ADRENOCORTICAL CARCINOMA TREATED WITH O,P' -DDD

EDP-mitotane in children: reassuring evidence of reversible side-effects and neurotoxicity

Adrenocortical carcinoma affects one in 5 million children each year. Since prognosis for children older than 4 years is limited, clinicians often choose aggressive treatment with etoposide, doxorubicin, cisplatin (EDP) and mitotane after resection. However, little is known about the impact of EDP-mitotane in children. We provide an overview of case-reports and case series listing side-effects and neurotoxicity of EDP-mitotane in children. Fourteen studies were identified describing a range of gastro-intestinal, endocrine, developmental and neuropsychological side-effects. Neurotoxicity included motor- and speech delay, decreased concentration and lower school performance. These side-effects appear to be reversible after mitotane discontinuation. We have added our own experience with a 10 year old girl with advanced adrenocortical carcinoma treated with EDP and 2 years of mitotane after irradical resection. She developed an impactful, but reversible, decrease in cognitive development measured by a standardized neuropsychological assessment before, during and after mitotane therapy. This decrease was mostly measurable in terms of decreased processing speed and concentration and a significant drop in school performance. Combined with fatigue and insecurity, this caused problems in short-term memory and the need to change her school type. In conclusion, EDP-mitotane is associated with several side-effects including neurotoxicity in pediatric cases, all reversible after mitotane discontinuation.

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.

The natural history of treated Cushing's syndrome

The long-term (2-15 years) results of treatment of a consecutive series of 60 patients with Cushing's syndrome are analysed. Of 41, in whom no evidence of tumour was found initially, 12 were eventually found to have tumours in the pituitary (including 3 suspected), the adrenal, or the bronchus.

Most of the 46 with benign lesions (adrenal hyperplasia, without evidence of malignant tumour, or adrenal adenoma) were treated by adrenalectomy with an operative mortality of 4 per cent. All who survived operation underwent remission. One-quarter died within 3 years, but thereafter the proportion that survived remained fairly constant (between 64 and 76 per cent) up to 15 years. Cushing's syndrome recurred in 11 per cent (3 patients) of those having subtotal adrenalectomy. In each case the recurrence was treated effectively. Two of 9 patients with benign pituitary adenomas were cured by transfrontal hypophysectomy and packing of the fossa with yttrium 90.

Fourteen patients had malignant tumours of the pituitary, the adrenal, or the bronchus and all died within 5 years. Five of these had invasive pituitary tumours which failed to respond to various combinations of hypophysectomy and irradiation.

Arterial hypertension and serious cardiovascular lesions were found initially in 93 per cent and 40 per cent, respectively. Adrenalectomy lowered the pressure effectively and permanently. The average post-operative systolic pressure was about normal and the average diastolic pressure was within 10 mm. Hg of normal. Some cardiovascular lesions resolved, but others persisted or became apparent only later. They were the major cause of death within 1 year of adrenalectomy.

Hypokalaemia (40 per cent) and osteoporosis (47 per cent) resolved after effective treatment of Cushing's syndrome. Diabetes, which was present in 29 per cent, was cured by adrenalectomy when mild, but in only 1 of 3 cases in which it was more severe.

Prepuberal boys had retarded growth but normal ossification, before treatment, and grew rapidly after adrenalectomy. Prepuberal girls (with adrenal carcinomas) were of normal height, but had precocious ossification.

Severe mental abnormality, mainly depression, was present in 20 per cent of patients initially and cleared up completely in those who obtained remission of Cushing's syndrome. Temporary psychiatric symptoms after adrenalectomy were mostly due to adrenal insufficiency or excessive replacement therapy.

Sexual function was impaired in most patients initially and restored after adrenalectomy. Of 8 women who might be expected to bear children after adrenalectomy 6, between them, had 10 pregnancies with 7 live births.

Serious infections were rare initially, but commonly complicated the operation of adrenalectomy. During remission 2 patients developed meningococcal meningitis, which was fatal in 1, and 1 died from encephalitis.

Comparison of the 46 patients with benign lesions in this series (and 12 treated recently) with the 30 reported by Plotz, Knowlton, and Ragan (1952), before the advent of cortisone, reveals a much higher rate of adrenal exploration (91 versus 48 per cent) with a much lower operative mortality (4 versus 29 percent), a greatly increased proportion of patients in remission after 2 years (78 versus 17 per cent), and a higher proportion alive at the time of the report (76 versus 50 per cent).

The best methods of treatment of patients in different aetiological groups are discussed, and the relative advantages and disadvantages of total and subtotal adrenalectomy and of different approaches to the adrenals are considered. Particular emphasis is placed on the early recognition of pituitary tumours and on the need for early radical treatment.