension 66(4), 724–730 (2015)CrossRefGoogle Scholar
  14. 14.
    C.E. Gomez-Sanchez, E.P. Gomez-Sanchez, Immunohistochemistry of the adrenal in primary aldosteronism. Curr. Opin. Endocrinol. diabetes Obes. 23(3), 242–248 (2016)CrossRefGoogle Scholar
  15. 15.
    F. Kubota-Nakayama, Y. Nakamura, S. Konosu-Fukaya, A. Azmahani, K. Ise, Y. Yamazaki, Y. Kitawaki, S.J. Felizola, Y. Ono, K. Omata et al. Expression of steroidogenic enzymes and their transcription factors in cortisol-producing adrenocortical adenomas: immunohistochemical analysis and quantitative real-time polymerase chain reaction studies. Hum. Pathol. 54, 165–173 (2016)CrossRefGoogle Scholar
  16. 16.
    T. Dekkers, M. ter Meer, J.W. Lenders, A.R. Hermus, L. Schultze Kool, J.F. Langenhuijsen, K. Nishimoto, T. Ogishima, K. Mukai, E.A. Azizan et al. Adrenal nodularity and somatic mutations in primary aldosteronism: one node is the culprit? J. Clin. Endocrinol. Metab. 99(7), E1341–E1351 (2014)CrossRefGoogle Scholar
  17. 17.
    S. Monticone, I. Castellano, K. Versace, B. Lucatello, F. Veglio, C.E. Gomez-Sanchez, T.A. Williams, P. Mulatero, Immunohistochemical, genetic and clinical characterization of sporadic aldosterone-producing adenomas. Mol. Cell. Endocrinol. 411, 146–154 (2015)CrossRefGoogle Scholar
  18. 18.
    H. Sasano, T. Suzuki, H. Nagura, T. Nishikawa, Steroidogenesis in human adrenocortical carcinoma: biochemical activities, immunohistochemistry, and in situ hybridization of steroidogenic enzymes and histopathologic study in nine cases. Hum. Pathol. 24(4), 397–404 (1993)CrossRefGoogle Scholar
  19. 19.
    J.W. Funder, R.M. Carey, F. Mantero, M.H. Murad, M. Reincke, H. Shibata, M. Stowasser, W.F. Young Jr, The Management of Primary Aldosteronism: Case Detection, Diagnosis, and Treatment: An Endocrine Society Clinical Practice Guideline. J. Clin. Endocrinol. Metab. 101(5), 1889–1916 (2016)CrossRefGoogle Scholar
  20. 20.
    T.A. Williams, J.W.M. Lenders, P. Mulatero, J. Burrello, M. Rottenkolber, C. Adolf, F. Satoh, L. Amar, M. Quinkler, J. Deinum et al. Outcomes after adrenalectomy for unilateral primary aldosteronism: an international consensus on outcome measures and analysis of remission rates in an international cohort. Lancet Diabetes Endocrinol. 5(9), 689–699 (2017)CrossRefGoogle Scholar
  21. 21.
    L.K. Nieman, B.M. Biller, J.W. Findling, J. Newell-Price, M.O. Savage, P.M. Stewart, V.M. Montori, The diagnosis of Cushing’s syndrome: an Endocrine Society Clinical Practice Guideline. J. Clin. Endocrinol. Metab. 93(5), 1526–1540 (2008)CrossRefGoogle Scholar
  22. 22.
    M. Terzolo, A. Stigliano, I. Chiodini, P. Loli, L. Furlani, G. Arnaldi, G. Reimondo, A. Pia, V. Toscano, M. Zini et al. AME position statement on adrenal incidentaloma. Eur. J. Endocrinol. 164(6), 851–870 (2011)CrossRefGoogle Scholar
  23. 23.
    L.M. Weiss, Comparative histologic study of 43 metastasizing and nonmetastasizing adrenocortical tumors. Am. J. Surg. Pathol. 8(3), 163–169 (1984)CrossRefGoogle Scholar
  24. 24.
    C.E. Gomez-Sanchez, X. Qi, C. Velarde-Miranda, M.W. Plonczynski, C.R. Parker, W. Rainey, F. Satoh, T. Maekawa, Y. Nakamura, H. Sasano et al. Development of monoclonal antibodies against human CYP11B1 and CYP11B2. Mol. Cell. Endocrinol. 383(1–2), 111–117 (2014)CrossRefGoogle Scholar
  25. 25.
    D.A. Budwit-Novotny, K.S. McCarty, E.B. Cox, J.T. Soper, D.G. Mutch, W.T. Creasman, J.L. Flowers, K.S. McCarty Jr, Immunohistochemical analyses of estrogen receptor in endometrial adenocarcinoma using a monoclonal antibody. Cancer Res. 46(10), 5419–5425 (1986)Google Scholar
  26. 26.
    K. Nishimoto, M. Koga, T. Seki, K. Oki, E.P. Gomez-Sanchez, C.E. Gomez-Sanchez, M. Naruse, T. Sakaguchi, S. Morita, T. Kosaka et al. Immunohistochemistry of aldosterone synthase leads the way to the pathogenesis of primary aldosteronism. Mol. Cell Endocrinol. 441, 124–133 (2017)CrossRefGoogle Scholar
  27. 27.
    C. Volpe, B. Hamberger, A. Hoog, K. Mukai, J. Calissendorff, H. Wahrenberg, J. Zedenius, M. Thoren, Primary aldosteronism: functional histopathology and long-term follow-up after unilateral adrenalectomy. Clin. Endocrinol. 82(5), 639–647 (2015)CrossRefGoogle Scholar
  28. 28.
    K. Nishimoto, K. Nakagawa, D. Li, T. Kosaka, M. Oya, S. Mikami, H. Shibata, H. Itoh, F. Mitani, T. Yamazaki et al. Adrenocortical zonation in humans under normal and pathological conditions. J. Clin. Endocrinol. Metab. 95(5), 2296–2305 (2010)CrossRefGoogle Scholar
  29. 29.
    K. Nanba, M. Tsuiki, K. Sawai, K. Mukai, K. Nishimoto, T. Usui, T. Tagami, H. Okuno, T. Yamamoto, A. Shimatsu et al. Histopathological diagnosis of primary aldosteronism using CYP11B2 immunohistochemistry. J. Clin. Endocrinol. Metab. 98(4), 1567–1574 (2013)CrossRefGoogle Scholar
  30. 30.
    Y. Ono, Y. Nakamura, T. Maekawa, S.J. Felizola, R. Morimoto, Y. Iwakura, M. Kudo, K. Seiji, K. Takase, Y. Arai et al. Different expression of 11beta-hydroxylase and aldosterone synthase between aldosterone-producing microadenomas and macroadenomas. Hypertension 64(2), 438–444 (2014)CrossRefGoogle Scholar
  31. 31.
    S.G. Creemers, L.J. Hofland, E. Korpershoek, G.J. Franssen, F.J. van Kemenade, W.W. de Herder, R.A. Feelders, Future directions in the diagnosis and medical treatment of adrenocortical carcinoma. Endocr.-Relat. Cancer 23(1), R43–R69 (2016)CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Yi Yang
    • 1
  • Ming Xiao
    • 2
  • Ying Song
    • 1
  • Yi Tang
    • 2
  • Ting Luo
    • 1
  • Shumin Yang
    • 1
  • Wenwen He
    • 1
  • Qingfeng Cheng
    • 1
  • Linqiang Ma
    • 1
  • Yao Zhang
    • 3
  • Yunfeng He
    • 3
  • Youde Cao
    • 2
  • Jun Yang
    • 4
  • Bin Peng
    • 5
  • Jinbo Hu
    • 1
    Email author
  • Qifu Li
    • 1
    Email author
  1. 1.Department of Endocrinologythe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
  2. 2.Department of Pathology, College of Basic MedicineChongqing Medical UniversityChongqingChina
  3. 3.Department of Urologythe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
  4. 4.Cardiovascular Endocrinology LaboratoryHudson Institute of Medical ResearchClaytonAustralia
  5. 5.School of Public Health and ManagementChongqing Medical UniversityChongqingChina

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