eMedicine Specialties > Oncology > Carcinomas of Endocrine Organs

Adrenal Carcinoma: Follow-up

Author: Gabriel I Uwaifo, MBBS, Clinical and Research Attending, Assistant Professor of Medicine and Endocrinology, MedStar Clinical Research Center, The MedStar Research Institute and the Washington Hospital Center
Coauthor(s): Antonio Tito Fojo, MD, Senior Clinical Investigator, Medicine Branch, Division of Cancer Treatment, National Cancer Institute, National Institutes of Health
Contributor Information and Disclosures

Updated: May 22, 2006

Follow-up

Complications

  • Potential complications that may be associated with AC can be subclassified as follows:
    • Local tumor invasion, including the potential for tumor thrombus formation, which can embolize similar to renal cell carcinoma
    • Hormone excess syndromes (eg, Cushing syndrome, hyperaldosteronism, hirsutism, virilization, and hypertension)
    • Paraneoplastic syndromes (eg, cachexia)
    • Local pain in patients with bone metastases

Prognosis

  • Detection of tumors at early clinical stage is crucial for curative resection.
  • Total resection offers the only prospect for cure.
  • A majority of cases of AC are metastatic at the time of diagnosis. The most common sites of spread are the local periadrenal tissue, lymph nodes, lungs, liver, and bone.
  • Patients with functional AC may have a better prognosis because they present earlier, unlike nonfunctional variants that invariably present when they are very large or when they are associated with distant metastasis.
    • Estimates of the overall 5-year survival rate are approximately 20-35%.
    • For cases where total surgical resection is achieved, this rate is estimated to be approximately 32-47%.
    • In those cases where total surgical extirpation has not been possible, the 5-year survival rates are 10-30%.
    • Even after apparently complete surgical resection, local or distant relapse occurs in nearly 80% of cases.
  • The presence of distant metastasis generally is a sign of an especially poor outcome. Estimates suggest that as many as 50% of such patients are dead within 12 months of detecting the metastatic deposits, regardless of treatment.
    • The most important predictive clinical parameters of prognosis are disease stage at diagnosis, completeness of resection at surgery, and presence or absence of metastasis at the time of diagnosis.
    • Recent follow-up data from large centers, such as the MD Anderson Cancer Center, Memorial Sloan-Kettering Cancer Center, and the French association of Endocrine Surgery series from Europe, suggest a temporal improvement in clinical survival of patients with AC in more recent years since the late 1980s and early 1990s.
  • Although still somewhat controversial, some suggest that children with AC have a better prognosis than adults. A report from Icard and associates suggests that tumor prognosis also may be influenced by the hormonal product of the tumor, but this has not been replicated in other series. The mitotic index, the presence of atypical mitoses on histologic analysis, a tumor mass larger than 250 g, and tumor diameter larger than 10 cm are all indices of a poor prognosis.
  • Even for patients with curative surgery, life-long follow-up is mandatory because documented cases exist of AC recurrence more than 10 years after presumed curative surgery.
  • The prognosis for cases of AC occurring in pregnancy is equally grim; however, the fetal prognosis in these cases remains excellent.
  • Patients who show no response to mitotane or who relapse are probably best served by a referral a major cancer center, where they can be enrolled in one of several ongoing combination chemotherapeutic/radiation and/or surgical resection protocols. AC is too uncommon for most tertiary hospitals to have enough expertise to manage these patients adequately.

Miscellaneous

Medicolegal Pitfalls

  • Because the management of AC is still undergoing considerable flux, significant controversy exists and very few, if any, universally accepted standards have been determined. Until a consensus conference on AC is convened where the recent developments in the field and accumulated clinical experience of the last few decades are integrated, only broad guidelines can be suggested.
  • A full evaluation is advised in all patients with a distinct adrenal nodule or tumor larger than 1 cm in order to determine whether the tumor is functional. The general agreement is that all functional masses should be removed.
  • No definitive guidelines exist for all nonfunctional adrenal masses being followed serially. A suggested follow-up regimen is to perform repeat adrenal CT scans or MRI scans 3-6 months after the initial evaluation, then yearly (some suggest every 6 mo for the first few years) in order to detect any change in tumor size. Accompany these with periodic checks of hormonal profiles (after 1 y, then every 1-2 y thereafter).
  • Removal of all nonmetastatic adrenal masses larger than 6 cm is advisable (several authorities say 5 cm, while others say 4 cm), regardless of the patient's hormonal profile.
  • Use a higher index of suspicion for children with adrenal masses; these may be malignant even when smaller than 4-5 cm in diameter.
 


More on Adrenal Carcinoma

Overview: Adrenal Carcinoma
Differential Diagnoses & Workup: Adrenal Carcinoma
Treatment & Medication: Adrenal Carcinoma
Follow-up: Adrenal Carcinoma
References
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Further Reading

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Keywords

adrenal carcinoma, AC, adrenocortical carcinoma, adrenal cancer, adrenocortical cancer, primary adrenocortical malignancies, malignant adrenocortical neoplasms, malignant adrenal tumors, malignant adrenocortical tumors, adrenocortical masses, adrenal incidentalomas

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Contributor Information and Disclosures

Author

Gabriel I Uwaifo, MBBS, Clinical and Research Attending, Assistant Professor of Medicine and Endocrinology, MedStar Clinical Research Center, The MedStar Research Institute and the Washington Hospital Center
Gabriel I Uwaifo, MBBS is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians-American Society of Internal Medicine, American Diabetes Association, American Medical Association, American Society of Hypertension, and Endocrine Society
Disclosure: Nothing to disclose.

Coauthor(s)

Antonio Tito Fojo, MD, Senior Clinical Investigator, Medicine Branch, Division of Cancer Treatment, National Cancer Institute, National Institutes of Health
Disclosure: Nothing to disclose.

Medical Editor

Michael C Perry, MD, Professor, Department of Internal Medicine, Nellie B Smith Chair of Oncology, Director, Division of Hematology and Oncology, University of Missouri at Columbia/Ellis Fischel Cancer Center
Michael C Perry, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Cancer Research, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Medical Association, American Society of Clinical Oncology, American Society of Hematology, Missouri State Medical Association, Southern Association for Oncology, and Southern Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Benjamin Movsas, MD, Vice-Chairman, Department of Radiation Oncology, Fox Chase Cancer Center
Benjamin Movsas, MD is a member of the following medical societies: American College of Radiology, American Radium Society, American Society for Therapeutic Radiology and Oncology, and American Society of Clinical Oncology
Disclosure: Nothing to disclose.

CME Editor

Rajalaxmi McKenna, MD, FACP, Consulting Staff, Department of Medicine, Southwest Medical Consultants, SC, Good Samaritan Hospital, Advocate Health Systems
Rajalaxmi McKenna, MD, FACP is a member of the following medical societies: American Society of Clinical Oncology, American Society of Hematology, and International Society on Thrombosis and Haemostasis
Disclosure: Nothing to disclose.

Chief Editor

John S Macdonald, MD, Professor of Medicine, New York Medical College; Chief, Division of Medical Oncology, St Vincent's Hospital and Medical Center; Medical Director, Saint Vincent's Comprehensive Cancer Center
Disclosure: Nothing to disclose.

 
 
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