CLINICAL AND PATHOPHYSIOLOGIC ASPECTS OF ADRENOCORTICAL CARCINOMA

Peripheral blood steroid levels in Cushing syndrome due to adrenocortical carcinoma or adenoma

Measurement of the peripheral vein levels of the steroids in the adrenal biosynthetic pathway affords a further possible definitive method of differentiating adrenocortical carcinoma from adrenal adenoma in the presence of Cushing syndrome. In patients with adrenal carcinoma the blood levels of 17-hydroxyprogesterone, testosterone, androstenedione, and dehydroepiandrosterone are far higher than those seen in association with adenoma. In addition, the adrenal cortical carcinoma appears to have a higher ratio of precursors to product in the early part of the biosynthetic path and a lower one in the distal portion than adrenal adenomas. In Cushing syndrome due to adrenal tumor the measurement of serum cortisol is preferably made after chromatographic separation from 11-deoxycortisol in view of the marked cross reactivity in the protein binding procedure.

Adrenal cortical carcinoma. A study of 77 cases

Seventy-seven patients with histologically proven adrenal cortical carcinoma seen at the University of Texas M. D. Anderson Hospital (1950-1981) were studied. Thirty-nine were women (mean age at diagnosis, 36.6 years), and 38 were men (mean age at diagnosis, 48.3 years). On presentation, 41 of 74 had abdominal symptoms (55.4%) and 25 of 74 had an abdominal mass (33.8%). Twenty-six patients (33.8%) were found to have clinically functional disease (18 women, 8 men). At diagnosis, 26 (33.8%) had clinical or radiologic signs of distant metastases. Preoperative radiologic studies yielded an abnormal intravenous pyelogram in 42 of 51 (82%), an abnormal abdominal ultrasound in eight of nine (88.9%), abnormal computerized tomography in 10 of 10 (100%), and abnormal arteriogram in 18 of 19 (94.7%). Surgery for localized or regional disease was associated with a disease-free interval of at least 2 years in 16 of 34 patients (47%). The use of op'DDD, abdominal radiotherapy, and systemic chemotherapy produced demonstrable effects in nine of 47 (19.1%), two of nine (22.2%), and three of 26 (11.5%), respectively. Distant metastases occurred in 60 patients, commonly in lung, liver, peritoneal and pleural surfaces, lymph nodes, and bone. Analysis of survival data showed a 5-year survival of approximately 30%. The authors concluded that early diagnosis and radical surgery offer the only prospects of long-term survival and the possibility of cure.

Experimental evidence for biosynthesis of steroids in metastatic tissue originating from a primitive adrenocortical carcinoma

1. Cortisol, cortisone, 11-deoxycortisol and deoxycorticosterone were synthesized in large amounts in vitro by a metastatic tissue from an adrenocortical carcinoma. 2. Both 11 beta- and 21-hydroxylase were very active. 3. A secreting metastasis can be thus responsible for a biological relapse. 4. A metastasis originating from another secreting adrenocortical carcinoma was found to be non-secreting.

Development of Cushing's syndrome and virilization after presentation of a nonfunctioning adrenocortical carcinoma

Adrenocortical carcinoma is traditionally divided into functioning and nonfunctioning tumors. However, a case is presented of a 50-year-old woman with a clinically nonfunctioning adrenocortical carcinoma who later developed a Cushingoid appearance and symptoms of virilization with laboratory evidence of marked steroid hormone hypersecretion. The metabolic behavior and the rationale for division of these tumors into two categories (functioning and nonfunctioning) are discussed. It is suggested that such a division may be misleading and may not reflect the true state of the tumors.

Hyperaldosteronism due to unsuspected adrenal carcinoma: discovery during investigation of hypertension in a young woman

During investigation for hypertension a 19-year-old black woman was found to have an unsuspected adrenal carcinoma. Hyperaldosteronism was established as the cause of the hypertension by observing suppressed plasma renin activity and nonsuppressible plasma aldosterone concentration. The causal relationship was confirmed by a cure of the hypertension and a return in the responsiveness of the renin-angiotensin-aldosterone axis to normal after removal of the carcinoma. This report emphasizes the value of a comprehensive investigation of hypertension, especially in young patients.

Clinical and laboratory findings and results of therapy in 58 patients with adrenocortical tumors admitted to a single medical center (1951 to 1978)

We reviewed 150 findings in 58 patients (14 males and 44 females) with adrenocortical tumors (26 with adenoma and 32 with carcinoma) admitted to Vanderbilt Hospital during 28 years. In general, our findings agree with those reported by others in multi-institutional series or literature reviews. Adenomas took longer to diagnose than carcinomas. Adenomas usually caused Cushing's syndrome, but two caused virilization and three caused no endocrine syndrome. There was no difference in time required for diagnosis of carcinoma in men or women or in those with Cushing's syndrome, virilization or no endocrine syndrome. Urinary 17-hydroxycorticoid (17-OHCS) levels were similar in those with adenoma and those with carcinoma, but 17-ketosteroid (17-KS) levels were usually less than 20 mg per day in patients with adenoma and greater than 20 mg per day in patients with carcinoma. Adenomas were uniformly independent of endogenous ACTH stimulation, but frequently responded to exogenous ACTH. As with adenomas, no carcinoma demonstrated normal suppression with dexamethasone or normal response to metyrapone, but only one responded to exogenous ACTH. Some patients had no clinical Cushing's syndrome despite high levels of plasma cortisol and urine 17-OHCS. "Nonfunctional" tumors probably merely secreted insufficient steroids to cause signs and symptoms. Patients with adenoma were uniformly cured by surgical tumor resection. Occasional patients with carcinoma enjoyed long survival despite incomplete resection of their tumors, but most patients died of recurrent of metastatic carcinoma within seven years, often within a year of two. Small tumor size and benign histologic features were insufficient to predict benign clinical behavior. The adrenocorticolytic drug, o,p'DDD, offered objective remission for only an occasional patient.

Natural history of adrenal cortical carcinoma: a clinicopathologic study of 42 patients

To study the biologic behavior and natural history of this rare but challenging tumor faced by oncologists, a clinicopathologic study of 42 patients with histologically proven adrenal cortical carcinoma from Roswell Park Memorial Institute (1929--1977) was done. These constituted .04% of all cancer cases and 0.2% of all autopsy cases. Age range was 3--74 years with median of 53 years; female to male ratio was 1.5 to 1. Clinical manifestations were: abdominal mass (36%), metastatic disease (30%), hormonal excess (17%) and weakness with lethargy (17%). Nine of ten functioning tumors were seen in female patients. Tumors arose in left adrenal in 26 patients, right adrenal in 12, and in four the site could not be determined because of bilateral presence of cancer. Median duration of symptoms was six months. At diagnosis, 52% had distant metastases, 41% had locally advanced tumor and 7% had tumor confined to adrenal. Sixteen patients underwent "curative" resection. Tumor diameter ranged from 1--30 cm with median of 10 cm. Of 28 patients who received different chemotherapeutic regimens, three (11%) had objective response; four of ten patients had objective response to radiation therapy. Overall median and five-year survival rates were 14 months and 24%. Prolonged survival (P less than .05) was noted in women, patients who had "curative" resection, a disease-free interval of more than 12 months, and tumor size greater than 10 cm diameter. Patients with functional tumors had longer median survival than those with non-functional ones (28 vs. 12), but P value was greater than .05. A second primary cancer was noted in 22.4% of cases, breast and lymphoma being the most common. At autopsy in 31 patients, the most common metastatic sites were retroperitoneal lymph nodes 68%, lung 71%, liver 42%, and bone 26%. To improve survival, an aggressive surgical approach is recommended to extirpate the tumor with involved organs and retroperitoneal lymph nodes. Adrenal carcinoma should be suspected in patients with metastatic cancer with an occult primary.

Modification of steroidogenesis in a mouse adrenal cell line (Y-1) transformed by simian adenovirus SA-7

Transformation of a steroidogenic mouse adrenal cell line (Y-1) by simian adenovirus SA7 produced a cell line with low apparent steroidogenic activity. The effect of ACTH and cholera toxin on cyclic AMP production was similar in both not transformed and virus-transformed cells and activity of cyclic AMP-dependent protein kinase was also similar in both cells. In transformed cells, cholesterol was metabolized to delta 5-3 beta-hydroxysteroids, mainly 20 alpha-dihydropregnenolone while in not transformed cells, the major metabolites were delta 4-3 ketosteroids (20 alpha-dihydro- and 11 beta-hydroxy-20 alpha-dihydroprogesterone). In both cell lines ACTH increased the metabolism of cholesterol. Further studies with labelled pregnenolone and progesterone revealed a loss of delta 5-3 beta-hydroxysteroid dehydrogenase/isomerase and 11 beta-hydroxylase activity in the transformed cells.

Adrenal adenocarcinomas: diagnosis and management

Thirty-two patients with adrenal adenocarcinoma are reviewed. Eleven of them had symptoms suggestive of a hormonally functional tumor. The median survival in 17 patients who had the primary tumor removed was 13.5 months from the time of surgery, with one patient surviving disease-free 19 years later. The median survival of 11 patients who did not have surgery owing to delays in diagnosis was 7.5 months from the onset of symptoms. Of six patients given O,P'DDD, two patients had objective regression, one partial, one complete. Early diagnosis may improve survival and curability of this malignant tumor.

Recurrent adrenal cortical carcinoma with Cushing's syndrome: twenty-five-year follow-up of a patient

A 43-year-old female patient is currently being treated by us for a recurrence of adrenal cortical carcinoma associated with Cushing's syndrome and virilization. Despite many relapses of metastatic spread she has not only survived for 25 yr after the removal of the primary tumor but also until now preserved her ability to work in a textile factory.

Adrenal cortical carcinoma: a clinical and pathologic study of 49 cases

The clinical and pathologic features of 49 patients with adrenal cortical carcinoma are presented. The series included 26 men and 23 women with a mean age of 34 years. The average duration of symptoms prior to diagnosis was 6.6 months. Eighteen patients (37%) presented with recognizable endocrine syndromes secondary to excess tumor steroid production. Surgical excision was the only mode of therapy to offer any opportunity for prolonged survival. Nine of the 21 patients (43%) with a completely resectable tumor were alive with no evidence of disease an average of 7.2 years postoperatively. Death due to metastatic tumor occurred in 36 of the 49 patients (73%) an average of 8.7 months following diagnosis. Chemotherapy had no apparent effect on outcome while radiotherapy produced an objective palliative response in 50% of treated patients. The average size and weight of the tumors were 12.4 cm and 875.6 g, respectively. The difficulty of precise pathologic classification of certain large adrenal tumors is discussed and the importance of histopathologic features relative to gross morphologic findings is emphasized.

Virilizing adrenal cortical carcinoma with hypertrophy of spermatic tubules in childhood

A review of adrenal cortical carcinoma in childhood is presented, including endocrinologic aspects. Electron microscopic features are presented, as well as the finding of hypertrophied spermatic tubules. The importance of serial steroidal determinations is stressed as a "tumor marker" that may help in early detection of recurrent disease and possibly increased long-term survival.

Adrenal cortical carcinoma

A review of 28 cases of adrenal cortical carcinoma provides some insights into the natural history of this disease and suggests modifications in current techniques of diagnosis and management. Our patients ranged in age from 1 to 69 years but it is notable that all of our male patients were more than 39 years old. In addition the men tended to have high stage tumors that were nonfunctional. Female patients, on the other hand, were more evenly distributed in terms of stage, function and age at diagnosis. Staging was extremely important and is discussed in some detail. A dismayingly large number of patients were found to have stage 3 or 4 tumor at initial diagnosis, suggesting that aggressive and rapid evaluation and a high index of suspicion are important to optimize survival. Function is helpful but non-function is common and should not dissuade one from the diagnosis. Excretory urography with tomography followed by angiography frequently will provide the diagnosis. Endocrinologic evaluation should be done with alacrity. Survival with high stages of disease is poor and lengthy evaluation should not be allowed to delay prompt and, hopefully, curative surgery. Surgical resection is the key to cure; chemotherapy and radiotherapy provided relatively poor results in our hands although mitotane has shown a 34 to 54 per cent response rate.

Quantitative analysis of steroid profiles from urine by capillary gas chromatography. I. Accuracy and reproducibility of the sample preparation

A method is described for the determination of steroid profiles from urine by means of gas chromatography using high-efficiency glass capillary columns. The accuracy and reproducibility of essential steps in the sample preparation (extraction of steroids and steroid conjugates by means of XAD-2, enzymatic hydrolysis with Helix pomatia juice, solvolysis in acidified ethyl acetate and alkali wash) are established using different endogenously labelled urine samples, obtained from normal subjects to whom labelled steroids had been administered. Preliminary results are given on the reproducibility of the derivatization procedure (formation of methoxime-trimethylsilyl (MO-TMS) ethers), the gas chromatographic analysis and the whole method. Two procedures for the purification of MO-TMS steroid derivatives are compared. Application of the method to urine samples of patients with various endocrine disorders is included.

Late functioning adrenocortical carcinoma in a 5-year-old girl

A 5-year-old with adrenocortical carcinoma presented with acute paraplegia. The tumour was initially nonfunctioning but finally showed rapid dissemination and the patient then developed Cushingoid features and virilisation.

Inferior vena caval involvement by adrenal cortical carcinoma

A case of preoperative demonstration of inferior vena caval extension of tumor thrombus from adrenal cortical carcinoma is presented. Surgery showed that extension had occurred via the adrenal vein rather than by direct invasion. A search of the literature failed to uncover either any mention of preoperative attention to the possibility of caval involvement or of this particular mode of extension. Review of our experience with 17 adrenal cortical carcinomas suggested that carcinoma of the right adrenal gland involves the vena cava more commonly than does carcinoma of the left. We recommend that cavography be performed in the evaluation of adrenal carcinoma.

Virilizing adrenal cortical carcinoma

A 43-year-old man with a 36-year history of virilization due to an adrenal carcinoma is presented. The initial presentation at age 7 with precocious puberty and epiphyseal bone fusion suggested increased androgen effect at a very early age. The patient's 36-year course before his death suggested either a very slow growing adrenal carcinoma or untreated congenital adrenal hyperplasia that progressed to an adrenal carcinoma. Endocrine evaluation showed markedly increased DHEA and DHEA-sulfate levels. These were associated with elevated plasma and urinary estradiol levels and suppressed LH and FSH plasma concentrations. The 24-hour mean levels of cortisol and testosterone were normal. Studies of the circadian periodicity of cortisol showed a disturbed temporal pattern but a normal 24-hour mean concentration that correlated with a normal cortisol production rate. The 24-hour LH secretory pattern showed a decrease in the normal episodic fluctuation of this hormone over the 24-hour period.

Experience with adrenal cortical carcinoma

Eight cases of histologically proved cortical carcinoma are reviewed and compared with several series from the literature. Emphasis is given to defining endocrinologic function in these tumors and to the role of nonoperative treatments. Whereas surgical therapy offered significant demonstrated in any of the patients.

Radiation therapy of adrenal cortical carcinoma

The role of radiation therapy in the management of adrenal cortical carcinoma has had little documentation in the literature. Fourteen patients with this malignancy were given 18 courses of palliative, preoperative or postoperative irradiation. The clinical results are presented. Significant palliation was obtained in all patients along with occasional long term local control of unresectable lesions.

Adrenocortical neoplasms. Prognosis and morphology

The clinical data and morphologic findings in 16 cases of adrenocortical carcinoma were compared with those in 11 cases of surgically removed functional adenomas and 12 cases of nonfunctional adenomas found at autopsy. Histopathologic changes of architectural disarray, pleomorphism, increased mitotic activity, vascular invasion, hemorrhage, or necrosis were generally reliable criteria for diagnosis of malignancy. However, weight was the parameter that most consistently correlated with outcome, since all patients with tumors under 50 Gm. survived and all lesions of 95 Gm. or over proved to be malignant.

Adrenal cortical carcinoma. A study of 32 patients

Fifteen males and 17 females with adrenal cortical carcinoma were reviewed. Their average age at diagnosis was 50.33 years plus or minus 12.26 SD for males and 39.76 years plus or minus 12.02 SD for females. The 5-year survival rate in this series was 31.25%. Abdominal pain, weakness, and weight loss were the primary presenting symptoms, whereas abdominal mass, distant lymphadenopathy, hepatomegaly, and edema of the lower extremities were the main presenting signs. The major sites of distant metastatic involvement were the lungs, liver, lymph nodes, and bones. The best available mode of therapy was surgery. The use of ortho para 'DDD (o,p'DDD), either in addition to surgery or as the only mode of therapy, was not associated with any significant advantage to the patient. Female patients had a longer survival than males, probably because of their younger age at diagnosis.

Congenital adrenal hyperplasia caused by 11 beta-hydroxylase deficiency with onset of symptoms after one spontaneous pregnancy

A case of adrenogenital syndrome due to 11beta-hydroxylase deficiency is described in a mother, 25 years of age, who had experienced a successful pregnancy 5 years previously. At that time no abnormality had been suspected and pregnancy was achieved without therapy. Subsequently the patient was examined because of secondary sterility. The menstrual cycles were anovulatory. Only slight virilization was observed and blood pressure was normal. Diagnosis was based on the observation of highly increased urinary excretion of 17-ketosteroids and 17-ketogenic steroids, with especially high excretion of tetrahydro-11-deoxycortisol. Following suppression with dexamethasone and adequate maintenance treatment, the patient conceived and had an uneventful pregnancy. This is apparently the first report of pregnancy in adrenogenital syndrome due to 11beta-hydroxylase deficiency.

Feminizing Adreno-Cortical Carcinoma: Report of a Case

A case of feminizing adreno-cortical carcinoma is reported and features of these tumours are commented on. The differential diagnosis of gynaecomastia and its investigation are discussed. The features of adrenal carcinoma are also discussed, the literature is reviewed and treatment is outlined.

Abnormal regulation of adenosine 3',5'-monophosphate and corticosterone formation in an adrenocortical carcinoma

A spontaneously occurring rat adrenocortical carcinoma which produces corticosterone was maintained by transplantation. The carcinoma appeared to utilize corticosterone biosynthetic steps similar to those of the normal adrenal, but the tumor produced only about 1-10% as much corticosterone per unit tissue weight as nontumorous adrenal glands. The tumor demonstrated little or no increase in corticosterone production in response to adrenocorticotropic hormone (ACTH) either in vivo or in vitro. In normal adrenals, ACTH increases the activity of adenyl cyclase which catalyzes the conversion of adenosine triphosphate (ATP) to adenosine-3',5'-monophosphate (cyclic AMP), the latter then serving as an intracellular regulator of steroidogenesis. ACTH failed to increase cyclic AMP levels in the tumor in vivo or in slices in vitro, conditions under which there were 50- and 20-fold increases in nontumorous adrenals. However, in homogenates fortified with exogenous ATP, adenyl cyclase activity was comparable in the tumor and adrenals, and cyclic AMP formation was increased 3-fold by ACTH in each. As measured in homogenates, the tumor did not possess a greater ability to destroy cyclic AMP than did normal adrenals. Although ATP levels in the carcinoma were found to be considerably lower than those in normal adrenals, it was not clear that this finding can explain the inability of ACTH to increase cyclic AMP levels in intact tumor cells. While the failure to normally influence cyclic AMP levels in the carcinoma cells could be an important factor in the lack of a steroid response to ACTH, several lines of evidence suggest that the tumor possesses one or more additional abnormalities in the regulation of steroidogenesis. First, in the absence of ACTH stimulation, the tissue concentrations of cyclic AMP were comparable in the tumor and in nontumorous adrenals, but these cyclic AMP levels were associated with a lower level of steroidogenesis in the tumor. Second, tumor slices failed to increase corticosterone production when incubated with cyclic AMP, in contrast to 5-fold increases observed with nontumorous adrenals.