Functioning adrenocortical neoplasms in children

Radiotherapy for Pediatric Adrenocortical Carcinoma – Review of the Literature

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Radiotherapy (RT) is mostly performed for curative intent, only few cases in palliative setting are reported.

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The site of RT was predominantly tumor bed, abdominal cavity, and/or metastases.

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Adjuvant RT has to be discussed—even in the context of TPSs—especially for patients with high risk factors.

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Evidence regarding RT in in pediatric adrenocortical carcinoma is too limited to give any general recommendation. However, we suggest to consider adjuvant radiotherapy in individual patients with high risk of recurrence.

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A systematic international study with a common data platform is needed to establish evidence. on the role of RT in the treatment of children with adrenocortical carcinoma and to improve the outcome in this rare disease.

Background and purpose

Pediatric adrenocortical carcinoma (pACC) is a rare disease with poor prognosis. Publications on radiotherapy (RT) are scarce. This review summarizes the current data on RT for pACC and possibly provides first evidence to justify its use in this setting.

Materials and methods

We searched the PubMed and Embase database for manuscripts regarding RT for pACC.

Results

We included 17 manuscripts reporting on 76 patients treated with RT, after screening 2961 references and 269 full articles. In addition, we added data of 4 unreported pACC patients treated by co-authors. All reports based on retrospective data. Median age at first diagnosis was 11.1 years (70% female); 78% of patients presented with hormonal activity. RT was mostly performed for curative intent (78%). 88% of RT were administered during primary therapy. The site of RT was predominantly the local tumor bed (76%). Doses of RT ranged from 15 to 62 Gy (median 50 Gy). Information on target volumes or fractionation were lacking. Median follow-up was 6,9 years and 64% of the patients died of disease, with 33% alive without disease. In 16 of 48 patients with available follow-up data after adjuvant RT (33%) no recurrence was reported and in 3 of 9 patients palliative RT seemed to induce some benefit for the patient.

Conclusions

Our first systematic review on RT for pACC provides too few data for any general recommendation, but adjuvant RT in patients with high risk might be considered. International collaborative studies are urgently needed to establish better evidence on the role of RT in this rare malignancy.

Adrenocortical Carcinoma in Childhood: A Systematic Review

Adrenocortical tumors are rare in children. This systematic review summarizes the published evidence on pediatric adrenocortical carcinoma (ACC) to provide a basis for a better understanding of the disease, investigate new molecular biomarkers and therapeutic targets, and define which patients may benefit from a more aggressive therapeutic approach. We included 137 studies with 3680 ACC patients (~65% female) in our analysis. We found no randomized controlled trials, so this review mainly reflects retrospective data. Due to a specific mutation in the TP53 gene in ~80% of Brazilian patients, that cohort was analyzed separately from series from other countries. Hormone analysis was described in 2569 of the 2874 patients (89%). Most patients were diagnosed with localized disease, whereas 23% had metastasis at primary diagnosis. Only 72% of the patients achieved complete resection. In 334 children (23%), recurrent disease was reported: 81%-local recurrence, 19% (n = 65)-distant metastases at relapse. Patients < 4 years old had a different distribution of tumor stages and hormone activity and better overall survival (p < 0.001). Although therapeutic approaches are typically multimodal, no consensus is available on effective standard treatments for advanced ACC. Thus, knowledge regarding pediatric ACC is still scarce and international prospective studies are needed to implement standardized clinical stratifications and risk-adapted therapeutic strategies.

Adrenocortical tumours in children: a review of surgical management at a tertiary care centre

BACKGROUND

Adrenocortical tumours (ACT) are rare tumours of childhood usually presenting with endocrine dysfunction. This retrospective study is designed to review our institutional experience in surgical management.

METHODS

Records of children treated for ACT between 1999 and 2019 were reviewed retrospectively.

RESULTS

The median age of 24 children was 78 months. Fourteen patients had adrenocortical carcinoma, nine had adrenocortical adenoma and one had neuroendocrine differentiation of ACT. Endocrine dysfunction was noted in 79% of the patients. Five patients had preoperative chemotherapy but none had a decrease in tumour size. Transabdominal approach was used in all but two patients who had thoracoabdominal incision for excision of giant tumours and ipsilateral lung metastases. Two patients had visceral excision to achieve R0 resection. Five patients, four of whom had spillage and one with partial resection died of widespread disease. Two patients with stage 4 adrenocortical carcinoma are still on chemotherapy. All patients with stage I-III disease who had total excision without spillage (n = 17) are disease-free for 2-170 months.

CONCLUSIONS

Our results show the importance of excision in ACT without spillage for survival. However, multicentre prospective studies should enhance the knowledge of children about ACT and develop alternative therapies for stage III and IV cases.

Adrenal incidentaloma: the influence of a decision-making algorithm on the short-term outcome of laparoscopy

BACKGROUND

At the present time, the precise indications for laparoscopic surgery of adrenal incidentaloma (AI) have yet to be completely clarified. The most controversial issue is the role of laparoscopy in the treatment of potentially malignant and large adrenal masses. Trying to address these questions, we retrospectively examined a group of patients with AIs.

MATERIALS AND METHODS

Forty-two patients with AIs who were laparoscopically treated since 1995 were enrolled in this study. The patients were divided into two groups: the 27 patients of the immediate surgery (IS) group were operated on immediately, whereas the 15 subjects in the delayed surgery (DS) group needed further evaluations and/or a follow-up period before surgery. Surgical timing for both groups was decided according to a widely accepted decision-making algorithm. Many outcome parameters of laparoscopy (operative time, blood loss, conversion rate, time to liquid and solid food nutrition, drainage removal, resumption of normal bowel habits, and average hospital stay) were analyzed in the two groups. The subjects had AIs of various sizes and different histotypes.

RESULTS

Patients in the DS group had a higher risk for malignancy. The definitive pathology revealed a malignant biology in 26.6% of DS vs. 0% of IS cases. No difference in the outcome parameters of laparoscopy was observed between the two groups or among pathologically different AIs. A significant correlation was found between the operative time and the size of the AI (r=0.836, P<0.001, linear regression test).

CONCLUSION

Our study shows that laparoscopy is feasible and safe for AIs, regardless of the preoperative probability of malignancy. The size of the AI was the only determinant for choosing a laparotomy. Further long-term studies are necessary to confirm the laparoscopic efficacy in terms of oncologic safety.

Tratamento do tumor do córtex adrenal na infância

O tumor do córtex adrenal (TCA) na infância é raro. Entretanto, no Paraná sua incidência é 15 vezes maior do que a observada em outros países. A mutação germinativa R337H TP53, presente em mais de 95% dos nossos pacientes, provavelmente está relacionada à maior incidência. Cento e vinte e cinco pacientes foram tratados no período de 1966 a 2003. A cirurgia é o único tratamento curativo. Em nossa experiência, tumores no estádio I, ausência de spillage durante a cirurgia e ausência de trombo são parâmetros relacionados à maior sobrevida. Dados preliminares mostram que a associação de etoposídeo, doxorrubicina, cisplatina e mitotano produziu remissão completa do tumor e/ou das metástases em alguns pacientes. Os efeitos colaterais destas drogas são comuns e pode ocorrer insuficiência adrenocortical. As doses de reposição de glicocorticóides e mineralocorticóides devem ser 2 a 3 vezes maiores que as doses fisiológicas.

A comprehensive approach to adrenal incidentalomas

Improvements in abdominal imaging techniques have increased the detection of clinically inapparent adrenal masses, or incidentalomas (AI), the appropriate diagnosis and management of which have become a common clinical problem for health care professionals. Once an adrenal mass has been detected, the clinician needs to address two questions: 1) is the tumor hormonally active? and 2) is there any chance of the mass being malignant? The majority of AI is non-hypersecretory cortical adenomas, but an endocrine evaluation can lead to the identification of subtle hormone excess. An overnight low-dose dexamethasone suppression test, fractionated urinary or plasma metanephrine assay and, in hypertensive patients, establishing the upright plasma aldosterone/plasma renin activity ratio are recommended as preliminary screening steps. Masses greater than 4cm are at greater risk of malignancy. Morphological imaging features may be helpful in the distinction between benign and malignant forms. Fine-needle aspiration biopsy is an important tool in the evaluation of oncological patients to establish any metastatic disease. Adrenalectomy is indicated by evidence of a functional adrenal mass, or a suspected malignant form. We advocate adrenalectomy of subtle hypercortisolism, especially in the presence of hypertension, obesity, diabetes or osteoporosis potentially aggravated by glucocorticoid excess. A close follow-up is needed, particularly in the first year after diagnosis.

Tumores do córtex adrenal na infância

O tumor do córtex adrenal (TCA) na infância é raro. Entretanto, no Paraná sua incidência é 15 vezes maior do que a observada em outros países. Descrevemos as características clínicas, laboratoriais, tratamento e evolução de 125 pacientes atendidos em uma única instituição no Paraná. A média de idade ao diagnóstico foi de 4,3 anos, com uma relação feminino:masculino de 2,6:1. As formas clínicas mais comuns foram virilização isolada (51,2%) e virilização e síndrome de Cushing (42%). Em 4,8% dos casos, os tumores foram não-funcionantes. Dois pacientes (1,6%) apresentaram síndrome de Cushing isolado e 1 (0,8%) síndrome de Conn. Hipertensão arterial ocorreu em 56% dos pacientes. O único tratamento curativo é a cirurgia. Os dados da nossa casuística mostram que estádio clínico 1 do TCA, ausência de trombo intra-venoso e ausência de spillage durante a cirurgia estão associados a uma maior sobrevida.

Childhood adrenocortical tumours

Childhood adrenocortical tumours (ACT) constitute only about 0.2% of all paediatric malignancies. However, the incidence of ACT varies across geographic regions and is remarkably high in southern Brazil. At presentation, most children show signs and symptoms of virilisation, which may be accompanied by manifestations of the hypersecretion of other adrenal cortical hormones. Fewer than 10% of patients with ACT show no endocrine syndrome at presentation; these are often older children and adolescents. ACT is commonly associated with constitutional genetic abnormalities, particularly mutations of the P53 gene. Histological features are used to classify the tumours as adenomas or carcinomas; however, the distinction between these two subtypes is often difficult. The extent of disease is best evaluated by computed tomography or magnetic resonance imaging; the role of positron-emission tomographic scans has not been defined. Cure of ACT requires complete tumour resection. The role of chemotherapy or radiotherapy has not been established, although definitive responses to several anticancer drugs have been documented. Among patients who undergo complete tumour resection, favourable prognostic factors include age <4 years, smaller tumour size, signs of virilisation alone at presentation, and adenomatous tumour histology. Some children with ACT show abnormalities of growth and development at the time of presentation, but these usually resolve after surgery.

A surgical approach to adrenocortical tumors in children: the mainstay of treatment

BACKGROUND

Adrenocortical tumors (ACTs) are rare in the pediatric population. The pathogenesis, prognostic indicators, and management of these tumors are still unclear because of its infrequent occurrence. This case series presents the surgical experience of the authors' center over 29 years.

METHODS

The medical records of children treated for ACTs between 1974 and 2003 were reviewed. Information on age, sex, presenting symptoms, hormonal levels, pathology, stage, treatment, and outcome was obtained.

RESULTS

Nine children (5 girls, 4 boys) were treated for ACTs. The median age at presentation was 29 months (range, 5 months to 11 years). Endocrine dysfunction was found in 8 patients. Four presented with virilizing symptoms, 4 presented with both virilizing and Cushing's symptoms, and 1 patient with Beckwith-Wiedemann syndrome was identified during routine screening. One was an adenoma, and 8 were carcinomas. Of the carcinomas, 3 were stage I, and 5 were stage II. The mean tumor weight was 125 g (range, 42 g to 336 g) with a mean volume of 139 cm3 (range, 30 cm3 to 626 cm3). All patients had complete excision of the tumor with spillage occurring in 2 cases. Lymph node biopsies were done in all but 2 patients. Two patients were treated with chemotherapy because of large tumor size and nodal involvement. All patients are doing well including those with tumor spillage.

CONCLUSIONS

This study shows that surgical excision continues to be the mainstay of treatment for ACTs. Extensive lymph node biopsy in small ACTs can probably be avoided given the generally good outcome with surgery alone. The role of adjuvant chemotherapy remains unclear because most of the children in our series were effectively treated with surgical resection only. Patients should be enrolled in multicenter trials to assess the added value of chemotherapy.

The clinically inapparent adrenal mass: update in diagnosis and management

Clinically inapparent adrenal masses are incidentally detected after imaging studies conducted for reasons other than the evaluation of the adrenal glands. They have frequently been referred to as adrenal incidentalomas. In preparation for a National Institutes of Health State-of-the-Science Conference on this topic, extensive literature research, including Medline, BIOSIS, and Embase between 1966 and July 2002, as well as references of published metaanalyses and selected review articles identified more than 5400 citations. Based on 699 articles that were retrieved for further examination, we provide a comprehensive update of the diagnostic and therapeutic approaches focusing on endocrine and radiological features as well as surgical options. In addition, we present recent developments in the discovery of tumor markers, endocrine testing for subclinical disease including autonomous glucocorticoid hypersecretion and silent pheochromocytoma, novel imaging techniques, and minimally invasive surgery. Based on the statements of the conference, the available literature, and ongoing studies, our aim is to provide practical recommendations for the management of this common entity and to highlight areas for future studies and research.

Adrenal cortical tumours: 25 years' experience at the Royal Children's Hospital, Melbourne

AIMS

Adrenal cortical tumours remain a rare entity with inconsistent consensus about treatment and follow up. This article reviews 25 years of experience in the Royal Children's Hospital, Melbourne, Australia.

METHODS

All records with the diagnosis of adrenal adenoma or carcinoma between 1976 and 2001 were reviewed, excluding tumours of the adrenal medulla. Details were recorded for age, gender, family history, presentation, biochemistry, imaging, histology, diagnosis, treatment and outcome.

RESULTS

Twelve children (six boys, six girls) were diagnosed with adrenal cortical tumours in this period. Median age at diagnosis was 2.5 years (range 0.5-15.6 years). Six of the 12 children presented with virilization. The remaining six identified by ultrasound performed for hemi-hypertrophy (2), hypertension (2), and fever with abdominal pain (2). Five children had a family history of tumour and two of these five had a p53 mutation demonstrated on molecular genetic analysis. Tumours in five of the 12 children were defined as malignant on histology. Surgery was deemed curative in nine cases. Only one case required further surgery and two required chemotherapy. Time since diagnosis ranged from 1 to 25.8 years. Two children died from complications of the tumour. One other child died following development of a second tumour.

CONCLUSION

Adrenal cortical tumours should always be considered in the differential for adrenal hormone excess. New information provided by mutational analysis may predict ongoing risks. Lifelong regular follow up is required.