We describe a thorough genomic characterization of adrenocortical carcinoma (ACC). patients (Else et al., 2014b; Fassnacht et al., 2009; Fassnacht et al., 2013). Histologic grading of ACC based on proliferation (Giordano, 2011; Weiss et al., 1989) refines treatment decisions for specific patient subgroups, but is not universally accepted (Miller et al., 2010). Chemotherapy, radiotherapy and the adrenolytic agent mitotane are the current standard therapeutic modalities for unresectable or metastatic ACC, but all are palliative (Else et al., 2014a). Our understanding of ACC pathogenesis is usually incomplete and additional therapeutic avenues are needed. Molecular studies have nominated several genes as potential drivers involved in sporadic adrenocortical tumorigenesis, including insulin-like growth factor 2 ((Giordano et al., 2003; Tissier et al., 2005). -catenin gain-of-function mutations are obvious in approximately 25% of both benign and malignant sporadic adrenocortical neoplasms (Tissier Torcetrapib et al., 2005). Recent genomic profiling efforts of ACC have identified candidate driver genes such as and and and in ACC are well recognized (Tissier et al., 2005). As expected, missense mutations in were confined to exon 3 (Physique Torcetrapib 1A). Six (7%) tumors harbored inactivating mutations in in ACC (Assie et al., 2014). While our cohort is the largest to be sequenced to date, a much larger number of samples is needed to identify all candidate malignancy genes (Lawrence et al., 2014). To overcome the limitation of sample size, we compared the mutated genes with the Malignancy Gene Census (Futreal et al., 2004). This approach identified two malignancy genes mutated in more than 5% of the cohort, and mutations cause Carney complex and benign main pigmented nodular adrenocortical disease (PPNAD) (Kirschner et al., 2000), malignant transformation has been reported in the adrenals of patients with this rare condition (Anselmo et al., 2012), and sporadic loss-of-function mutations in have been found in adrenocortical adenomas and rare carcinomas (Bertherat et al., 2003). Interestingly, DNA sequencing of sporadic adrenocortical adenomas recently revealed a recurrent activating L206R mutation in the catalytic subunit of the cAMP-dependent protein kinase A (PKA) (mutations in our cohort, we observed decreased expression and increased MEK and BRAF protein expression (Physique S1F and S1G) in mutant cases, suggesting a potential role Torcetrapib for inhibition of the RAF-MEK-ERK cascade in treatment of some ACCs. We observed two frameshift mutations in ribosomal protein L22 (in three ACCs. These findings suggest a role for somatic alteration of in 7% of ACC, which has previously been related to MDM2-mediated p53 ubiquitination and degradation (Zhang and Lu, 2009). Using two complementary analytical methods to detect fusion transcripts in mRNA-seq data (McPherson et al., 2011; Torres-Garcia et al., 2014), we recognized 156 singleton but no recurrent gene fusion events in 48 of 78 (62%) tumors (range: 1C16) (Number S1H and Table S1). Gene fusions happen at much lower frequencies than mutations and copy number variants (Yoshihara et al., 2015), and a larger cohort is needed to CBFA2T1 determine the rate of recurrence of fusions reported here. However, we did determine private inCframe fusions including known malignancy genes (Number 1B). A highly expressed fusion retained the mTOR catalytic website and resulted in elevated levels of total and phosphorylated mTOR protein with this tumor (Number S1I). The fusion point of a fusion fell within the breakpoint cluster region associated with acute myeloid leukemia (Krivtsov and Armstrong, 2007). Both fusion instances lacked mutations in SMGs. A fusion involving the gene (5p15.33), (16q22.1), (12q14.1) and (19q12) and deletions of (13q14.2), (9p21.2) and (22q12.1) (q 0.01; Number 1C and Table S1). A focal deletion maximum around 4q34.3C4q35.1 centered on a long noncoding RNA homozygous deletions appeared in 16% (n=14) of tumors assayed; by including non-silent mutations, 19.3% of ACCs harbored.