Was It an Adrenocortical Adenoma or an Adrenocortical Carcinoma? Limitation of the Weiss Scoring System in Determining the Malignant Potential of Adrenocortical Tumor: Report on Two Cases

Table 3

Summary of published classification systems for adrenocortical tumors and their diagnostic threshold for adrenocortical carcinoma.

Criteria	Weiss [6]	Hough [16]	Van Slooten [17]	Modified Weiss [7]	Reticulin algorithm [12]	Helsinki score [13]
Nuclear atypia (Fuhrman grade III or IV)	1	0.39	2.1
Nuclear hyperchromatism			2.6
Abnormal nucleoli			4.1
Atypical mitoses	1			1
Mitoses > 5/50 HPF >10/100 HPF > 2/10 HPF	1	0.60	9.0	2	Optional	3
Clear cells < 25% of total tumor volume	1			2
Architecture diffuse loss of normal structure	1	0.92	1.6
Venous invasion	1	0.92
Capsular invasion	1	0.37		1
Sinusoidal invasion	1
Vascular invasion					Optional
Capsular or vascular invasion	1		3.3
Necrosis	1	0.69		1	Optional	5
Regressive changes (necrosis, hemorrhage, fibrosis, or calcification)			5.7
Thick fibrous band		1.00
Response to ACTH (17-hydroxysteroids increased two times after 50 mcg of IV ACTH)		0.42
Urinary 17-ketosteroids (10 mg/1 g creatinine 24 h)		0.50
Cushing’s syndrome with virilism, virilism alone, or no clinical manifestations		0.42
Weight loss (>10 Ib/3 months)		2.00
Tumor mass (>100 g)		0.60
Disruption of reticulin network					Mandatory
Proliferative index (Ki-67) in the most proliferative area of tumor						1-100
Diagnostic threshold of ACC	≥3	>2	≥8	≥3	Mandatory criteria + any 1 optional	3 × mitoses + 5 necrosis + PI in % by Ki-67 > 8.5