Current Evidence on Local Therapies in Advanced Adrenocortical Carcinoma

Adrenocortical carcinoma: a practical guide for clinicians

Adrenocortical carcinoma is a rare endocrine malignancy. The management of patients with adrenocortical carcinoma is challenging for several reasons, including its heterogeneous but frequently aggressive biological behaviour; tumour-related hormonal excess (eg, Cushing's syndrome or virilisation); the overall paucity of evidence regarding diagnostic investigation and treatment; the approval of only one drug (mitotane); and the scarcity of centres with sufficient experience. In this Review, we present 25 questions on the most important aspects of the clinical management of adult patients with adrenocortical carcinoma that we have frequently asked ourselves over the past 25 years. We offer our personal answers and perspectives, drawing upon published evidence as well as more than 60 years of collective clinical experience and insights from our management of more than 1700 patients across two centres in Germany and Italy.

Clinical outcomes of image-guided therapies in patients with adrenocortical carcinoma: a tertiary referral center retrospective study

BACKGROUND

Image-guided therapies (IGTs) are commonly used in oncology, but their role in adrenocortical carcinoma (ACC) is not well defined.

MATERIALS AND METHODS

A retrospective review of patients with ACC treated with IGTs. We assessed response to therapy using RECIST v1.1, time to next line of systemic therapy, disease control rate (DCR), local tumor progression-free survival (LTPFS), and complications of IGTs (based on the Common Terminology Criteria for Adverse Events [CTCAE] version 5.0).

RESULTS

Our cohort included 26 patients (median age 56 years [range 38-76]; n = 18 female) who had 51 IGT sessions to treat 86 lesions. IGTs modalities included cryoablation (n = 49), microwave ablation (n = 21), combined microwave and bland trans-arterial embolization (n = 8), bland trans-arterial embolization alone (n = 3), radio-embolization (n = 3), and radiofrequency ablation (n = 2). DCR was 81.4% (70 out of 86), of which 66.3% of tumors showed complete response, 18.6% showed progressive disease, 8.1% showed partial response, and 7.0% showed stable disease. LTPFS rates were 73% and 63% at 1 and 2 years, respectively. Fourteen lesions underwent re-ablation for incomplete response on initial treatment. Sixteen patients (61.5%) received new systemic therapy following IGTs, with a median time to systemic therapy of 12.5 months (95% CI: 8.6 months upper limit not reached). There was 1 reported CTCAE grade 3 adverse event (biloma) following IGT.

CONCLUSIONS

IGT use in properly selected patients with ACC is safe and associated with prolonged disease control and delay in the need for systemic therapy.

Adrenocortical Carcinoma: A Challenging Diagnosis

Adrenocortical carcinoma (ACC) is a rare malignancy with aggressive behaviour and a poor prognosis. Patients can present with adrenal hormonal excess or with nonspecific symptoms driven by the presence of an abdominal mass or metastatic disease. Many are completely asymptomatic and diagnosed incidentally. ACC can cause considerable morbidity and mortality, mostly due to its ability to invade surrounding tissues, produce hormones, and spread to distant organs. The authors describe a case of a 62-year-old woman who presented with subacute dorso-lumbar pain. A computed tomography (CT) scan revealed osteolytic lesions in her dorsal spine and sacrum, suggesting metastatic disease. Later on, she presented with hypercortisolism and refractory hypokalemia, so an abdominal and pelvis CT was performed, which showed a suspicious mass in the right adrenocortical gland. A CT-guided adrenal biopsy confirmed ACC. Unfortunately, our patient's clinical status rapidly deteriorated, resulting in her death only a few weeks later. ACC is often found at an advanced stage and with distant metastases, most commonly in the liver, lungs, lymph nodes, and bone. The overall prognosis of ACC is generally poor, but it varies depending on the extent of the disease. Multiple factors have been shown to be relevant in the prognostic classification, such as tumor stage, cell proliferation markers, and resection status. Currently, the only curative treatment is complete surgical resection. Adjuvant therapies have often been shown to decrease recurrence rates or as an alternative in patients with advanced disease. Many studies have been conducted to better understand the molecular basis of ACC, thus enabling the classification into molecular subtypes, but more studies are necessary to identify targets amenable to pharmaceutical intervention. With this case report, we want to emphasize that the diagnosis of ACC is not always obvious. Although metastases are infrequent, their presence is by far the strongest indicator of poor prognosis. All patients with proven or suspected ACC benefit from multidisciplinary monitoring, preferably at a specialized center.

The Value of Local Therapies in Advanced Adrenocortical Carcinoma

International guidelines recommend local therapies (LTs) such as local thermal ablation (LTA; radiofrequency, microwave, cryoablation), transarterial (chemo)embolisation (TA(C)E), and transarterial radioembolisation (TARE) as therapeutic options for advanced adrenocortical carcinoma (ACC). However, the evidence for these recommendations is scarce. We retrospectively analysed patients receiving LTs for advanced ACC. Time to progression of the treated lesion (tTTP) was the primary endpoint. The secondary endpoints were best objective response, overall progression-free survival, overall survival, adverse events, and the establishment of predictive factors by multivariate Cox analyses. A total of 132 tumoural lesions in 66 patients were treated with LTA (n = 84), TA(C)E (n = 40), and TARE (n = 8). Complete response was achieved in 27 lesions (20.5%; all of them achieved by LTA), partial response in 27 (20.5%), and stable disease in 38 (28.8%). For the LTA group, the median tTTP was not reached, whereas it was reached 8.3 months after TA(C)E and 8.2 months after TARE (p < 0.001). The median time interval from primary diagnosis to LT was >47 months. Fewer than four prior therapies and mitotane plasma levels of >14 mg/L positively influenced the tTTP. In summary, this is one of the largest studies on LTs in advanced ACC, and it demonstrates a very high local disease control rate. Thus, it clearly supports the guideline recommendations for LTs in these patients.