Adrenal carcinoma: Difference between revisions
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All patients with suspected adrenocortical carcinoma should be carefully examined for Cushing's syndrome ([[glucocorticoid]] excess) these include [[weight gain]], [[muscle wasting]], purple lines on the abdomen, a fatty [[Buffalo hump|"buffalo hump"]] on the neck, a [[Moon face|"moonlike" face]], and thinning, fragile skin. Virilism ([[androgen]] excess) is most obvious in women, and may produce [[Hirsutism|excess facial and body hair]], [[acne]], enlargement of the [[clitoris]], deepening of the voice, coarsening of facial features, and [[Amenorrhea|cessation of menstruation]]. [[Conn syndrome]] ([[mineralcorticoid]] excess) is marked by [[high blood pressure]], which can result in [[headache]], and [[hypokalemia]] (low serum potassium), which can produce muscle weakness, confusion, and [[palpitations]]. low plasma [[renin]] activity, and high serum [[aldosterone]]. [[Feminization]] ([[estrogen]]<nowiki/>excess) is most readily noted in men, and includes [[Gynecomastia|breast enlargement]], decreased [[libido]] and [[impotence]]. | All patients with suspected adrenocortical carcinoma should be carefully examined for Cushing's syndrome ([[glucocorticoid]] excess) these include [[weight gain]], [[muscle wasting]], purple lines on the abdomen, a fatty [[Buffalo hump|"buffalo hump"]] on the neck, a [[Moon face|"moonlike" face]], and thinning, fragile skin. Virilism ([[androgen]] excess) is most obvious in women, and may produce [[Hirsutism|excess facial and body hair]], [[acne]], enlargement of the [[clitoris]], deepening of the voice, coarsening of facial features, and [[Amenorrhea|cessation of menstruation]]. [[Conn syndrome]] ([[mineralcorticoid]] excess) is marked by [[high blood pressure]], which can result in [[headache]], and [[hypokalemia]] (low serum potassium), which can produce muscle weakness, confusion, and [[palpitations]]. low plasma [[renin]] activity, and high serum [[aldosterone]]. [[Feminization]] ([[estrogen]]<nowiki/>excess) is most readily noted in men, and includes [[Gynecomastia|breast enlargement]], decreased [[libido]] and [[impotence]]. | ||
== Laboratory findings == | ===Laboratory findings=== | ||
Hormonal syndromes should be confirmed with laboratory testing. Laboratory findings in Cushing syndrome include increased [[serum glucose]] (blood sugar) and increased urine [[cortisol]]. Adrenal virilism is confirmed by the finding of an excess of serum [[androstenedione]] and [[dehydroepiandrosterone]]. Findings in [[Conn syndrome]] include [[Hypokalemia|low serum potassium]], low plasma [[renin]] activity, and high serum [[aldosterone]]. Feminization is confirmed with the finding of excess serum [[estrogen]] | Hormonal syndromes should be confirmed with laboratory testing. Laboratory findings in Cushing syndrome include increased [[serum glucose]] (blood sugar) and increased urine [[cortisol]]. Adrenal virilism is confirmed by the finding of an excess of serum [[androstenedione]] and [[dehydroepiandrosterone]]. Findings in [[Conn syndrome]] include [[Hypokalemia|low serum potassium]], low plasma [[renin]] activity, and high serum [[aldosterone]]. Feminization is confirmed with the finding of excess serum [[estrogen]] | ||
Revision as of 15:09, 2 August 2019
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Adrenal Carcinoma Microchapters |
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Adrenal carcinoma On the Web |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Sara Mohsin, M.D.[2]
Overview
Adrenocortical carcinoma, also adrenal cortical carcinoma (ACC) and adrenal cortex cancer, is an aggressive cancer originating in the cortex (steroid hormone-producing tissue) of the adrenal gland. Adenocortical carcinoma is remarkable for the many hormonal syndromes which can occur in patients with steroid hormone-producing ("functional") tumors, including Cushing's syndrome, Conn syndrome, virilization, and feminization.
Classification
Adrenal cancer is subclassified according to its activity into:[1]
- Functional
- Non-functional
Pathophysiology
Pathology
Adrenal tumors are often not biopsied prior to surgery, so diagnosis is confirmed on examination of the surgical specimen by a pathologist.[2][3][4][5]
Prognosis
ACC, generally, carries a poor prognosis and is unlike most tumours of the adrenal cortex, which are benign (adenomas) and only occasionally cause Cushing's syndrome. Five-year disease-free survival for a complete resection of a stage I-III ACC is approximately 30%.[6][7]
Diagnosis
History and Symptoms
- Adrenocortical carcinoma may present differently in children and adults[8][9][10]
- Most tumors in children are functional, and virilization is by far the most common presenting symptom, followed by Cushing's syndrome and precocious puberty
- Among adults presenting with hormonal syndromes, Cushing's syndrome alone is most common, followed by mixed Cushing's and virilization (glucocorticoid and androgen overproduction)
- Feminization and Conn syndrome (mineralcorticoidexcess) occur in less than 10% of cases[11]
- Rarely, pheochromocytoma-like hypersecretion of catecholamines has been reported in adrenocortical cancers. Non-functional tumors (about 40%, authorities vary) usually present with abdominal or flank pain, or they may be asymptomatic and detected incidentally
- All patients with suspected adrenocortical carcinoma should be carefully evaluated for signs and symptoms of hormonal syndromes
- For Cushing's syndrome (glucocorticoid excess) these include weight gain, muscle wasting, purple lines on the abdomen, a fatty "buffalo hump" on the neck, a "moonlike" face, and thinning, fragile skin
- Virilism (androgen excess) is most obvious in women, and may produce excess facial and body hair, acne, enlargement of the clitoris, deepening of the voice, coarsening of facial features, and cessation of menstruation
- Conn syndrome (mineralcorticoid excess) is marked by high blood pressure, which can result in headache, and hypokalemia (low serum potassium), which can produce muscle weakness, confusion, and palpitations
- Low plasma renin activity, and high serum aldosterone. Feminization (estrogen excess) is most readily noted in men, and includes breast enlargement, decreased libido and impotence
- Jump up↑ Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson JL. Harrison's Principles of Internal Medicine. New York: McGraw-Hill, 2005. ISBN 0-07-139140-1
Physical Examination
All patients with suspected adrenocortical carcinoma should be carefully examined for Cushing's syndrome (glucocorticoid excess) these include weight gain, muscle wasting, purple lines on the abdomen, a fatty "buffalo hump" on the neck, a "moonlike" face, and thinning, fragile skin. Virilism (androgen excess) is most obvious in women, and may produce excess facial and body hair, acne, enlargement of the clitoris, deepening of the voice, coarsening of facial features, and cessation of menstruation. Conn syndrome (mineralcorticoid excess) is marked by high blood pressure, which can result in headache, and hypokalemia (low serum potassium), which can produce muscle weakness, confusion, and palpitations. low plasma renin activity, and high serum aldosterone. Feminization (estrogenexcess) is most readily noted in men, and includes breast enlargement, decreased libido and impotence.
Laboratory findings
Hormonal syndromes should be confirmed with laboratory testing. Laboratory findings in Cushing syndrome include increased serum glucose (blood sugar) and increased urine cortisol. Adrenal virilism is confirmed by the finding of an excess of serum androstenedione and dehydroepiandrosterone. Findings in Conn syndrome include low serum potassium, low plasma renin activity, and high serum aldosterone. Feminization is confirmed with the finding of excess serum estrogen
Imaging studies
CT
- Radiological studies of the abdomen, such as CT scans and magnetic resonance imaging are useful for identifying the site of the tumor, differentiating it from other diseases, such as adrenocortical adenoma, and determining the extent of invasion of the tumor into surrounding organs and tissues.[12]
- CT scans of the chest and bone scans are routinely performed to look for metastases to the lungs and bones respectively. These studies are critical in determining whether or not the tumor can be surgically removed, the only potential cure at this time.
PET scan
Molecular imaging
- Iodometomidate (IMTO) as tracer for molecular imaging of cytochrome P450 family 11B (Cyp11B) enzymes[15]
Medical Therapy
Radiation therapy and radiofrequency ablation may be used for palliation in patients who are not surgical candidates.
Chemotherapy regimens typically include the drug mitotane, an inhibitor of steroid synthesis which is toxic to cells of the adrenal cortex, as well as standard cytotoxic drugs. One widely used regimen consists of cisplatin, doxorubicin, etoposide) and mitotane. The endocrine cell toxin streptozotocin has also been included in some treatment protocols. Chemotherapy may be given to patients with unresectable disease, to shrink the tumor prior to surgery (neoadjuvant chemotherapy), or in an attempt to eliminate microscopic residual disease after surgery (adjuvant chemotherapy).
Hormonal therapy with steroid synthesis inhibitors such as aminoglutethimide may be used in a palliative manner to reduce the symptoms of hormonal syndromes.
Surgery
The only curative treatment is complete surgical excision of the tumor, which can be performed even in the case of invasion into large blood vessells, such as the renal vein or inferior vena cava. The 5-year survival rate after successful surgery is 50-60%, but unfortunately, a large percentage of patients are not surgical candidates.
References
- ↑ "Adrenocortical Carcinoma Treatment - National Cancer Institute".
- ↑ Weiss LM (1984). "Comparative histologic study of 43 metastasizing and nonmetastasizing adrenocortical tumors". Am J Surg Pathol. 8 (3): 163–9. PMID 6703192.
- ↑ "Mechanism of abnormal production of adrenal androgens in patients with adrenocortical adenomas and carcinomas | The Journal of Clinical Endocrinology & Metabolism | Oxford Academic".
- ↑ "Variable Expression of the Transcription Factors cAMP Response Element-Binding Protein and Inducible cAMP Early Repressor in the Normal Adrenal Cortex and in Adrenocortical Adenomas and Carcinomas | The Journal of Clinical Endocrinology & Metabolism | Oxford Academic".
- ↑ Fassnacht M, Libé R, Kroiss M, Allolio B (2011). "Adrenocortical carcinoma: a clinician's update". Nat Rev Endocrinol. 7 (6): 323–35. doi:10.1038/nrendo.2010.235. PMID 21386792.
- ↑ Weiss LM, Medeiros LJ, Vickery AL (1989). "Pathologic features of prognostic significance in adrenocortical carcinoma". Am J Surg Pathol. 13 (3): 202–6. PMID 2919718.
- ↑ Moreno S, Montoya G, Armstrong J, Leteurtre E, Aubert S, Vantyghem MC; et al. (2004). "Profile and outcome of pure androgen-secreting adrenal tumors in women: experience of 21 cases". Surgery. 136 (6): 1192–8. doi:10.1016/j.surg.2004.06.046. PMID 15657575.
- ↑ "Hypoaldosteronism accompanied by normal or elevated mineralocorticosteroid pathway steroid: a marker of adrenal carcinoma. | The Journal of Clinical Endocrinology & Metabolism | Oxford Academic".
- ↑ "ADRENAL CORTICAL CARCINOMA IN A MALE WITH EXCESS GONADOTROPIN IN THE URINE | The Journal of Clinical Endocrinology & Metabolism | Oxford Academic".
- ↑ "UpToDate".
- ↑ Moreno S, Guillermo M, Decoulx M, Dewailly D, Bresson R, Proye Ch (2006). "Feminizing adreno-cortical carcinomas in male adults. A dire prognosis. Three cases in a series of 801 adrenalectomies and review of the literature". Ann Endocrinol (Paris). 67 (1): 32–8. PMID 16596055.
- ↑ Szolar DH, Korobkin M, Reittner P, Berghold A, Bauernhofer T, Trummer H; et al. (2005). "Adrenocortical carcinomas and adrenal pheochromocytomas: mass and enhancement loss evaluation at delayed contrast-enhanced CT". Radiology. 234 (2): 479–85. doi:10.1148/radiol.2342031876. PMID 15671003.
- ↑ Groussin L, Bonardel G, Silvéra S, Tissier F, Coste J, Abiven G; et al. (2009). "18F-Fluorodeoxyglucose positron emission tomography for the diagnosis of adrenocortical tumors: a prospective study in 77 operated patients". J Clin Endocrinol Metab. 94 (5): 1713–22. doi:10.1210/jc.2008-2302. PMID 19190108.
- ↑ Khan TS, Sundin A, Juhlin C, Långström B, Bergström M, Eriksson B (2003). "11C-metomidate PET imaging of adrenocortical cancer". Eur J Nucl Med Mol Imaging. 30 (3): 403–10. doi:10.1007/s00259-002-1025-9. PMID 12634969.
- ↑ Hahner S, Stuermer A, Kreissl M, Reiners C, Fassnacht M, Haenscheid H; et al. (2008). "[123 I]Iodometomidate for molecular imaging of adrenocortical cytochrome P450 family 11B enzymes". J Clin Endocrinol Metab. 93 (6): 2358–65. doi:10.1210/jc.2008-0050. PMID 18397978.