Successful long-term disease-free survival following multimodal treatments in a patient with a repeatedly recurrent refractory adrenal cortical carcinoma

New targeted therapies for adrenocortical carcinomas

Adrenocortical carcinoma (ACC) is a rare malignancy with poor prognosis. It has undergone in-depth clinical and laboratory investigations, with the help of the most important research groups all over the world. Nonetheless the cure for this kind of neoplasia is not right around the corner, given its complexity and multi-faceted feature, that lead researchers to think at "one person one ACC." Currently total resection is the most concrete option for ACC patients, whenever possible. Mitotane remains the main drug for primary or adjuvant therapy, but gives partial and unsatisfactory therapeutic results, especially in metastatic ACC. This prompted the researchers to find other ways to fight against this malignancy: targeted therapy seems the most promising answer, as it is based on biomolecular and genetic cancer signature. Numerous specific targets were explored for the treatment of ACC, such as those involving angiogenesis, steroidogenesis, Wnt/β-catenin pathway and many others key factors. Even if large efforts have been made, no effective target therapy entered in the clinical use. This data should not be considered only as detrimental, rather it should propel scientific research to invest more resources into the therapeutic exploration of ACC and in particular on the most promising strategy, the targeted therapy.

MANAGEMENT OF ENDOCRINE DISEASE: Adrenocortical carcinoma: differentiating the good from the poor prognosis tumors

Adrenocortical carcinoma (ACC) is a rare malignancy with a poor prognosis, the five-years overall survival being below 40%. However, there is great variability of outcomes and we have now a better view of the heterogeneity of tumor aggressiveness. The extent of the disease at the time of diagnosis, best assayed by the European Network for the Study of Adrenal Tumors (ENSAT) Staging Score, is a major determinant of survival. The tumor grade, including the mitotic count and the Ki67 proliferation index, also appears as a strong prognostic factor. The assessment of tumor grade, even by expert pathologists, still suffers from inter-observer reproducibility. The emergence of genomics in the last decade has revolutionized the knowledge of molecular biology and genetics of cancers. In ACC, genomic approaches - including pan-genomic studies of gene expression (transcriptome), recurrent mutations (exome or whole-genome sequencing), chromosome alterations, DNA methylation (methylome), miRNA expression (miRnome) - converge in a new classification of ACC, characterized by distinct molecular profiles and very different outcomes. Targeted measurements of a few discriminant molecular alterations have been developed in the perspective of clinical routine, and thus, may help defining therapeutic strategy. By individualizing patients' prognosis and tumor biology, these recent progresses appear as an important step forward towards precision medicine.

Adrenocortical carcinoma mimicking lung cancer and responding to vinorelbine/carboplatin and pemetrexed/carboplatin

Adrenocortical carcinoma is an aggressive cancer, with an incidence of 0.5-2 per million. We present a case of adrenocortical carcinoma with all the clinical and partly immunohistochemical features of disseminated undifferentiated lung cancer, and 'accidentally' treated as such. Four cycles of carboplatin-vinorelbine conferred partial response in the adrenal, lung and disappearance of a 2 cm subcutaneous iliac nodule that had appeared suddenly before the first course. Owing to progression, four cycles of carboplatin-pemetrexed were administered inducing partial response and then stable disease for an additional 12 months. As fluoro-d-glucose (FDG)-positron emission tomography (PET) only showed activity in the adrenal, laparoscopic adrenalectomy was performed. Three months later FDG-PET revealed a lung nodule unresponsive to carboplatin-pemetrexed, removed by wedge resection. Finally, re-evaluation by a tertiary centre confirmed adrenocortical carcinoma with Ki67-50% in the adrenal and the lung. The patient is alive and tumour free almost 3.5 years after retrospective diagnosis of metastatic adrenocortical cancer.

Alpha-fetoprotein (AFP)-producing adrenocortical carcinoma--long survival with various therapeutic strategies including a lung resection: report of a case

We experienced a very rare case of late pulmonary metastasis from ACC. The patient was a 40-year-old woman who had undergone a left adrenectomy 12 years earlier. Instead of a large metastatic lung tumor with hemothorax and the existence of metastases in other organs, combined therapy of repeated resections for metastases and adjuvant therapy allowed for almost a 36-month survival following the first recurrence and a good quality of life. In addition, a blood and pathological study revealed that the tumor in this case was an alpha-fetoprotein-producing ACC, which is, as far as we could ascertain, the first case of its kind.

Surgical outcome of stage III and IV adrenocortical carcinoma

BACKGROUND

Adrenocortical carcinoma (ACC) is a rare tumor usually diagnosed at an advanced stage on invasion of or adherence to adjacent organs. We report surgical outcome of stage III and IV ACCs.

METHODS

ACCs from seven patients at clinical stage II (n = 1), III (n = 4), or IV (n = 2) were resected. Combined resection of the liver and inferior vena cava was performed in six patients. Morbidity, mortality, recurrence and survival were analyzed.

RESULTS

The pathological stage was stage III in five patients and stage IV in two patients. The mortality was zero and the morbidity was two of seven (29%) patients. The estimated 3-year disease-free and overall survivals for stage III were 20% and 40%, respectively, with a median follow-up of 32 months (range, 11-58). The mean disease-free survival was 21.0 +/- 9.0 months (95% CI: 3.3-38.7). The 3-year disease-free and overall survivals for stage III and IV were 14.3% and 28.6%, respectively. The mean disease-free survival time was 18.6 +/- 6.7 months (95% CI: 5.4-31.8). The most frequent site of metastasis was the lungs, seen in four patients, and liver in three patients. Loco-regional, intra-abdominal lymph node, peritoneum, bone, brain recurrences were also seen in one patient each. The mean survival after recurrence was 19.0 +/- 3.3 months (95% CI: 12.6-25.5), and the 50% survival was 18.4 months with mitotan and cytotoxic drug therapy.

CONCLUSIONS

Resection for stage III, IV ACCs affords the possibility of negative margins, acceptable peri-operative morbidity and mortality, and prolongs survival in selected patients.