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* Sahdev et al.2011
Background
Therapeutical management:
oSurgery intervention curative / palliative
recurrence reintervention
oMitotane adjuvant /+EDP down-staging
Fig. 1-Survival rate correlated with stage at
oDrugs for the treatment of hormonal excess
diagnostic *Fassnacht et al, 2009
o Radiotherapy/ Local therapy adjuvant/ palliative / metastasis
oMetronomic therapy
oBiological therapy
Aim/objectives
Clinical data of all patients with ACC diagnosed and treated in the
Department of Endocrinology of Iasi, Romania between 2004 and
2013 were retrospectively reviewed.
Risk factors
Evaluated parameters:
Clinical presentation
Hormonal profile
Particularities in manifestation
Morphopathological features
Staging
Survival time
Therapeutical aproach
Recurrences and metastasis
Results/Discussions
Fig.7.Age distribution
years
years
40,6 years
51 years
years
Fig.8.Gender distribution
male
female
Female predominance(58,2%)
Results/Discussions
Fig.9.Tumour dimension in study group vs literature data
Tumour size
<=5 cm
6-10 cm
10-20 cm
>20 cm
4/8
4/8
Variation of
tumour dimension
unrelated with
patients evolution
29%
55%
Malignant
tumours are
usually >6 cm
Fig.10.Anatomopathological features
Metastasis
Invasion of veins
Invasion of capsule
Invazia of nearby organs
1/9
2/8
3/8
3/8
8/8
Necroses
Results/Discussions
incidentaloma
Cushing syndrome
virilisation
Inflamatory syndrome
Cushing syndrome+
virilisation
Hypertension+virilisation
Increased polimorphism
13 -
16,7%
Mass
efect
metastasis)
Systematic, complete evaluation of functional
Cushing syndrome
incidentalomas
virilisation
feminising
Mass efect
Palpable mass
Inflamatory syndrome
incidentaloma
Results/Discussions
Non functional
Cortisol
Androgens
Non functional
Estrogens
Altered glucocorticoid
secretion
Androgens
Cortisol+androgens
Estrogens
Aldosteron
Multiple secretion
Altered
glucocorticoid
secretion
Hormonal profile
Fig.12.Hormonal profile in study group
Results/Discussions
Treatment:
Suprarenalectomy:
Chemotherapy:
Doxorubicin, Cisplatin, Etoposid, Carboplatin, Farmorubicin
in association , adjuvant or for local or distant recurrences
1 patient exhibit a good response on chemotherapy , probably due to early diagnostic, stage II;
4 cases: temporary stabilization
FIRM-ACT trial:M-EDP :temporary stabilization in one IV stage case
Mitotane
Drugs for hormonal hypersecretion -1 caz-necomplianhypersecretioncomplicationsdeath
Radioterapy/local therapy- 2 cases-temporary control of liver metastasis
Results/Discussions
Fig.14.Secondary effects of Mitotane administration
*adrenal
Gastrointestinal
Adrenocortical insufficiency
Elevated liver enzymes
Dyslipidemia
Enzyme induction
Leucopenia
Trombocitopenia
Anemia
Results/Discussions
Fig.15.Postsurgical evolution: recurrences
Number of
recurrences
Local
case 1
case2
case3
case4
case5
case6
case7
case8
2(I, II)
1(I)
I, II, III
I, II, III
I, II
Controlateral
Sites of
adrenal
Liver
metastasis/
Bone
recurrences
I
I, II
Lung
Peritoneal
Pleural
I, II
Out
Dis
of
eas
reco
rd
free
Dise
I, II, III
ase
I, II, III
III
free
9
-
Di
se
as
e
fr
II
I
50 % local recurrence
50 % postsurgical metastasis
Fig.16.Metastasis sites
case
ee
Results/Discussions
Fig.15.Postsurgical evolution: recurrences
Number of
recurrences
Local
case 1
case2
case3
case4
case5
case6
case7
case8
2(I, II)
1(I)
I, II, III
I, II, III
I, II
Controlateral
Sites of
adrenal
Liver
metastasis/
Bone
recurrences
I
I, II
Lung
Peritoneal
Pleural
I, II
Out
Dis
of
eas
reco
rd
free
Dise
I, II, III
I, II, III
III
ase
free
9
-
Di
se
as
e
fr
II
I
50 % local recurrence
50 % postsurgical metastasis
Fig.16.Metastasis sites
case
ee
Results/Discussions
Fig.15.Postsurgical evolution: recurrences
Number of
recurrences
Local
case 1
case2
case3
case4
case5
case6
case7
case8
2(I, II)
1(I)
I, II, III
I, II, III
I, II
Controlateral
Sites of
adrenal
Liver
metastasis/
Bone
recurrences
I
I, II
Lung
Peritoneal
Pleural
I, II
Out
Dis
of
eas
reco
rd
free
Dise
I, II, III
ase
I, II, III
III
free
9
-
Di
se
as
e
fr
II
I
50 % local recurrence
50 % postsurgical metastasis
Fig.16.Metastasis sites
case
ee
Results/Discussions
Fig.18.Survival parameters
PFS
DFS
>18
>18
>11
>11
11
36
18
40
11
11
15 years
15years
15 years
Particular aspects:
Long term use of oral contraception in two patients history (over
10 years)
Survival time
PFS-Progression free survival
DFS-Disease free survival
Results/Discussions
Imaging evaluation:
o
o
o
Issues:
o Agressive and rapid evolution in 2 patients presenting recurrences within two months
after surgery
Would imagistic evaluation under 2 months in patients with high relapse risk
(advanced stage, capsular invasion, venous invasion, size >8 cm, Rx,1,2
postresectional status, Ki-67 index>10%) improve the overall survival?
o 1.2cm incidentaloma6 months imagistic reevaluation: 6 cm
o differential dianostic between pulmonary inflammatory lesions and metastasis:
2 patients responded to antibiotics treatment/ 1 patient had lung metastasis
Case presentation
D.P. 55 years
02. 2012
Incidentaloma-US
Asymptomatic
Estradiol+ DHEAs
CT- right adrenal masscentral necroses, invasion
of capsule, posible
infiltration of right kidney,
liver and bone metastasis
Diagnostic laparotomy
Weiss 6, positive
imunohistochemistry
staining
07.T4N1M1
2012 stage
Adrenalectomy+liver
metastasis resection,
lymph node resection
Renal or inferior vena
cava invasion have not
been identified
T4N0M1 stage
03. 2012
Wurzburg
Similar clinical
and paraclinical
features
EDP-M:first
04. 2012
05.2012
06.2012
2nd cure
Anemia
Neutropeni
a
CTstabilization
3rd cure
CT-stabilization
posible inferiour
vena cava and renal
invasion
Four th cure
cure
12. 2012
04. 2014
07. 2014
Conclusions
1) ACC is characterized by clinical, paraclinical and evolutive polymorphism
2) Imagistic evaluation:
1) Systematic evalation of adrenals
2) Adrenal imagistic reevaluation interval for under 5 cm incidentalomas shoud be reconsidered.
3) Frequent imagistic monitorization of pacients with elevated risc of recurrence might be usefull.
Thank you!
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