Congenital adrenal cortical carcinoma

Fetal and newborn adrenocortical tumors

Adrenocortical tumors occur less often in the fetus and newborn than later in life. The purpose of this study was to focus on the fetus and newborn in an attempt to determine the various ways these tumors differ in their biologic behavior, pathology, clinical presentation and response to therapy from those occurring in the older child and adolescent. Twenty-five fetuses and newborns were diagnosed with ACTs prenatally (n = 3) and in the newborn period (n = 22). The study consisted of two main neoplasms: adrenocortical adenoma, 24%, and adrenocortical carcinoma, 76%. The most common presenting finding was an abdominal mass. Overall survival for patients with ACA and ACC were 33% and 53%, respectively.

Diagnosis of adrenocortical tumor in a neonate by detection of elevated blood 17-hydroxyprogesterone measured as a routine neonatal screening for congenital adrenal hyperplasia: a case report

We report herein a case of prenatally detected neonatal adrenocortical tumor (ACT). The patient was an otherwise healthy newborn girl. No signs of Beckwith-Wiedemann syndrome were identified, and her family medical history did not suggest predisposition to cancer. Computed tomography and ultrasonography after birth revealed a round solid tumor 40 mm in diameter in the right suprarenal area. The precise diagnosis of ACT was unexpectedly obtained based on results from the Japanese neonatal mass screening program. Blood 17-hydroxyprogesterone is routinely measured as a part of this program for early detection of congenital adrenal hyperplasia in Japan. Abnormally elevated level of 17-hydroxyprogesterone was reported in the patient and, thus, led to the diagnosis of ACT. Surgical resection was safely performed with perioperative steroid replacement. Adrenocortical tumors are extremely rare in childhood, particularly in the neonatal period. Some of these tumors secrete abnormally high levels of cortisol, suppressing function of the contralateral adrenal gland and, thus, leading to life-threatening postoperative adrenal insufficiency. Scheduled steroid replacement enables safe perioperative management in such cases. Adrenocortical tumor should always be considered among the differential diagnoses for neonatal suprarenal mass because precise diagnosis will enable the physician to develop appropriate treatment strategies.

Clinical and outcome characteristics of children with adrenocortical tumors: a report from the International Pediatric Adrenocortical Tumor Registry

PURPOSE

We created a registry for pediatric adrenocortical tumors (ACTs), which are rare and are not well characterized. We provide a descriptive analysis of 254 patients registered on the International Pediatric Adrenocortical Tumor Registry.

PATIENTS AND METHODS

Between January 1990 and December 2001, 254 patients younger than 20 years of age with newly diagnosed or previously treated ACTs were registered. A histologic diagnosis of ACT was required, although central review was not mandatory. Follow-up information was periodically requested from the referring physician. Treatment was chosen by the primary physician.

RESULTS

The overall female-male ratio was 1.6:1, but it varied widely among age groups. The most common presenting sign (84.2%) was virilization. Cushing's syndrome without virilization was uncommon (5.5%). Tumors were completely resected in 83% of patients. Patients with disseminated or residual disease received mitotane, cisplatin, etoposide, and/or doxorubicin, and rarely, radiation therapy. At a median follow-up of 2 years and 5 months, 157 patients (61.8%) survived without evidence of disease and 97 patients (38.2%) had died. The 5-year event-free survival estimate was 54.2% (95% CI, 48.2% to 60.2%). In a multivariate analysis, disease stage, presenting signs of endocrine dysfunction, and age were independently associated with prognosis.

CONCLUSION

Childhood ACTs occur predominantly in females and almost always causes clinical signs. Complete resection is required for cure. Residual or metastatic disease carries a poor prognosis. Our results demonstrate the feasibility of a disease-specific database for obtaining meaningful clinical and outcome information.

Adrenocortical carcinoma with cerebral metastasis in a child: case report and review of the literature

OBJECTIVE AND IMPORTANCE

Adrenocortical carcinoma (ACC) is rare in the pediatric population, and brain metastasis seldom occurs.

CLINICAL PRESENTATION

The authors report a case of metastatic ACC to the brain in a 9-year-old patient who had an adrenal cortex neoplasm removed at 4 years of age, and was free of symptoms for 5 years. Two weeks before admission she complained of blurred vision in both eyes.

INTERVENTION

Examination revealed bilateral papilledema, and a Magnetic Resonance Imaging (MRI) of the brain revealed a mass in the left lateral ventricle with extensive vasogenic edema and hydrocephalus. The tumor was removed, and histopathologic examination demonstrated metastatic ACC.

CONCLUSION

Although ACC is a rare neoplasm it must be considered in the differential diagnosis of cerebral lesions in patients with a history of this tumor. Periodic long-term brain imaging is suggested as part of the follow up in patients with adrenocortical neoplasms.

Metastatic congenital adrenocortical carcinoma: a case report with tumor remission at 3 1/2 years

We describe a case of metastasizing congenital adrenocortical carcinoma and a follow-up of 3 1/2 yr. Treatment with surgery and mitotane was associated with multiple complications. The patient was in remission at 3 1/2 yr. Because of the rarity of this condition, we discuss step-by-step problems encountered during management.

Adrenocortical neoplasms in children: radiologic-pathologic correlation

Primary neoplasms of the adrenal cortex are rare in children and differ significantly in epidemiology, clinical characteristics, and biologic features from their counterparts in adults. In children, the inclusive term adrenocortical neoplasm is applied because adrenal adenoma and adrenal carcinoma may be difficult to distinguish histopathologically. Pediatric adrenocortical neoplasms typically occur before 5 years of age, affect young girls more commonly than boys, and are associated with hemihypertrophy and Beckwith-Wiedemann and Li-Fraumeni syndromes. Most children with an adrenocortical neoplasm present with signs and symptoms of endocrine abnormality, including virilization and Cushing syndrome. Cross-sectional imaging studies typically demonstrate a large, circumscribed, predominantly solid suprarenal mass with variable heterogeneity due to hemorrhage and necrosis. Calcification is not uncommon. Local invasion and metastases to the lungs, liver, and regional lymph nodes may be present at diagnosis. When friable tumor thrombus extends into the inferior vena cava, it poses a high risk of pulmonary embolization. The finding of increased retroperitoneal fat due to hypercortisolism on computed tomographic and magnetic resonance images of children with an adrenal mass favors the diagnosis of adrenocortical neoplasm. Surgical resection is the mainstay of therapy, with chemotherapy used for patients with metastases or persistent elevated hormone levels following surgery. Patients younger than 5 years with aggressive adrenocortical neoplasms fare better than older children.

Adrenocortical tumors in childhood: a report of four cases

In the last 10 years, four children with adrenocortical tumors were treated in our hospital. Three of them had symptoms of adrenogenital virilizing syndrome, and another, nonfunctional, was found during a routine examination. A diagnosis of adrenocortical tumor was established given the symptoms, hormonal tests, and radiologic studies. Two of the tumors were located in the left side, and the histologic diagnosis was pleomorphic cortical adenoma; the ones that affected the right side were adenocarcinomas. All the patients were treated by surgery and none received chemotherapy. At both presurgical and postsurgical stages, the patients were treated with cortisol. All four children have had a favorable course, with normal growth and the disappearance of public hair and hirsutism; however, macrogenitals still persist.

Spontaneously regressing adrenocortical carcinoma in a newborn. A case report with DNA ploidy analysis

Adrenal cortical carcinoma is an uncommon neoplasm in children. Only a handful of congenital adrenal cortical carcinoma cases have been described. A newborn who had metastatic adrenal cortical carcinoma (skin metastases and cerebral lesions) is described. This patient underwent surgical resection of the right adrenal primary, but no further treatment was given. Hemihypertrophy developed in this patient by 2 months of age, and at 4 months of age spontaneous regression of all skin nodules and central nervous system (CNS) lesions was observed. Follow-up at 1 year shows the patient to be alive, well, and disease-free. Evaluation of the tumor included DNA ploidy analysis that showed the tumor to be polyploid, a pattern recently associated with nonmetastasizing adrenal cortical neoplasm. The observation of apparent metastatic disease that regressed spontaneously highlights the prognostic value of DNA ploidy analysis and raises the possibility of an adrenal tumor with properties similar to those of Stage IV-S neuroblastoma.

Unsuspected adrenal masses in the neonate: adrenal cortical carcinoma and neuroblastoma. A report of two cases

Masses involving the adrenal in the neonate are most commonly due to hemorrhage. The literature involving the neonatal adrenal reflects this propensity. Although there have been reports of newborns with neuroblastoma [1, 2] and other tumors [3], which are more common in older children, ultrasonographic descriptions of masses involving the adrenal secondary to such tumors are rare [1]. Within a 6-month span we have discovered a clinically unsuspected adrenal carcinoma and adrenal neuroblastoma.

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).

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.

Adrenal cortical tumors in children

A review of the literature reveals 230 cases of adrenal cortical tumors in children. We add an additional 7 cases. Signs, symptoms, laboratory studies, and treatment of this rare rate tumor are discussed.