Management of endocrine manifestations and the use of mitotane as a chemotherapeutic agent for adrenocortical carcinoma

Adrenal cortical carcinoma (ACC) is a rare malignancy in which patients have poor overall 5-year survival. Patients with ACC can present with symptoms of hormone excess, including Cushing's syndrome, virilization, feminization, or--less frequently--hypertension with hypokalemia. In many patients with ACC, advanced disease at presentation precludes surgery or is followed by local relapse or distant metastatic disease that cannot be managed surgically. In these instances, chemotherapy is often tried, but its limited efficacy all too often leaves the problem of persistent hormonal excess. Physicians who treat patients with ACC and severe hypercortisolism should recognize that uncontrolled hormone production is a malignant disease, which has severe consequences that require aggressive management. Because chemotherapy benefits only a small percentage of patients, steroidogenesis inhibitors, including mitotane, ketoconazole, metyrapone, and etomidate, should be used singly or in combination even as chemotherapy is administered. Diligent management with frequent adjustments is required, especially in patients with chemotherapy-refractory tumors that continue to grow. In the absence of randomized, controlled trials, adjuvant use of mitotane remains controversial, although the authors of a recent case-control study argue for its use. Despite difficulty administering effective doses, most clinicians agree that mitotane should be used if the tumor cannot be removed surgically or should be used as adjuvant therapy if there is a high likelihood of recurrence. The option of long-term monotherapy is restricted to patients who tolerate mitotane and either experience a clinical response or are at high risk for recurrence. Recommendations are provided to help manage patients with this difficult disease and to improve the quality of their lives.

Adrenal cortical carcinoma--review of current knowledge and treatment practices

Adrenal cortical carcinoma is a rare endocrine malignancy with a poor long-term prognosis. Accurate diagnosis and preoperative evaluation of the patient presenting with an adrenal mass maximize the opportunity for optimal treatment planning. Surgery still offers the best chance for cure. Despite curability with complete surgical resection, the rate of recurrence is unacceptably high. In metastatic or recurrent disease, systemic treatment options are limited to chemotherapy with or without mitotane. Therapeutic options are often outdated and associated with significant toxicities. A multidisciplinary approach has the best chance for offering optimized management of this lethal disease. Improved understanding of the molecular pathogenesis of this rare malignancy will lead to advancement in the available therapies that may improve this outcome.