Fig. 4: Clinical and molecular features of aggressive ACTH tumors.

a Timeline of diagnosis, treatment, recurrence, and persistence for patient ACTH1, with MRI images at key points and tumor borders outlined in yellow dashed lines. b Serum cortisol and ACTH levels during the treatment of patient ACTH1. c, Bar plot of recurrence time after initial surgery for ACTH patients. d Bar plot of Ki67 index, Knosp grade, p53 IHC staining, and Trouillas classification (TC) in ACTH patients. e IHC staining of Ki67 and p53 in tissue sections from patients ACTH1 and ACTH2 (n = 3 technical replicates for each patient). f Gene-rank plot of marker genes in cluster 44, with p53 pathway genes in red and proliferation-related genes in blue. g Expression of cell cycle-related p53 pathway genes across clusters. Boxes span the interquartile range (IQR) and whiskers extend to points that lie within 1.5 IQRs of the lower and upper quartile. Center line is drawn at the median. h Boxplot of p53-associated cell cycle scores by cluster, using the Kruskal–Wallis test. Boxes span the interquartile range (IQR) and whiskers extend to points that lie within 1.5 IQRs of the lower and upper quartile. Center line is drawn at the median. For (g, h) a total of 54,607 cells were analyzed across 12 clusters: 0 (n = 11,109), 1 (n = 9,127), 3 (n = 8,674), 8 (n = 5,033), 11 (n = 4,455), 16 (n = 3,789),21 (n = 3,021), 24 (n = 2,692),29 (n = 2,291), 36 (n = 851), 39 (n = 378), and 44 (n = 217). i Kaplan-Meier progression-free survival curves for 18 patients with tumor recurrence, stratified by p53 staining and Ki67 index, analyzed by log-rank test. j Lollipop plot showing TP53 mutation sites in patients ACTH1 and ACTH2. Source data are provided as a Source Data file for (h) and (i).