Cis-platinum treatment of metastatic adrenal carcinoma

Pediatric Adrenocortical Carcinoma: The Nuts and Bolts of Diagnosis and Treatment and Avenues for Future Discovery

Adrenocortical tumors (ACTs) are infrequent neoplasms in children and adolescents and are typically associated with clinical symptoms reflective of androgen overproduction. Pediatric ACTs typically occur in the context of a germline TP53 mutation, can be cured when diagnosed at an early stage, but are difficult to treat when advanced or associated with concurrent TP53 and ATRX alterations. Recent work has demonstrated DNA methylation patterns suggestive of prognostic significance. While current treatment standards rely heavily upon surgical resection, chemotherapy, and hormonal modulation, small cohort studies suggest promise for multi-tyrosine kinases targeting anti-angiogenic pathways or immunomodulatory therapies. Future work will focus on novel risk stratification algorithms and combination therapies intended to mitigate toxicity for patients with perceived low-risk disease while intensifying therapy or accelerating discoveries aimed at improving survival for patients with difficult-to-treat disease.

Favorable Response of Metastatic Adrenocortical Carcinoma to Etoposide, Adriamycin and Cisplatin (EAP) Chemotherapy. Report of two Cases

The usefulness of non-specific chemotherapy for advanced adrenocortical carcinoma (ACC) Is controversial. We report on 2 young female patients (25 and 19 yr) who presented with a clinical picture of Cushing's syndrome due to histologically confirmed ACC. The first patient underwent radical surgery, but after a disease-free interval of 6 months a local recurrence was apparent. She was reoperated and treated with 6 courses of cisplatin and etoposide chemotherapy. Mitotane (8 g daily) was begun, but 2 months later debulking surgery was again performed. A second-line chemotherapy with the etoposide, adriamycin, cisplatin (EAP) scheme attained a partial remission lasting 7 months, then metastatic spread to the brain led to death of the patient. The survival time was 30 months. The second patient underwent radical surgery and adjuvant mitotane (4 g daily), but multiple lung and mediastinal metastases were diagnosed after an interval of 29 months. Chemotherapy with the EAP regimen (6 courses) without interrupting mitotane attained a partial remission lasting 21+ months. We suggest that the EAP scheme is active in advanced ACC and that Its association with mitotane is feasible.

Adrenocortical carcinoma: past, present, and future

Adrenocortical carcinoma (ACC) is a rare endocrine malignancy. Due to its rarity, heterogeneity, and a lack of a comprehensive understanding of the pathogenesis, little progress has been made in treatment and outcomes. The current review explores the past, present, and future of the understanding and treatment of this disease process.

Cytotoxic treatment of adrenocortical carcinoma

Adrenocortical carcinoma (ACC) is a rare, aggressive tumor that is often detected in an advanced stage. Medical treatment with the adrenotoxic drug mitotane has been used for decades, but critical prospective trials on its role in residual disease or as an adjuvant agent after surgical resection are still lacking. The concept of a critical threshold plasma level of the drug must be confirmed in controlled studies. Because individual responsiveness cannot be predicted, the use mitotane is still advised for nonresectable disease. In case of cortisol or other steroid overproduction, several drugs (e.g., ketoconazole or aminoglutethimide) may be used. Chemotherapy with single agents (e.g., doxorubicin or cisplatin) have been disappointing, with low response rates (< 30%) and a short response duration. Part of this refractoriness may be explained by the fact that ACC tumors express the multidrug-resistance gene MDR-1. Chemotherapy with multiple agents has been tested in smaller series and has resulted in significant side effects. The best results were achieved by the combination of etoposide, doxorubicin, and cisplatin associated with mitotane, achieving a response rate of 54%, including individual complete responses. To be able to make progress in treating advanced ACC disease, adjuvant multicenter trials must be encouraged. When mitotane-based therapies are used, monitored drug levels are mandatory.

Cytotoxic therapy with etoposide and cisplatin in advanced adrenocortical carcinoma

Adrenocortical carcinoma (ACC) is a rare tumour with a poor prognosis. Cisplatin is the most widely tested cytotoxic agent in this disease. A total of 18 patients with advanced ACC were enrolled. Cytotoxic therapy consisted of etoposide (VP16) (100 mg m(-2) day(-1) on days 1-3) and cisplatin (100 mg m(-2) day(-1) on day 1) every 4 weeks. Mitotane treatment was maintained during chemotherapy in 14 patients. A complete response was observed in three cases and a partial response in three cases, giving an overall response rate of 33%. Tumour response was observed in three of the six patients with progressive disease during treatment with mitotane given at an effective dosage, as shown by serum levels >14 mg l(-1). Toxic effects were as expected and were non-life-threatening; no treatment interruption was required.

Treatment of metastatic adrenal cortical carcinoma with etoposide (VP-16) and cisplatin after failure with o,p'DDD. Clinical case reports

A 42-year-old woman with liver metastasis from adrenal cortical carcinoma was treated with mitotane (o,p'DDD) for 11 months with a minimal response. Mitotane was stopped because of severe adverse effects. Thereafter a combination of cisplatin and etoposide was given every 3 weeks. A partial response was achieved after five chemotherapy courses. Following this chemotherapy, the patient had a surgical excision of the liver metastasis and entered into a complete remission for 17 months. Etoposide plus cisplatin may be an active combination for the treatment of adrenal cortical carcinoma.

The Italian Registry for Adrenal Cortical Carcinoma: analysis of a multiinstitutional series of 129 patients. The ACC Italian Registry Study Group

BACKGROUND

Adrenal cortical carcinoma is an uncommon tumor with a poor prognosis. The low incidence of this tumor makes it difficult to achieve reliable data on clinical manifestations, natural history, and the impact of therapies. The purpose of this study was to evaluate such aspects in a large series.

METHODS

A retrospective series of 129 cases (55 men and 74 women, mean age of 49 years) was collected from 18 surgical institutions. At the time of diagnosis 45.7% of patients had endocrine symptoms. One hundred twenty-four patients underwent surgery, which was considered curative in 91 cases and palliative in 33. Sixty-three patients had local disease, 48 had regional disease, and 43 had distant metastases.

RESULTS

This study confirmed a higher incidence in the 40- to 50-year-old population with a female prevalence; hormonal hyperincretion was more common in women, but it was not caused by advanced disease. The overall 5-year survival rate was 35%. Tumor stage and curative resection affected prognosis significantly. The influence of gender, side, age, and hormonal function has not been confirmed. Adjuvant therapies were ineffective in prolonging survival. Reoperated patients experienced better survival (mean, 41.5 months) than nonreoperated cases (mean, 15.6 months).

CONCLUSIONS

The poor prognosis of adrenal cortical carcinoma may be improved by early diagnosis and complete resection. Radical surgery is the sole effective therapy, particularly in early stages. Surgical treatment of recurrence seems to improve survival and should be attempted systematically. Adjuvant therapies obtained contrasting results, and their role should be evaluated in prospective multicentric trials.

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.

5-Fluorouracil, doxorubicin, and cisplatin as treatment for adrenal cortical carcinoma

Fourteen patients with progressive metastatic adrenal cortical carcinoma were treated with a combination of 5-fluorouracil (5-FU), doxorubicin, and cisplatin (FAP). All had a large tumor burden. Six patients had a hormone-producing tumor; mitotane treatment was given to five of them during chemotherapy for its possible antihormonal effects. Treatment could be evaluated in 13 patients. The overall response rate was 23% (95% confidence interval [CI], 5% to 54%). A complete remission, which lasted for 42 months, was achieved in one patient. Partial remissions, which lasted for 6 and 11 months, were achieved in two patients. Cardiotoxicity appeared in three patients, myelotoxicity in four, and nephrotoxicity in one. This confirms that this regimen is an active combination for the treatment of metastatic adrenal cortical carcinoma.

Uneventful delivery following series of successive treatments for virilized Cushing syndrome due to adrenocortical carcinoma

A twenty-one-year-old virilized woman with Cushing syndrome due to a huge adrenocortical carcinoma was successively treated with trilostane (3 beta-hydroxysteroid dehydrogenase inhibitor), subsequent adrenalectomy, and postoperative cis-platinum. Clinical or biochemical abnormalities peculiar to Cushing syndrome gradually subsided, and three and one-half years after the adrenal surgery, the patient delivered a normal female infant. This study points out some of the clinical and biochemical responses of each treatment.

Clinical features of adrenocortical carcinoma, prognostic factors, and the effect of mitotane therapy

Adrenocortical carcinoma is a rare tumor, and only limited information is available about its natural history and the effects of therapy. We studied 105 patients (75 female and 30 male; mean age, 46 years) with adrenocortical carcinoma who were referred to us between 1963 and 1987. The average duration of symptoms before diagnosis was 8.7 months. At the time of diagnosis, 68 percent of the patients had endocrine symptoms, and 30 percent had distant metastases. Hormonal studies showed that 79 percent of the tumors were functional. Eighty patients underwent surgery, and 59 also received the adrenal cytotoxic agent mitotane. The median disease-free interval after surgery was 12.1 months (range, 1 to 175). Tumor dissemination occurred in 82 percent of the patients, most commonly to the lung, liver, and adjacent organs. The median survival time was 14.5 months (range, less than 1 to 175), and the five-year survival was 22 percent. Age over 40 years and the presence of metastases at the time of diagnosis were the only factors recognized as indicating a poor prognosis. Mitotane controlled hormonal secretion in 75 percent of the patients. Eight mitotane-treated patients had partial tumor regression, but the drug did not have a significant effect on survival. We conclude that adrenocortical carcinoma carries a poor prognosis. Mitotane therapy may offer transient benefits, particularly in controlling endocrine symptoms.

Combination chemotherapy for adrenal carcinoma: response in a 5 1/2-year-old male

Adrenocortical carcinoma is an uncommon tumor of childhood, and systematic studies of therapeutic options are not available. Children with very large tumours have a poor outlook with surgery alone, so that other treatment should be considered, but the literature is unhelpful in suggesting what this should be. In the case reported here, combination chemotherapy, including cisplatinum, gave a well-documented good partial response, suggesting a possible role for adjuvant chemotherapy using such a drug combination.

5-Fluorouracil, doxorubicin, and cisplatin regimen in adrenal cortical carcinoma

Five patients with metastatic adrenal cortical carcinoma were treated with a combination of 5-fluorouracil (5-FU), doxorubicin, and cisplatin. All patients had a nonhormone producing tumor. A large tumor burden made them unsuitable for mitotane treatment. Treatment could be evaluated in four patients. A complete remission was achieved in one patient and lasted for 38 months: this patient is still alive and free of disease. Furthermore, a minor response and a disease stabilization also were observed. Cardiotoxicity occurred in one patient and myelosuppression in another patient. This regimen appears to be an active combination for the treatment of metastatic adrenal cortical carcinoma.

Treatment of adrenocortical carcinoma: a case report and review of the literature

A case report of adrenocortical carcinoma is presented, and its natural history and treatment are discussed. Adrenocortical carcinoma is a rare malignant disease. The mean survival time for untreated patients is less than three months. The tumor is classified as functioning or nonfunctioning depending on biochemical and clinical evidence of steroid overproduction. Surgical resection of the tumor is the primary treatment. Chemotherapy is indicated for antitumor and antihormonal effects. Mitotane is a direct adrenolytic, and is the only drug currently available that has extended survival in patients with this disease. Its clinical usefulness is limited by its gastrointestinal and neurological toxicity. Aminoglutethimide inhibits steroid synthesis by blocking the conversion of cholesterol to pregnenolone. It has no antitumor effect in adrenocortical carcinoma, but is effective in relieving the signs and symptoms of excessive hormone production in functioning tumors. Both mitotane and aminoglutethimide have complex mechanisms of action. Their combined use in the treatment of adrenocortical carcinoma requires a complete understanding of their individual actions and awareness of the potential for additive effects, both therapeutic and toxic.

Adrenal adenocarcinomas: histologic grading and survival

Thirty-eight patients with adrenal adenocarcinoma were reviewed. Two of 23 males and 8 of 15 females had a functioning tumor (P less than 0.005). The most striking finding in this review was the variation in survival according to histologic grade. The median survival from histologic diagnosis was for grade I tumors 54 months, for grade II tumors 26 months, for grade III tumors 1 month. The difference in survival between patients with grade I or II tumors and those with grade III tumors was significant (P less than 0.001). The majority of the patients with grade III tumors were admitted with clinical evidence of disseminated disease and died within 1 month. Among the patients with well-differentiated tumors, five who received surgical treatment of their recurrence had a median survival of 51 months, whereas seven patients who received no surgical treatment had median survival of 20 months following first recurrence (0.05 less than P less than 0.10).

Adrenocortical carcinoma in children

Adrenocortical carcinoma in childhood is a rare yet potentially fatal disease. We present 5 cases of adrenocortical carcinoma detected and managed in childhood. Of the 5 patients 4 presented with clinical signs of excess corticosteroid production and 1 presented suddenly with abdominal pain. All patients had palpable abdominal masses. All tumors were removed surgically and adjuvant therapy with mitotane was used in 4 children. Two patients are alive and 3 are dead. Our experience demonstrates that mitotane may be used safely in children, and that early diagnosis, aggressive surgical extirpation, and the use of mitotane and chemotherapy may lead to an increased survival of children with adrenocortical carcinoma.