Original Article
Clinical Features of Adrenocortical Carcinoma, Prognostic Factors, and the Effect of Mitotane Therapy
N Engl J Med 1990; 322:1195-1201April 26, 1990
- Abstract
- Abstract
Adrenocortical carcinoma is a rare tumor, and only limited information is available about its natural history and the effects of therapy.
We studied 105 patients (75 female and 30 male; mean age, 46 years) with adrenocortical carcinoma who were referred to us between 1963 and 1987. The average duration of symptoms before diagnosis was 8.7 months. At the time of diagnosis, 68 percent of the patients had endocrine symptoms, and 30 percent had distant metastases. Hormonal studies showed that 79 percent of the tumors were functional. Eighty patients underwent surgery, and 59 also received the adrenal cytotoxic agent mitotane. The median disease-free interval after surgery was 12.1 months (range, 1 to 175). Tumor dissemination occurred in 82 percent of the patients, most commonly to the lung, liver, and adjacent organs. The median survival time was 14.5 months (range, <1 to 175), and the five-year survival was 22 percent. Age over 40 years and the presence of metastases at the time of diagnosis were the only factors recognized as indicating a poor prognosis. Mitotane controlled hormonal secretion in 75 percent of the patients. Eight mitotane-treated patients had partial tumor regression, but the drug did not have a significant effect on survival.
We conclude that adrenocortical carcinoma carries a poor prognosis. Mitotane therapy may offer transient benefits, particularly in controlling endocrine symptoms. (N Engl J Med 1990; 322:1195–201.)
Article Activity
- Article
ADRENOCORTICAL carcinoma is a rare tumor1 , 2 with a poor prognosis.3 4 5 6 Its true incidence is unknown,7 but according to the Third National Cancer Survey of 19758 the incidence is approximately 0.5 to 2 cases per million people per year, accounting for 0.2 percent of the deaths from cancer in the United States.1 , 2 , 9 , 10 The infrequent occurrence of this carcinoma precludes extensive clinical experience with its diagnosis and treatment, and reports of more than 50 patients from single or multiple centers are exceptional.3 4 5 , 9 , 11 12 13
Surgical resection is the treatment of choice,5 , 9 , 14 15 16 but the role of adjuvant chemotherapy is controversial.5 , 11 , 17 18 19 20 Mitotane (0,p′-DDD or 1,1-dichlorodiphenyldichloroethane), which was introduced in 1960,21 is the only drug that has been associated with cures, long-term remissions, regression of metastases, and increases in survival.9 , 14 , 21 22 23 However, there have been no randomized or controlled studies of its efficacy in prolonging survival. Furthermore, its use after apparently successful surgery, as has been proposed by some investigators,9 , 12 , 23 , 24 is controversial.
The objectives of this study were to describe the clinical and hormonal characteristics of 105 patients with adrenocortical carcinoma who were referred to a single center, to review the outcomes in the 88 patients who were treated and followed up at this same center, to identify potential prognostic factors, and to evaluate the effect of mitotane on the outcome in these patients.
Methods
Patients
One hundred five patients with adrenocortical carcinoma were referred to the Endocrine Department of the Hôpital Cochin from 1963 through 1987. These patients underwent clinical, radiologic, and hormonal evaluation. The diagnosis in each patient was confirmed by histologic examination of adrenal tumor tissue.
Follow-up
Eighty-eight patients were followed up at the same hospital by a single group of physicians for a mean of 24.9 months (median, 12; range, <1 to 175). Each patient underwent clinical evaluation four times a year, and hormonal and radiologic studies were performed twice a year.
Definitions
Patients were considered to have functional tumors if they had abnormal hormone levels in serum, urine, or both. The secretion of glucocorticoids was assessed by measurements of urinary excretion of 17-hydroxycorticosteroids, 17-ketosteroids, and cortisol, basally and after low-dose (2 mg per day) and high-dose (8 mg per day) dexamethasone suppression, and by the measurement of plasma cortisol concentrations every four hours. Androgen secretion was evaluated by the measurement of plasma testosterone, androstenedione, and dehydroepiandrosterone sulfate; estrogen secretion by the measurement of plasma estradiol-17β; and mineralocorticoid secretion by the measurement of plasma aldosterone and 11-desoxycorticosterone. We also measured plasma 17-hydroxyprogesterone and 11-desoxycortisol. Urinary excretion of 17-hydroxycorticosteroids and 17-ketosteroids was measured by the Porter—Silber and Zimmerman methods, respectively, urinary and plasma cortisol were measured by a competitive protein-binding assay,25 and the other plasma steroids were measured by specific radioimmunoassays in routine use at the time.
Staging at the time of diagnosis was based on clinical data and the results of radiologic studies, CT scanning, or both, and was corroborated by the findings at surgery and on pathological examination. Localized disease was defined as disease confined to one adrenal gland. Regional disease was defined as disease extending beyond the limits of the adrenal gland to the surrounding organs and tissues, including the regional lymph nodes. Metastatic disease was defined as disease in which there were distant metastases, whether regional disease was present or absent. In the patients who had no metastases initially, the disease-free interval was defined as the time between curative surgery and a local recurrence or the occurrence of distant metastases. Survival periods were calculated from the time of diagnosis. When possible, the extent of disease was measured on the roentgenograms, CT scans, or both. During follow-up, the diagnosis of distant metastases or local recurrences was based on clinical and radiologic findings and on examination at autopsy (of 67 patients who died, 13 were examined at autopsy). A partial regression was defined as a regression of the area of at least one measurable tumor deposit by more than 10 percent.
Treatment
Surgical Treatment
Of the 88 patients treated at the Hôpital Cochin, 80 underwent surgery; in 57 it was apparently curative. Eleven patients had second operations for local recurrences. Eight (seven female and one male patient; mean age, 44 years; range, 7.5 to 67) were judged to have inoperable tumors and were treated medically.
Mitotane Treatment
Fifty-nine of the 80 patients who underwent surgery received mitotane therapy at some time, after giving their informed consent (Table 1Table 1
Methods of Treatment in 80 Patients with Adrenocortical Carcinoma Who Underwent Surgery.). Twenty patients with Cushing's syndrome were treated with mitotane for one to six months before surgery, and 52 patients, including 13 of those treated preoperatively, were treated after surgery. In most patients mitotane therapy was continued until death, whether or not there was a response, a progression of disease, or a recurrence. Included among the 59 patients who received mitotane were 23 who received it after apparently curative surgery and 14 who received it only after recurrence of their disease.Mitotane (Roussel–UCLAF) was given by mouth, as capsules containing 0.5 g of micronized mitotane mixed with cellulose acetylphthalate. The mean initial dose was 10 g per day (range, 4 to 16). The mean maintenance dose (the daily dose used for the longest period during treatment) was 7 g per day (range, 3 to 20). The daily dose was given in three divided doses. The median duration of treatment was 10.5 months (range, 1 to 96). Thirty to 40 mg of cortisol and 50 μg of 9α–fluorocortisol were given daily with the mitotane, usually starting after the third week of mitotane treatment. This corticosteroid coverage was temporarily withdrawn at the time of each subsequent hormonal evaluation, to assess functional adrenal status. Most patients took mitotane without interruptions in treatment, and they were strongly encouraged at each visit to take the drug as prescribed.
From 1963 through 1970, 4 patients also were treated with chemotherapy, 11 with radiotherapy, and 14 with aminoglutethimide (Table 1).
Statistical Analysis
The statistical associations between pairs of variables were tested by the chi-square test, the Kruskall—Wallis test, and the Spearman rank correlation coefficient, as appropriate. All P values are two-tailed.
Survival rates were calculated by the Kaplan–Meier method26 and were compared with use of the Tarone—Ware statistic.27 The prognostic factors were evaluated with use of the Cox proportional-hazards model.28
Among the patients treated with mitotane, the heterogeneity of the therapeutic regimens precluded the definition of a treated and an untreated group. To evaluate the effect of mitotane therapy on survival, an additional analysis was performed with use of the time-dependent Cox proportional-hazards model.28 , 29 In this model, the variable for mitotane therapy was assigned a value of 1 from the beginning of the third month of therapy with the drug until two months after the end of each period of treatment. A value of 0 was assigned during the remaining months of follow-up. This two-month period reflected our best estimate of the delay in the action of mitotane after its initiation and the persistence of action after its cessation, based on the drug's known kinetics. The value of the variable for metastasis was 0 in the absence of metastases and 1 after a metastasis was found. This form of analysis was intended to deal with the problem of the heterogeneity of treatment periods among the treated patients, also taking into account the kinetics of mitotane.
Results
Clinical Characteristics and Initial Manifestations of Disease
The distribution according to sex and age of all 105 patients with adrenocortical carcinoma is shown in Figure 1Figure 1
Distribution of 105 Patients with Adrenocortical Carcinoma, According to Age and Sex.. The sex ratio (female to male) was 2.5, and the mean age was 46 years (range, 6 to 81). The male patients tended to be older than the female patients (P = 0.07). Table 2Table 2
Presenting Symptoms in 105 Patients with Adrenocortical Carcinoma. shows the initial clinical findings in these patients. Seventy-one patients (68 percent) were referred to us because of endocrine symptoms and signs that indicated excess secretion of glucocorticoids (in 32 patients), androgens (in 8 patients), glucocorticoids and androgens concomitantly (in 28 patients), mineralocorticoids (in 2 patients), or estrogens (in 1 male patient). Sixteen of these 71 patients also had local or systemic symptoms of neoplastic disease. In seven female patients, adrenocortical carcinoma was discovered during pregnancy because of glucocorticoid excess. In one patient, the abdominal mass was associated with symptomatic hypoglycemia.The functional status of the 105 carcinomas is shown in Table 3Table 3
Functional Status of 105 Adrenocortical Carcinomas, as Determined by the Measurement of Steroids in Plasma, Urine, or Both.. The sex ratio was 3.6 in the patients with functional tumors and 0.8 in those with nonfunctional tumors (P = 0.005). The most common abnormalities were concomitant hypersecretion of glucocorticoids and androgens (in 42 percent), hypersecretion of glucocorticoids alone (in 41 percent), and hypersecretion of androgens alone (in 10 percent). Androgen-secreting tumors were more frequent in the female patients (P = 0.003).The mean time from initial symptoms to diagnosis was 8.7 months (range, 0 to 53). This interval was similar in the male and female patients and in the patients with functional tumors and those with nonfunctional tumors. Fifty-two of the 105 carcinomas (50 percent) involved the left adrenal gland, and 49 (47 percent) the right; in three patients, both adrenal glands were involved. One patient presented with a carcinoma in the pelvis; presumably, it originated in ectopic adrenal tissue. Of 76 tumors, the mean tumor weight was 532 g (range, 14 to 3000).
Among the 88 patients followed up in our center, 45 were found to have local disease (51 percent), 17 regional disease (19 percent), and 26 metastatic disease (30 percent). Eleven patients in the last group had associated regional disease. The ratio of functional to nonfunctional tumors was similar in each of the three stages.
Follow-up Studies and Survival
Among the 57 patients who underwent curative surgery, the median disease-free interval was 12.1 months (range, 1 to 175). The intervals were similar in the patients with functional and those with nonfunctional tumors. The presence of regional disease at the time of diagnosis was associated with a significantly shorter disease-free interval (P = 0.024).
Among the 88 patients followed up, the most common sites of tumor dissemination were the liver (43 patients), the lung (43), and organs or tissues adjacent to the adrenal glands (41). Less common sites of disease were bone (13 patients), pancreas (4), small bowel (3), brain (2), ovary (1), orbit (1), skin (1), pleura (1), spleen (1), and contralateral adrenal gland (1). The most common combination was of the lung and liver (22 patients).
Of the 67 patients who died, the majority (82 percent) died with metastastic disease. In this group, eight patients had mediastinal compression, seven had an inferior vena cava syndrome, five had neurologic complications, four had gastrointestinal hemorrhage, one had hepatic coma, and one had septicemia. Eight patients (10 percent of the patients who underwent surgery) died of acute surgical complications — cardiovascular collapse in five, pulmonary edema in one, and pulmonary embolism in two.
Figure 2Figure 2
Actuarial Survival Rates from the Time of Diagnosis in 88 Patients with Adrenocortical Carcinoma. shows the actuarial survival data for the 88 patients. The median survival time was 14.5 months (range, <1 to 175). At five years, 22 percent of the patients were alive. There was no statistically significant difference in survival with regard to sex or the functional status or weight of tumors. In contrast, survival was significantly lower in the patients over 40 years old and in those with distant metastases at the time of diagnosis (Fig. 3Figure 3
Actuarial Survival Rates from the Time of Diagnosis in 88 Patients with Adrenocortical Carcinoma, According to Age and Initial Staging.).Evaluation of Treatment
We evaluated the efficacy of mitotane in regard to hormonal response, tumor response, and survival from the time of diagnosis. Fifty-nine of the 80 patients who had surgery received mitotane (Table 1) —45 soon after diagnosis, and 14 at the time of relapse. In the 45 patients who were treated before surgery, immediately afterward, or both, mitotane therapy was not found to be associated with the year of entry into the study, sex, tumor weight, functional-tumor status, or disease stage at diagnosis. However, the patients who received mitotane were younger than those who did not (P = 0.02). Twenty-three patients received mitotane despite having had apparently curative surgery.
Of the 59 patients treated with mitotane in whom the responses were evaluated, 47 had functional tumors and 12 had nonfunctional tumors. These patients all had adrenal insufficiency, which was permanent in 75 percent of them. Fourteen patients whose tumors were initially functional had recurrences of hormone hypersecretion when distant metastases or local recurrences developed. In one patient with a mixed excess of glucocorticoids and androgens, only cortisol secretion decreased during mitotane therapy.
Tumor response was evaluated in 37 patients with measurable disease who were treated with mitotane for at least two months. Twenty-seven of these patients had tumor progression, two had stabilization of their disease (during 36 to 56 months of therapy, respectively), and eight had tumor regression. In all eight the regression was transient. Details of the responses of these eight patients are shown in Table 4Table 4
Extent of Tumor Regression during Mitotane Therapy in Eight Patients with Adrenocortical Carcinoma.; none of them received other therapy. Tumor regression occurred only in patients who received mitotane therapy.To evaluate the influence of treatment on survival, the Cox proportional-hazards model was used, with treatment and the presence of metastasis as time-dependent covariates. The results of this analysis are shown in Table 5Table 5
Multivariate Analysis of Survival Using the Cox Proportional-Hazards Model.*. Only age (P = 0.06) and the presence of metastasis (P = 0.0001) were found to influence cumulative survival independently. The effect of mitotane therapy on survival was not significant (P = 0.24).Side Effects
Twelve patients had side effects of sufficient severity to require a reduction or temporary withdrawal of mitotane therapy; in three patients the drug was withdrawn permanently. The major side effects were gastrointestinal symptoms, such as anorexia, nausea, and vomiting (eight patients), and neurologic disturbances, such as ataxia, speech difficulty, somnolence, vertigo, and lethargy (eight patients). Most patients had hepatic disturbances, including increases in serum levels of alkaline phosphatase, aspartate aminotransferase, alanine aminotransferase, and gamma glutamyl transferase activity; increases in the serum levels of corticosteroid-binding globulin and sex-hormone—binding globulin; hypercholesterolemia; and hypouricemia; some patients had low serum concentrations of total thyroxine, free thyroxine, or both, but normal concentrations of thyroid-stimulating hormone. Gynecomastia developed in 7 of the 21 male patients who were treated with mitotane.
Discussion
Our study of 105 patients with adrenocortical carcinoma from a single center confirms previous reports4 , 9 , 11 , 24 , 30 , 31 that the majority of patients with adrenocortical carcinoma are female (sex ratio, 2.5). This tumor occurs at all ages; however, the male patients tended to be older than the female patients. In children, adrenocortical carcinomas are uncommon,31 often manifested by a virilizing syndrome,32 33 34 35 36 37 and sometimes associated with other cancers or congenital malformations, such as hemihypertrophy or visceromegaly.38 39 40
Whereas some reports indicate the predominant site to be the left adrenal gland,16 , 24 , 41 we found the numbers of tumors in each adrenal gland to be similar.3 , 19 , 42 Ectopic43 and bilatera14 , 10 , 15 , 29 carcinomas are extremely rare. The tumors are generally large44 45 46; in our series, 84 percent weighed more than 100 g. On the basis of hormonal assays, 79 percent of our patients had functional tumors. Among them were 12 patients who had no clinical manifestations of hormone hypersecretion, some of whose tumors produced only steroid precursors.47 Estrogen-secreting adrenocortical carcinomas are rare, and occur almost exclusively in male patients48 , 49; only one of our patients had such a tumor, and it secreted other hormones in addition to estrogen.
The most common clinical presentation was an endocrine syndrome, usually Cushing's syndrome, either in isolation or associated with virilizing features.4 , 9 , 24 , 42 Hyperaldosteronism is unusual.50 51 52 53 54 55 The clinical presentation was nonendocrine in 31 percent of the patients, which is a lower proportion than has been described in some reports5 , 15 , 16 , 24 but higher than has been described in others.11 , 56 In the literature, the mean time from the onset of symptoms to the diagnosis of tumor ranges from 6 to 14 months2 , 11 , 16 , 40; in our series, this interval was 9 months. The interval was not shorter in patients with functional tumors, as has been proposed previously5 , 24; and as reported by Bertagna and Orth,11 this interval was similar in female and male patients.
The diagnosis of adrenocortical cancer was made in 14 women during pregnancy. The discovery of Cushing's syndrome during pregnancy is uncommon, presumably because it often results in infertility. Since Cushing's disease is the most frequent cause of hypercortisolism in young women, the preponderance of adrenal tumors as the cause of this condition in pregnant women is surprising.57 , 58
A high proportion of the patients described (50 to 80 percent) have had metastatic disease at the time of diagnosis5 , 12 , 16; in the present series, the proportion was somewhat smaller (30 percent). Metastatic disease ultimately developed in the majority of patients (82 percent), frequently involving the lung, liver, and organs or tissues adjacent to the adrenal gland. Among the 57 patients in this series who underwent curative surgery, the median disease-free interval was 12.1 months (range, 1 to 175), which is similar to the interval reported by Nader et al.5 In three patients the interval was exceptionally long —more than 10 years.59 , 60
Like others,4 , 5 , 7 , 12 , 16 we found the prognosis of patients with adrenocortical carcinoma to be poor, with the five-year survival rates ranging between 20 and 30 percent in the more recent studies.5 , 15 , 16 Didolkar et al.16 identified sex and tumor stage as prognostic factors. Our results confirm the prognostic value of staging. We also found an influence of age. Like others, however, we found no effect of sex or of the weight5 , 41 or functional status5 , 14 , 41 of the tumor.
The first therapeutic approach to adrenocortical carcinoma is surgical resection,7 , 9 , 14 15 16 , 22 , 61 even in patients with extensive metastatic disease. Radiotherapy is ineffective and should be considered only as palliative treatment for metastatic disease.10 , 22 , 24 , 41 , 45 , 62 Adjuvant chemotherapy has been used to control hormonal excess and induce tumor regression. The experience with cytotoxic agents other than mitotane is limited, and their effects are uncertain.20 , 63 64 65 Drugs that block the synthesis of steroids, such as metyrapone, aminoglutethimide, and more recently ketoconazole, or that block the action of steroids in their target tissue, such as antiandrogen agents, antimineralocorticoid agents, and more recently antiglucocorticoid agents such as mifepristone (RU 486), may be of benefit in controlling the clinical manifestations induced by hypersecretory tumors; none have been reported to inhibit tumor growth. Mitotane has been used extensively because of its specific cytotoxic effect. In most retrospective studies, it was used only in patients with inoperable tumors.9 , 14 Its antineoplastic action has been considered to be unpredictable, inconsistent, restricted, and transient.5 , 11 , 17 , 19 , 44 , 66 With the exception of van Slooten et al.,12 who measured serum mitotane levels, to our knowledge no previous investigators have documented improved survival as a result of mitotane therapy.2 , 7 The main limitations of previous reports9 , 14 , 21 have been the absence of a control group and the lack of details about staging, previous treatment, and the time of the initiation of mitotane therapy.
Our retrospective analysis has some obvious, unavoidable limitations. In this study, which started 26 years ago, treatment was not assigned at random. Therefore, our first step was to search for any possible factor that could bias the assessment of survival. The two groups of patients were comparable, with the sole exception of age. The use of the time-dependent Cox proportional-hazards model was prompted by the need to solve the problem of group assignment. This approach should reduce bias but is unlikely to eradicate it. A positive bias may result from the fact that the patients treated soon after diagnosis were younger than those who were not treated until they had a recurrence. Conversely, a negative bias is likely to result from the use of mitotane in the patients who were doing worse (those who had metastases). We found that mitotane prolonged survival slightly but not significantly. Moreover, eight patients had objective tumor regression, as has been reported by others.2 , 23 , 59 , 67 68 69 70 71 72 73 74 No regression occurred in patients not treated with the drug. These observations suggest that in some patients, at least, mitotane is beneficial. It controlled endocrine hypersecretion in 75 percent of the patients, as reported elsewhere.9 , 17 , 67 Patient compliance was high, as indicated by the frequency of adrenal insufficiency and abnormalities in liver function or serum lipid or uric acid concentrations. The side effects of mitotane were minimal, contrary to what others have reported.9 , 14 , 17 , 75 76 77 This difference in side effects may be explained by differences in drug formulations.62 , 78
In view of these findings, and despite the lack of a significant effect on survival, we believe that mitotane should be used as adjuvant therapy after aggressive surgery and as a reference treatment in controlled trials with other drugs in patients with adrenocortical carcinoma.
We are indebted to Dr. Christine Bertagna for careful review of the manuscript and to Ms. Dominique Guiban, Ms. Michèle Le Scouarnec, Ms. Marie-Claude Rizzo, and Ms. Laurette Vasselier for assistance in the preparation of the manuscript.
Source Information
From the Clinique des Maladies Endocriniennes et Métaboliques (J.-P.L., S.C., L.B., B.G., X.B., H.B.), the Laboratoire d'Hormonologie (M.-H.L), the Service d'Anatomo-pathologic (A.L.), the Clinique Chirurgicale (Y.C.), and the Service de radiologic A (A.B.), Hôpital Cochin; the Département de Toxicologie Clinique, Hôpital Fernand Widal (G.T.); and Chirurgie IV, Hôpital Broussais (P.B.), all in Paris. Address reprint requests to Dr. Luton at the Clinique des Maladies Endocriniennes et Métaboliques, Hôpital Cochin, 27, rue du Faubourg Saint Jacques, 75674 Paris Cedex 14, France.
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