Primary Aldosteronism: Spatial Multiomics Mapping of Genotype-Dependent Heterogeneity and Tumor Expansion of Aldosterone-Producing Adenomas

Background: Primary aldosteronism is frequently caused by an adrenocortical aldosterone-producing adenoma (APA) carrying a somatic mutation that drives aldosterone overproduction. APAs with a mutation in KCNJ5 (APA- KCNJ5 MUT ) are characterized by heterogeneous CYP11B2 (aldosterone synthase) expression, a particular cellular composition and larger tumor diameter than those with wild-type KCNJ5 (APA- KCNJ5 WT ). We exploited these differences to decipher the roles of transcriptome and metabolome reprogramming in tumor pathogenesis. Methods: Consecutive adrenal cryosections (7 APAs and 7 paired adjacent adrenal cortex) were analyzed by spatial transcriptomics (10x Genomics platform) and metabolomics (in situ matrix-assisted laser desorption/ionization mass spectrometry imaging) co-integrated with CYP11B2 immunohistochemistry. Results: We identified intratumoral transcriptional heterogeneity that delineated functionally distinct biological pathways. Common transcriptomic signatures were established across all APA specimens which encompassed 2 distinct transcriptional profiles in CYP11B2-immunopositive regions ( CYP11B2 -type 1 or 2). The CYP11B2 -type 1 signature was characterized by zona glomerulosa gene markers and was detected in both APA- KCNJ5 MUT and APA- KCNJ5 WT . The CYP11B2 -type 2 signature displayed markers of the zona fasciculata or reticularis and predominated in APA- KCNJ5 MUT . Metabolites that promote oxidative stress and cell death accumulated in APA- KCNJ5 WT . In contrast, antioxidant metabolites were abundant in APA- KCNJ5 MUT . Finally, APA-like cell subpopulations—negative for CYP11B2 gene expression—were identified in adrenocortical tissue adjacent to APAs suggesting the existence of tumor precursor states. Conclusions: Our findings provide insight into intra- and intertumoral transcriptional heterogeneity and support a role for prooxidant versus antioxidant systems in APA pathogenesis highlighting genotype-dependent capacities for tumor expansion.