o,p'--DDD and adrenal carcinoma

Adrenal cortical carcinoma. Epidemiology and treatment with mitotane and a review of the literature

BACKGROUND

Adrenal cortical carcinoma is rare; the authors have treated only eight patients with the disease at Good Samaritan Regional Medical Center since 1974. No exhaustive collection of cases of this cancer has been done since 1952.

METHODS

The authors retrospectively reviewed the medical records of their eight patients with adrenal cortical carcinoma. They also searched the English literature from 1952 to 1992 for reports of patients with the disease. They treated each report as a series if two or more previously unreported patients were reported. They paid special attention to patients for whom stage of disease was noted at diagnosis, treatment with mitotane (o,p'-DDD) was used, and the outcome was reported.

RESULTS

Five were male and three were female patients. Five had nonfunctional tumors. None were pediatric. The authors found 1891 cases in the English literature. Adrenal cortical carcinomas are more common in women (58.6%) than in men (41.4%). The age distribution of tumors is bimodal, with peaks in the first and fifth decades. Tumors in children are more commonly functional (83.5% in female patients, 85.6% in male patients), although nonfunctional tumors are more common in older patients (84.7%). Most (68%) of these tumors are diagnosed late in disease when surgery is no longer curative. Only 35% of patients treated with mitotane had a clinical response.

CONCLUSIONS

Adrenal cortical carcinomas are diagnosed most often in children because of functionality and older men because of mass effect. Most tumors are discovered too late for curative resection. Treatment of metastatic disease with mitotane has limited success.

The treatment of adrenocortical carcinoma with o,p'-DDD: prognostic implications of serum level monitoring

Thirty-four patients with adrenocortical carcinoma were treated with o,p'-DDD. Twenty-eight patients presented with metastases at entry, and spillage of tumour cells occurred at surgery in 6 other patients. Eight patients had objective tumour regression, of whom 7 had serum levels over 14 micrograms/ml. The 3 patients with a lasting remission had levels of greater than 15, greater than 25, greater than 25 micrograms/ml respectively during prolonged periods. Increased survival times were found in the group of 14 patients with o,p'-DDD serum levels higher than 14 micrograms/ml when compared with patients not treated after discovery of metastases. In the patients with levels less than or equal to 10 micrograms/ml no therapeutic effect was seen. Levels of over 20 micrograms/ml are associated with symptoms of reversible neuromuscular toxicity. Monitoring of serum levels during treatment is mandatory. It is suggested that serum levels of about 25 micrograms/ml during longer periods may be curative.

O,p'-DDD (mitotane) levels in plasma and tissues during chemotherapy and at autopsy

The distribution of o,p'-DDD in various body compartments of patients being treated for metastatic adrenocortical carcinoma was studied. A highly significant semilogarithmic relationship was found between plasma and adipose tissue concentrations during therapy and between plasma and brain at autopsy. A linear relationship was found at autopsy between concentrations in adipose tissue and those in various other tissues, such as tumour and brain. The semilogarithmic relationship can be explained by the assumption of two plasma pools for o,p'-DDD, one with low affinity and high capacity and one with high affinity and low capacity. Plasma concentrations must be carefully monitored to obtain an impression of the tumour concentration and to detect impending central nervous system intoxication.