Adrenocortical carcinoma: Single center experience

Loco-regional recurrence of adrenocortical carcinoma: A case report

INTRODUCTION

Adrenocortical carcinoma (ACC) is a rare and aggressive endocrine malignancy with a high recurrence rate. Approximately half of the patients are asymptomatic, while others experience symptoms due to the tumor's size or hormone secretion. Ro resection if possible is the best option for treatment of primary as well as locoregional recurrent ACC.

CASE PRESENTATION

A 20-year-old female who previously underwent open left adrenalectomy for Stage III ACC presented with complaints of heaviness and vague discomfort in the left upper abdomen. Current hormonal assays were normal. Imaging revealed a lesion in the spleen suggestive of recurrence. She underwent elective surgery involving en bloc resection of the spleen, diaphragm, and associated structures. Postoperative recovery was uneventful, histopathology confirmed recurrence and subsequent PET-CT showed no recurrence. She is currently on mitotane and remains symptom-free with no signs of recurrence after initial surgery.

CLINICAL DISCUSSION

Complete resection (Ro) if possible, for recurrent and metastatic disease has been linked to long-term survival and offers significant palliative benefits, particularly in cases involving symptomatic steroid production.

CONCLUSION

ACC has a high frequency of local recurrence therefore management of recurrence should be considered from the initial diagnosis. Ro resection of recurrence is the best potential treatment. Follow-up protocols and improving integration between surgical, oncological, and supportive care departments are crucial for overcoming healthcare challenges in Nepal.

Prognostic Factors of Adrenocortical Carcinoma: Experience from a Regional Medical Center in Eastern China

Objective

This study aimed to summarize and analyze the clinical and pathological features and prognostic risk factors of adrenocortical carcinoma (ACC).

Methods

We retrospectively analyzed clinical and pathological data and the prognoses of 39 adult ACC patients confirmed by pathologic diagnosis at the Affiliated Hospital of Qingdao University between August 2009 and October 2021. Kaplan-Meier curves and univariate and multivariate Cox regression models were used to analyze correlations between clinical and pathological parameters and prognosis. A nomogram prediction model was constructed for overall survival (OS) based on the independent prognostic factors and externally validated it with The Cancer Genome Atlas (TCGA) dataset.

Results

The mean age of the patient cohort was 53.87 ± 11.1 years (range: 29-80 years), which included 17 men and 22 women. The 1-, 2-, and 5-year OS rates were 83.7%, 64.4%, and 59.8%, respectively; the recurrence-free survival (RFS) rates at the same time points were 76.1%, 45.8%, and 23.5%, respectively. Kaplan-Meier curves showed that patients with poor OS were associated with M1 stage (P = 0.008), late ENSAT stage (P = 0.017), presence of venous tumor thrombus (P = 0.015), Ki67 >20% (P = 0.006), R1/R2 status (P = 0.018), and poorly differentiated tumors (P = 0.047). Patients with late ENSAT stage (P = 0.017), combined with venous tumor thrombus (P = 0.008), Ki67 >20% (P = 0.022) were more likely to have tumor recurrence. However, age, gender, BMI, tumor diameter, clinical symptoms and postoperative treatment were not correlated with OS or RFS (P > 0.05). Univariate and multivariate COX analyses showed that Ki67 >20% (P = 0.013) and R1/2 status (P = 0.040) were independent risk factors for OS, while only Ki67 >20% (P = 0.032) was an independent risk factor for RFS. A nomogram for predicting OS was constructed based on the above factors, and the area under the receiver characteristic curve (ROC)-1, 3, and 5-year survival were 0.8, 0.825 and 0.902, respectively. The C-index of the predicted nomogram was 0.813 and a high C-index value of 0.846 could still be achieved in the external validation of TCGA.

Conclusion

ACC is a rare and deadly endocrine malignancy with a high rate of recurrence. High Ki67 index (>20%) and R1/R2 resection status were independent risk factors for poor prognosis in ACC patients. A novel nomogram with a relatively good accuracy was established to assist clinicians in assessing the risk of OS in patients with ACC.

A 10-Year Tertiary Care Center Experience With Adrenalectomies for Adrenal Tumors

Background Due to limited data, our understanding of the trends and outcomes of adrenalectomy in the Saudi surgical practice is limited and insufficient. The aim of this study was to review the clinical data regarding the diagnosis and management of patients with adrenal masses and to assess the effect of surgeon specialty on the outcomes. Materials and methods The study included all adult patients who underwent an adrenalectomy for tumors from 2011 to 2021. The patient characteristics, tumor profile, and preoperative, perioperative, and post-operative variables were collected. Frequency and percentage were generated for the categorical variables, and mean and standard deviation were generated for the quantitative variables. Results A total of 55 patients were identified. Most of the patients had a well-defined (58.2%, n = 32), benign (85.5%, n = 47) mass located in the cortex (58.2% n = 32). The majority of the sample were asymptomatic (52.7%, n = 29), and the most frequent diagnosis was adrenal adenoma (47.27%, n = 26). The most frequent indication for surgery was tumor functionality (69.1%, n = 38). Surgeries were mostly laparoscopic (69.1% n = 38) and performed by a urologist (52.7%). The conversion to open surgery was 13%, the intraoperative complication rate was 9.1%, the post-operative complication rate was 7.3%, and the 30-day readmission rate was 3.6%. Intraoperative complications, post-operative complications, and conversion to open surgery were more frequent among general surgeons, while 30-day readmissions were more frequent among urologists. However, a statistically accurate association could not be found due to the small population size. Conclusion Open surgery was replaced by laparoscopic adrenalectomy as the surgery of choice for different adrenal pathologies. The findings reported in this study are substantiated by current literature, adding to our comprehension of adrenal tumor presentation. There are, however, some inconsistencies regarding the influence of gender on tumor development and the association between surgeon specialty and outcome in the literature that merit research. However, evidence regarding the contribution of comorbidities, such as hypertension, diabetes, and hypothyroidism, is lacking.

Histological scores and tumor size on stage II in adrenocortical carcinomas

Adrenocortical carcinomas (ACC) are aggressive tumors with a poor prognosis. Histological scores are advised for the diagnosis, however, there are borderline cases that may be misjudged as adrenocortical adenomas (ACA). The three main scores used are: Weiss Modified System (WMS), Reticulin Algorithm (RA), and Helsinki Score (HS). We intend to compare the accuracy of the three scores in ACC diagnosis and to identify predictive factors of overall survival (OS). Retrospective study (2004–2016) at Centro Hospitalar e Universitário de Coimbra of the adrenal tumors, classified as ACC or ACA, with a history of posterior tumor relapse/metastases, without lesions in the contralateral adrenal gland: 13F and 6M, with a median age of 51 ± 12.41 years. Nodules’ median size was 9.20 ± 6.2 cm. Patients had a median OS of 52 ± 18.6 months, with 57.9% and 46.3%, at 3 and 5 years. Seven patients had local recurrence and nine had metastases. Thirteen cases were in stage II. The WMS and the HS allowed a diagnosis of ACC in 15 cases and the RA defined ACC in 17 cases. All cases had, at least, focal disruption of the reticulin framework. More than 5 mitosis/50 HPF was associated with worse OS: 49.67 ± 21.43 versus 108.86 ± 14.02 months (p = 0.026). In patients with stage II, tumor size ⩾10 cm was associated with worse OS: 19.25 ± 7.15 versus 96.11 ± 16.7 months (p = 0.007), confirmed by multivariate analysis (p = 0.031). The correct diagnosis of ACC is a pathologist responsibility. The RA seems the most accurate. Any loss of the reticulin framework should raise awareness for malignancy. In patients on stage II, a size ⩾10 cm is a predictor of worse prognosis.

Ki67 in endocrine neoplasms: to count or not to count, this is the question! A systematic review from the English language literature

BACKGROUND

Endocrine neoplasms are generally slow-growing tumors that can show hormonal activity and give metastases. In most cases they are benign and clearly malignant forms are easy to diagnose. However, borderline forms may occur and be, for the pathologists, very difficult to classify. In these cases, there is a strong need to identify factors that may aid. Official classification systems for endocrine neoplasms are based on the evaluation of proliferation and, in most cases, they rely on mitotic count. In support, the study of Ki67 is carried out which, however, has not yet been included in any official classification system, except for neuroendocrine neoplasms of the gastro-entero-pancreatic tract.

PURPOSE

The aim of the present study was to investigate the proven or unproven role of Ki67 in endocrine neoplasms, in different districts, in order to bring to light the substantial differences, in terms of proliferation, existing between neoplasms so similar, but at the same time, so different.

METHODS

A thorough search of English language literature was performed, looking for articles concerning Ki67 in five endocrine neoplasms (pituitary adenomas, thyroid neoplasms, adrenocortical neoplasms, pheochromocytomas and paragangliomas).

RESULTS

From 2170, 236 articles were selected and it was seen that the endocrine neoplasm in which Ki67 was most studied was the pituitary, where it still shows a controversial role. In other neoplasms different roles were identified.

CONCLUSION

The pathologist should be aware of the contribution that this proliferative marker can give to the diagnosis and, sometimes, to the therapy selection, for the clinician.

May hemocytometer parameters be a biomarker in distinguishing between adrenal adenomas and carcinomas and in prognosis of adrenocortical carcinomas?

Recently, studies have reported that inflammatory response and elevated platelet counts are associated with several cancers. In the present study, we aimed to evaluate hemocytometer parameters in differentiating adrenal adenoma and carcinoma, and the prognostic utility of hemocytometer parameters in adrenocortical carcinoma (ACC). We included 30 patients with nonfunctional adrenal adenoma and 13 patients with ACC having undergone surgery between 2005 and 2017 and followed up postoperatively at our centre. The neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), red blood cell distribution width (RDW), mean platelet volume (MPV) and plateletcrit (PCT) were evaluated preoperatively in all patients included in the study. There was a significant difference between the adrenal adenoma and ACC groups in terms of neutrophil and lymphocyte counts, NLR and PLR. There was no significant difference between the two groups in terms of platelet count and MPV, but PCT levels were significantly lower in ACC group. There was no statistically significant difference between recurrent and/or metastasis positive patients and negative ones according to NLR, PLR, RDW and MPV. There was a statistically significant difference in RDW levels and tumor diameter between the groups. Our study is the first to evaluate hemocytometer parameters in differentiating adrenal adenomas and carcinomas, and also in the prognosis of ACC. The present study suggested that the hemocytometer parameters may be a marker in the differential diagnosis of adrenal adenomas and carcinomas. However, our study also showed that these parameters had no prognostic value in ACC.

Development and validation of prognostic nomograms in patients with adrenocortical carcinoma: a population-based study

BACKGROUND

Predicting the prognosis of patients with adrenocortical carcinoma (ACC) is difficult, due to its unpredictable behavior. The aim of this study is to develop and validate a nomogram to predict survival outcomes in patients with ACC.

METHODS

Nomograms were established using the data collected from the Surveillance, Epidemiology, and End Results (SEER) database. Based on univariate and multivariate Cox regression analyses, we identified independent risk factors for overall survival (OS) and cancer-specific survival (CSS). Concordance indexes (c-indexes), the area under the receiver operating characteristics curve (AUC) and calibration curve were used to evaluate predictive performance of these models. The clinical use of nomogram was measured by decision curve analysis (DCA) and clinical impact curves.

RESULTS

A total of 855 eligible patients, randomly divided into training (n = 600) and validation cohorts (n = 255), were included in this study. Based on the independent predictors, the nomograms were established and demonstrated good discriminative abilities, with C-indexes for OS and CSS were 0.762 and 0.765 in training cohorts and 0.738 and 0.758 in validation cohorts, respectively. The AUC and calibration plots also demonstrated a good performance for both nomograms. DCA indicated that the two nomograms provide clinical net benefits.

CONCLUSION

We unveiled the prognostic factors of ACC and developed novel nomograms that predict OS and CSS more accurately and comprehensively, which can help clinicians improve individual treatment, making proper clinical decisions and adjusting follow-up management strategies.

Association between Tumor Size and Malignancy Risk in Hormonally Inactive Adrenal Incidentalomas

Introduction

Adrenal incidentalomas (AI) are adrenal masses that are discovered during radiological examinations conducted for other reasons. In this study, we focused on the pathological and radiological properties of nonfunctional AI(NFAI) and the association with malignancy risk in our clinical series.

Methods

A total of 186 patients underwent adrenalectomy between 2010 and 2017; of these, 76 (40.8%) patients with non-functional AI were included in the current study. The radiological and pathologic characteristics of these AIs were retrospectively analyzed to determine the malignancy rate.

Results

There were 22 (28.9%) male and 54 (71.1%) female patients with nonfunctional AI included in this study. The median age was 55 (range: 24-85) years. Of the patients included, 37 (48.6%) had AI on the left and 39 (51.3%) had AI on the right adrenal gland. Sixty-one (80.2%) cases were treated laparoscopically, four (5.3%) required conversion to open surgery due to intraoperative difficulties such as bleeding and adhesions, and 11 (14.4%) were managed with open adrenalectomy. The rate of malignancy in the tumors with diameters of <4 cm, 4-6 cm, and >6 cm was found to be 0%, 2.9%, and 13.6%, respectively.

Conclusions

Determining the ideal cutoff value for surgical indication in an NFAI is challenging. Besides the malignancy risk, the rate of silent pheochromacytomas must be taken into account in the surgical decision.

Treatment and management of adrenal cancer in a specialized Australian endocrine surgical unit: approaches, outcomes and lessons learnt

BACKGROUND

Adrenocortical carcinoma is a rare and heterogeneous malignancy with poor outcomes. Recent research has suggested that outcomes may be improved by centralization of care in specialist centres. We review our evolving 21-year experience in managing adrenocortical carcinoma with a view towards outcomes and lessons learnt.

METHODS

A retrospective study of patients treated in our specialist endocrine surgical unit over 21 years was undertaken.

RESULTS

Thirty-five patients were treated from diagnosis, 29 forming a primary study cohort. Additionally, seven patients were referred to us for quaternary care, forming a secondary study cohort. The European Network for the Study of Adrenal Tumours (ENSAT) stage and immunohistochemical marker Ki-67 index were strong prognostic indicators for survival.

CONCLUSIONS

Early stage, complete resection and Ki-67 <10% are the best prognosticators for survival. Aggressive surgical resection at index operation and of recurrent oligometastatic disease along with multimodal adjuvant treatment has led to long-term survivors of patients with Stage 4 disease in our aggregate cohort.