Adrenocortical Carcinoma Clinical and Laboratory Observations

Bernardo Leo Wajchenberg, M.D.1 Maria A. Albergaria Pereira, M.D.1 Berenice B. Medonca, M.D.1 Ana C. Latronico, M.D.1

Paulo Campos Carneiro, M.D.2 Venancio A. Ferreira Alves, M.D.2 Maria Claudia N. Zerbini, M.D.2 Bernardo Liberman, M.D.2 Gilberto Carlos Gomes, M.D.3 Marvin A. Kirschner, M.D.4

1 Endocrine Service, Hospital Das Clinicas, Sao Paulo, Brazil.

2 Department of Pathology University of Sao Paulo School of Medicine, Sao Paulo, Brazil.

3 Radiology Department, Hospital Das Clinicas, Sao Paulo, Brazil.

4 Division of Endocrinology, UMDNJ-New Jersey Medical School, Newark, New Jersey.

Address for reprints: Marvin A. Kirchner, M.D., Division of Endocrinology, UMDNJ-New Jersey Medical School, MSB1-588, 185 South Orange Avenue, Newark, NJ 07103.

Received May 6, 1999; revision received Septem- ber 15, 1999; accepted October 25, 1999.

BACKGROUND. The clinical features and natural history of adrenocortical carci- noma are highly dependent on the type of center reporting their experience. Observations from oncology services suggest a high incidence of nonfunctioning tumors, whereas reports from endocrine clinics emphasize excessive corticoid and androgen production in the majority of tumors. The incidence rate and natural history of childhood adrenal carcinoma generally has been under emphasized. METHODS. Over the past 17 years, the authors have evaluated and treated 47 patients with adrenocortical carcinoma referred to the University of Sao Paulo, 22 of whom were children.

RESULTS. There is a bimodal age incidence of adrenal carcinoma, with the disease peaking in the first and fourth decades of life. Childhood adrenal carcinoma is characterized by a high rate of incidence of virilization, marked overproduction of androgens, and a less aggressive clinical course, and appears to be more amenable to surgical and other therapeutic modalities. By contrast, adrenocortical carcinoma occurring in adults presents more commonly as a mixed Cushing and virilizing syndrome, with overproduction of corticoids and androgens and a far more ag- gressive clinical course, leading to rapid death within months or years. Nonfunc- tioning adrenocortical carcinoma is less common; it generally occurs in older adults and exhibits a rapid downhill course. Modern day imaging methods have improved the diagnosis and staging of adrenal carcinoma greatly. In the authors’ experience, the histologic criteria of Weiss appeared to predict tumor prognosis most accurately, whereas immunologic markers, cytoskeletal markers, DNA ploidy, cell phase markers, and oncogenic probes have yielded inconsistent results to date. Surgical removal of a localized tumor remains the best hope for long term survival. Medical therapy with mitotane and its successors in patients with Stage III or IV (MacFarlane system as modified by Sullivan et al.) disease appear to have added little to longevity or quality of life.

CONCLUSIONS. When diagnosed in children, adrenal carcinoma is associated with virilism and a less aggressive natural history; however, when it occurs in adults, the disease presents more commonly as a mixed Cushing-virilizing syndrome and has a virulent course. The Weiss histologic criteria appear to correlate best with disease prognosis, but other histochemical, cell cycle, and genetic markers have not, to date, aided in disease management. Cancer 2000;88:711-36. @ 2000 American Cancer Society.

KEYWORDS: adrenal carcinoma, adrenocortical carcinoma, virilization, childhood virilization, mitotane.

A drenal cortical carcinoma is rare and can develop at any age in either sex.1 We have had the opportunity to evaluate and treat 47 patients with adrenal cortical carcinoma at the Hospital das Clinicas of the University of Sao Paulo Medical School over the past 17 years. In this report, we compare our findings with other reported studies,

TABLE 1 Epidemiologic and Clinical Parameters and their Relative Frequencies in Patients with Adrenal Cortical Carcinomas
Author/yr	No. of patients	Age at diagnosis (yrs)		Sex (%)		White race (%)	Mean duration (months)	NF (%)	F (%)
Author/yr	No. of patients	Mean	<10 yrs (%)	Male	Female	White race (%)	Mean duration (months)	NF (%)	F (%)
King and Lack, 197913	49	34	?	53	47	100	6.6	64	36
Bertagna and Orth, 19818	32	38	15	28	72	?	16	34	66
Nader et al., 198311	77	36	?	51	49	74	?	66	34
Henley et al., 198314	62	50	2	42	58	?	9	42	58
Karakousis et al., 198515	38	51	0	60	40	?	?	74	26
Cohn et al., 198612	47	43	?	45	55	?	?	28	72
Bodie et al., 198910	82	47	6	50	50	100	?	51	49
Venkatesh et al., 198916	110	42	?	47	53	?	?	64+-	36
Luton et al., 19909	105	46	2	29	71	?	8,7	32	68
Pommier and Brennan, 199217	73	40	1	38	62	?	?	40	60
Icard et al., 199218	41	42	0	30	70	?	10	29	71
Soreide et al., 199227	99	54	2	58	42	?	?	57	43
Zografos et al., 199419	53	51	0	57	43	?	21	61	39
Kasperlik et al., 199520	52	40	0	29	81	?	?	25	75
Current report, 1999	47	20	47	21	79	98	11	6	94
NF: nonfunctional; F: functional.

emphasizing the clinical presentation, radiologic and pathologic findings, molecular markers, and outcome in both children and adults. We separate adrenocor- tical carcinomas occurring in children from those oc- curring in adults, because the clinical features, labo- ratory findings, and clinical course of childhood adrenal carcinoma is different from that of adults.2 Our objective was to identify potential prognostic fac- tors for adrenocortical carcinoma in both children and adults.

Epidemiologic Features: Age, Gender and Race

Data obtained from several Cancer Registries in the United States indicate an approximate incidence rate of adrenocortical carcinoma of 0 .- 2.0 cases per million persons per year.3-6 These tumors are responsible for 0.2% of cancer deaths in the United States.3-7 Because of the low incidence rates, few cancer registries have had sufficient numbers of patients prior to 1968 for reasonable demographic analyses. Since the 1970s, several groups have reported larger series, enabling a better understanding of the clinical aspects and natu- ral history of the tumor.

Demographic and clinical data from several au- thors, including 47 cases studied at University of Sao Paulo over the last 17 years,3,8-20 are shown in Table 1. The mean age at diagnosis from one study to the next ranged from 20 years to 54 years, probably reflecting the type of endocrine service reporting. The majority of centers did not see children, or children constituted a very small percentage of the overall cases reported.

Our series had the lowest mean age of 20 years, be- cause approximately 50% of our patients were age < 10 years. Wooten and King21 reviewed cases published in English from 1952 to 1992 and demonstrated a bimodal distribution in incidence of adrenal carci- noma with peaks in the first and fourth decades of life, virtually identical to our series (see Fig. 1). The high incidence of adrenocortical malignancy in children was observed previously by Brazilian investigators working in all-age endocrine clinics like ours located in southeast Brazil.22-24

The age of patients seems to be quite important in adrenal carcinoma, because age appears to influence prognosis. Several studies have reported that children with nonmetastatic adrenocortical carcinoma at the time of diagnosis have a better prognosis after com- plete tumor resection compared with adults with the same type of pathology who undergo the same treat- ment.25-27 Adults show a skew toward a more aggres- sive tumor with shorter prognosis.12,14,17,18 Two pub- lications have suggested that young adults have a better prognosis than those age > 40 years.9,27 In our series, 20 of 47 patients with adrenocortical carcinoma had metastases at the time of diagnosis or during a follow-up period of 3-48 months after surgery on the primary tumor. Seventeen patients were adults age > 18 years, whereas only 3 patients were children (ages 2.5 years, 4.5 years, and 9 years). Of the 27 patients in our series who did not exhibit metastases at initial surgery, the mean age was 10 ± 14 years. Seventy percent of our patients with a favorable clinical course

FIGURE 1. Age distribution of patients with adrenal cortical carcinoma seen at Hospital das Clinicas, University of Sao Paolo Medical School. The bimodal age distribution parallels that in the previous report by Wooten and King.21

NUMBER OF PATIENTS

☒ MALE

FEMALE

Ist

2nd

3rd

4 th

5 th

6 th

7th DECADE

were children age < 7 years. Therefore, the predictive value of young age and favorable prognosis is evident from the evaluation of our data and similar reviews in the literature.11,27-32

The distribution of sex among patients with adre- nal carcinoma appears to vary in different series. Ta- ble 1 shows that some series had an equal distribution of both sexes, whereas other series had a predomi- nance of women. In only a few reports, there was a male predominance.8-11,20,27 This discrepancy be- tween series may be related to the type of service providing the epidemiologic data, with endocrine clin- ics reporting a female predominance and oncology services reporting a male predominance or an equal distribution of both sexes. In patients with functional tumors exhibiting hypercortisolism and/or hyperan- drogenism, there appears to be a female predomi- nance. In our service, there was a female-to-male pre- dominance of adrenal carcinoma patients of 4:1. The majority of publications reported no correlation be- tween survival and sex of the patient,10-14,17,18 whereas a few studies suggested a better survival rate in wom- en.20,23 In our series, most patients were women, pre- cluding an assessment of survival versus sex.

At present, there is little data on racial and/or ethnic characteristics in patients with adrenal cortical carcinoma. Some studies suggest a predominance of whites over blacks and Asians among those patients with adrenocortical carcinoma.11,13,33 In the current series, there was a predominance of white patients with adrenal carcinoma. Considering that ~50% of the Brazilian population is black or mixed (mulatto), these

data suggest a greater susceptibility of whites for the development of adrenal cortical cancer.

Clinical Features of Patients with Adrenal Carcinoma

Adrenal tumors can be classified as functional (FT) when their hormonal secretions result in clinical con- sequences: Cushing syndrome (CS), virilization syn- drome (VS), feminization syndrome (FS), or a mixed Cushing-virilizing syndrome (CVS). Tumors are con- sidered nonfunctional (NF) when the tumors do not secrete excessive hormones or produce hormonal pre- cursors and/or active hormones in quantities insuffi- cient to have clinical consequences. Such tumors still may secrete excessive amounts of steroids detected during laboratory evaluations.32,34 It should be noted that androgen-secreting tumors in men and estrogen- secreting tumors in women may not result in clinically significant syndromes, and both could be considered as NF. Furthermore, the clinical picture of a patient with an adrenal tumor may change due to either quantitative and/or qualitative changes in hormone production during the natural history of the tumor such that a clinically NF tumor could become an FT tumor or a clinical picture could change.35-37

A review of previous reports on patients with ad- renal carcinoma suggest that the clinical presentation varies based on whether the report comes from an endocrine clinic or an oncologic service. FT carci- noma, as might be predicted, is reported more com- monly from endocrine clinics, whereas, in surgical or oncologic services, there is a greater prevalence of NF carcinoma, or FT and NF are equal. In our series of 47

TABLE 2 Comparison of Clinical Features of 47 Patients with Adrenal Cortical Carcinoma Seen at the Hospital das Clinicas
Patients	Virilization	Cushing	Mixed	Nonfunctioning tumors
Children	13	0	9	0
Adults	4	3	15	3

patients with adrenal carcinoma, 44 had FT tumors, and only 3 were NF. By contrast, Wooten and King21 reported 59% FT tumors and 41% NF tumors in their survey. In that study, the correlation between hor- mone production and patient age showed that 85% of the NF tumors occurred in patients age > 30 years, and 57% of the FT tumors were present in patients age < 30 years.21 They concluded that FT tumors are more common in patients age < 30, and, in this age range, they are more common in women. NF tumors are predominant in patients age > 30 years and are more frequent in men.21 NF tumors are quite rare in children.25,26,28,38,39 In the current series, 44 of 47 pa- tients had FT tumors, and only 3 had NF tumors. The relation between age, gender, and functionality could not be evaluated because only 3 carcinoma patients had NF tumors, and all three were adults.

The clinical features of our 47 patients with adre- nal carcinoma are presented in Table 2. In children, the predominant picture is that of virilization (13 cases) followed in frequency by CVS (9 cases). Pure CS is rare as a manifestation of adrenal carcinoma in children.39 None of the children in the current study had features of “pure” CS or feminizing features, and none of the children had NF tumors.

In adults with FT adenocarcinoma of the adrenals (Table 2), the presentation was more frequently that of a mixed hormonal syndrome of hypercortisolism and virilization (CVS) (15 patients) with isolated viriliza- tion (VS) (4 patients), and “pure” CS (3 patients) less common.9,12,14-19,28 The syndrome of isolated primary hypermineralocorticism is quite rare in adrenal carci- noma.40-42 and was not present in any of the patients in the current study.

Considering children and adults together, we found that 63% of the patients with mixed hormonal syndromes and 100% of the patients with CS occurred were adults, whereas 76% of the patients with VS were children. These data are in complete agreement with literature cited above.

Hypertension was found to be quite common in our patients with adrenal carcinoma. In our 24 pa- tients with CVS, 13 of 15 adults and 8 of 9 children were hypertensive. In 17 patients with virilizing tu-

mors (VS), 3 of 4 adults and 9 of 13 children were hypertensive. All 3 patients with CS were hypertensive. Thus, in the total series of patients with FT adrenal carcinomas, 36 of 44 patients had elevated arterial blood pressure. The hypertension may be related to glucocorticoid and/or mineralocorticoid excess and/or activation of the renin-angiotensin system from tumor compression of the renal vascular sys- tem.19,33 If hypertension is present, then there usually is an improvement after tumor removal. In our 3 pa- tients with NF adrenal carcinoma, none had arterial hypertension.

Fasting or postabsorptive hypoglycemia also can be present in adrenal carcinoma and is dependent primarily on excessive tumor production of “big” in- sulin-like growth factor II (IGF-II), probably due to incomplete processing of pro-IGF-II. This growth fac- tor exerts insulin-like activity, acting on the insulin receptor.9,14,20,43,44 No patients in our series exhibited hypoglycemia.

Unusual endocrinologic manifestations reported in adrenal carcinoma include acromegaly and inap- propriate secretion of antidiuretic hormone, suggest- ing ectopic hormone production:20,45 None of these was present in our series. Adrenal carcinoma also can present other clinical manifestations independent of hormone production but related to tumor growth. The most common complaint is that of abdominal pain accompanied by a palpable tumor. Other clinical fea- tures include weight loss, weakness, and nonspecific gastrointestinal symptoms of anorexia, nausea, eme- sis, flatulence, epigastric pain, and myalgias.9,13- 16,19,20,28,46-48 The occurrence of fever has been re- ported by several authors, but its significance is obscure, possibly related either to tumor necrosis, in- tratumor hemorrhage, and/or opportunistic infec- tions. 49-51

Unusual clinical manifestations reported in patients with adrenocortical carcinoma include hematuria,15,18,47 lower extremity edema, Budd-Chiari syndrome,52,53 acute abdominal pain,55 pelvic complaints,55,56 urinary obstruction, and paraplegia.8 Dyspnea and thoracic pain47 may occur due to exaggerated tumor growth, its rupture and intratumor or retroperitoneal bleeding, or the development of metastases. In the current series, only 3 patients had NF carcinoma, and the clinical man- ifestations were abdominal pain and palpable tumor mass.

Natural History of Adrenal Cortical Carcinoma Subtypes

The correlation between clinical manifestations of ad- renocortical carcinoma and survival has been well studied in the literature; the majority of authors sug- gest that the prognosis for patients is not related to

TABLE 3 Clinical Staging Compared with Prognosis in 47 Patients with Adrenocortical Carcinoma
Stage (no.)	Age (yrs)		Clinical syndrome				Survival
Stage (no.)	Children	Adults	VS	CVS	CS	NF	Survival
I (9)	8	1	5	4	0	0	All > 45 months
II (23)	13	10	11	10	1	1	74% no recurrence after 65 months
III (3)	0	3	0	2	1	1	1 of 3 tumor recurrence after 36 months
IV (11)	2	9	0	9	0	2	10 of 11 dead after 24 months

VS: virilization syndrome; CVS: Cushing-virilizing syndrome; CS: Cushing syndrome; NF: nonfunctional.

tumor functionality,9,10,13,14,16-18,25,28,33 although Kara- kousis et al.15 and Hogan et al.28 suggested that FT malignant tumors exhibited a better prognosis than NF adrenal tumors.

We observed that 26 of 27 patients whose course was less aggressive had VS FT tumors, whereas, of 20 patients with aggressive disease, 15 had a CVS presen- tation. Our data suggest that, independent of tumor histology, the benign clinical course is seen more commonly in patients with a pure VS, 81% of whom were children. Patients with a mixed syndrome (CVS) had the more aggressive natural history, 63% of whom were adults. The small number of NF adrenal carcino- mas in our series did not allow generalizations regard- ing the clinical behavior of this type of tumor.

The duration of clinical symptoms prior to diag- nosis is another feature that influences the prognosis for patients with adrenocortical carcinoma. The mean duration from the onset of symptoms to the time of diagnosis of adrenal cortical carcinoma ranges from 6 months to 16 months.9,13,14 This time interval appears to be independent of tumor type, either FT or NF. Even FT tumors take a long time to increase hormone production to levels resulting in clinical syndromes because of inefficient steroid synthesis within the tu- mors.12,17,18,28,57 In our series, the time lag from symp- tom onset to diagnosis was 9 ± 7 months in the patients with less aggressive carcinoma and 11 ± 8 months in patients who developed metastatic disease.

Another consideration in the natural history of adrenal cortical carcinoma is the association with other tumors or pathologies. Venkatesh et al.16 pub- lished a series of 100 patients with adrenal carcinoma and showed that 13 patients had a second primary tumor and one patient had a third tumor. The most frequent secondary tumors appeared to be breast car- cinoma, thyroid carcinoma, and melanoma. Adrenal cortical carcinoma also has been described in families with histories of other types of tumors.58 The associ- ation of adrenal cortical carcinoma with congenital

malformations, such as hemihypertrophy and viscer- omegaly, also has been described.59,60

Tumor Staging and Prognosis

The staging system for patients with adrenocortical carcinoma originally proposed by MacFarlane61 and modified by Sullivan et al.62 is used frequently. Pa- tients with Stage I and II disease presented with tumor confined to the adrenal gland without local invasion or distant metastases and with a greatest tumor di- mension of <5 cm (Stage I) or >5 cm (stage II), re- spectively. Patients with these tumors have the best chance of cure with surgical excision. When there is local tumor invasion that does not involve adjacent organs or regional lymph nodes, the tumor is consid- ered to be Stage III. In Stage IV disease, there is distant metastases or invasion into adjacent organs plus re- gional lymph nodes. In the majority of reports of ad- renal carcinoma, the tumors generally are in an ad- vanced stage (Stage IV) of disease.10,14,16,17,19,20,28 In the review of Wooten and King,21 3% of patients were classified with Stage I disease, 29% Stage II, 19% were classified with Stage III disease, and 49% were classi- fied with Stage IV disease. Richie and Gittes63 noted that most male patients are diagnosed in the more advanced stages of the disease compared with women, in whom the diagnosis happens at earlier stages.28 Younger patients tend to have disease of lower tumor stages.63 In children, Stage IV disease was observed in few cases,22 explaining at least in part the better prognosis for children age < 10 years.

The correlation between disease stage and sur- vival after diagnosis demonstrated no differences in survival of patients with Stage I or II disease, but survival was reduced greatly in patients with Stage IV disease.29-62,64-70 The survival of patients with Stage III disease appears to be intermediate.10,14,17,28,33

Forty-six of 47 patients with adrenocortical carci- noma in the current study could be staged from avail- able clinical data. These data are summarized in Table

FIGURE 2. Steroid profiles in 21 children with adrenal carcinoma exhibiting varying clinical syndromes. The patients were from our series. The abbreviations refer to the following steroidal hormones. T: testosterone; DHEAS: dehydroepiandrosterone sulfate; DHEA: dehydro- epiandrosterone; A: androstenedione; S: 11 deoxycorti- sol; Aldo: aldosterone; E2: estradiol; 170H P: 17 æ-hy- droxyprogesterone; cortisol after DEX: serum cortisol measured after 2 days of 2 mg exogenous dexametha- sone; ng/dL: nanograms per deciliter; µg/dL: micro- grams per deciliter; pg/mL: picograms per mL (refers to the Y axis of the left side). The scale on the right side refers to serum cortisol values. For details, see text.

5000

4000

3000

2000

1000

Virilizing Syndrome

800

Normal Range

Mixed Cushing’s and Virilizing Group

600

400

200

△

DHEAS

DHEA ng/dl

Aldo ng/dl

170HP

CORTISOL (ug/dl)

ng/dl

4g/mL

ng/dL

ng/dl

pg/mL

ng/dl

Basal

After Dex

3, demonstrating earlier stages in children manifesting virilizing syndromes. Stage IV patients were chiefly adults, exhibiting mixed (CVS) clinical syndromes and exhibiting poor prognoses, with 10 of 11 patients hav- ing succumbed after 24 months. Our data clearly sup- port the hypothesis that higher stage tumors are asso- ciated with a poor prognosis.

BIOCHEMICAL AND HORMONAL FINDINGS IN CHILDREN AND ADULTS

Biochemical Abnormalities

Fasting hyperglycemia, which occurs in 15% of pa- tients with CS,71 was observed in only 2 of 34 patients in our series. Hypokalemia, which is frequent in ec- topic adrenocorticotropic hormone (ACTH) syn- dromes but uncommon in other etiologies of CS, was observed in 2 of 34 patients, both of whom had a mixed CVS picture.

Hormonal Findings

There have been numerous studies reporting steroid hormones in adrenocortical carcinoma.8,22,25,57,72-75 Detailed hormonal studies were performed in 46 of our patients and compared with previously recorded series. The hormonal data from children and adults with adrenocortical carcinoma were collated sepa- rately and are shown in Figures 2 and 3, respectively.

Children with adrenocortical carcinoma

Twenty-two of 47 patients with adrenocortical carci- noma were children, of these 13 demonstrated chiefly virilizing features. The serum hormone levels in our children with adenocortical carcinoma are presented in Figure 2. All children with virilizing features had elevated serum testosterone levels ranging from 30 ng/dL to 2300 ng/dL. The serum T levels were higher in those children with pure virilizing symptoms com- pared with the mixed CVS picture, as expected. Simi- larly androstenedione (A) and dehydroepiandros- terone (DHEA) were elevated in all children, with higher values in the pure virilizing picture compared with mixed CVS. dehydroepiandrosterone sulfate (DHEAS) levels were elevated in ~50% of the children studied as well as compound S and 17OHP. By con- trast, aldo, E-2, and cortisol parameters all were nor- mal in the children.

Adults with adrenocortical carcinoma

In the 25 adults with adrenal carcinoma in whom measurements were made, the hormonal pattern re- sembled more of a scattergram, as shown in Figure 3, but the findings largely conformed to the clinical fea- tures of the patients. In two patients who exhibited CS features only, serum cortisol levels were elevated as well as compound S, but serum 17 OHP, DHEAS, and

FIGURE 3. Steroid profiles in 25 adult patients with adrenal carcinoma from our series. For steroidal ab- breviations, see the legend to FIGURE 2. For details, see text.

4300

· Virilizing Syndrome

3300

· Cushing Syndrome

2300

A Mixed Cushing + Virilizing Group

Normal ranges for woman

1300

6 Male Value

1000

900

700

500

300

100

T ng/dl

DHEAS µg/mL

DHEA ng/dl

ng/dL

ng/dl

Aldo ng/dl

E2 pg/ml

170HP CORTISOL (ug/dl) Basal After Dex

ng/dl

the C19 androgens and androgenic prehormones gen- erally were normal. Similarly, three adults with VS only had elevated C19 hormones, and two of three had increased compound S but normal corticoids. Twenty of the 25 patients exhibited CVS and, as expected, this group had both elevated C19 and C21 hormones ton varying degrees. Thus, there was no universal steroidal “marker” that was elevated in all patients with adre- nocortical carcinoma, but DHEAS and T generally were elevated in VS, and cortisol and compound S were elevated in CVS.

IMAGING STUDIES

It is generally accepted that the plain film of the ab- domen has little value in identifying and evaluating adrenal tumors. Although calcification within an ad- renal mass is commonly thought to signal malignancy, it is equally well appreciated that adrenal calcification may be a late consequence of local hemorrhage into a malignant or benign lesion, and thus nonspecific.76

Ultrasonography

Ultrasonography (US) of the adrenal gland has proven to be an effective technique for identification of adre- nal masses but depends substantially on operator skills. Obesity and overlying gas are major drawbacks to US interpretations.71-79 Several groups have imaged adrenal masses ≥ 1.3-3.0 cm using conventional scan-

ning techniques.80 Most adrenal neoplasms appear as smoothly rounded, solid masses replacing the usual triangular or crescent configuration of the normal ad- renal gland. Furthermore, US can identify displace- ment of adjacent structures caused by the tumor.80 The use of decubitus positions and oblique scanning planes for aligning the adrenal gland between kidney and aorta or inferior vena cava has resulted in remark- able image improvement. 77-79

In some cases, US imaging has proven helpful in visualizing inferior vena caval (IVC) displacement and/or invasion. In our series, US was used in 17 patients with adrenal carcinoma and demonstrated the tumor in all 17 patients.

Computerized tomography

Computed tomography (CT) generally is considered the method of choice in the radiodiagnostic evalua- tion of adrenal diseases. The location, size, and shape of adrenal masses and nodules as small as 1 cm gen- erally are demonstrated using conventional CT tech- niques; however, using thin-section CT scanning, nodules as small as 3-5 mm can be identified.81-83 Many authors have attempted to differentiate benign versus malignant adrenal masses on the basis of size, indicating that lesions < 3 cm probably are benign, whereas lesions > 5 cm probably are malignant.84- However, there is much overlap, and masses between

FIGURE 4. Computed tomography scan of the abdomen reveals a heterogeneous right adrenal mass with hypodense areas and invasion of the inferior vena cava. Arrows delineate the tumor borders. For details, see text.

(256

5UMF

256

3 cm and 5 cm fall into a “gray” area of clinical deci- sion making.84,89-92 Because tumor size is a function of duration, it is clear that the malignant nature of an adrenal mass cannot be predicted on the basis of size alone. Thus, attenuation, consistency, and contrast enhancement have been considered as more reliable discriminators between malignant and benign adrenal tumors.81-83,89,93 Malignant adrenal lesions tend to be larger in diameter (> 3 cm), present with blurred mar- gins and irregular shape, and more often demonstrate inhomogeneous contrast enhancement, whereas be- nign masses are smaller (< 3 cm), have sharp borders, and exhibit homogeneous enhancement.81,82,86-89,94 Recently, some authors have advocated that the atten- uation value of an adrenal mass on unenhanced CT scans can distinguish between an adenoma and a nonadenoma. In the series by Korobkin et al.,95 all adrenal masses with an attenuation value < 18 HU were adenomas. According to Lee et al.,96 adrenal lesions with attenuation values < 0 HU need no fur- ther work-up, because these lesions have been shown to be adrenal adenomas.

In our series, CT scans were performed on 16 patients with malignant adrenal tumors. In each case, the tumor size was ≥ 5 cm in greatest dimension, and the majority were heterogeneous, as noted in Figure 4. In all cases in which contrast material was adminis- tered intravenously, there was irregular enhancement. We did not perform measurements of attenuation val- ues on unenhanced CT scans.

Magnetic Resonance Imaging

Whereas a CT scan can depict nearly all adrenal masses, it has limited specificity. Magnetic resonance imaging (MRI) improves adrenal imaging and provides prognos- tic help by appearance of the lesion on T1 and T2 imag- ing modes.97 Adrenal tissues appear dark compared with the surrounding fat tissue on both T1-weighted and T2- weighed images. The T1 signal of adrenal tissue is inter- mediate: it is equal to or slightly darker than that of liver and is close to the signal of muscle. On T2 imaging, the signal is dark, similar to that of muscle, equal to or slightly darker than that of the liver. In adrenal tumors, intravenous paramagnetic contrast (gadolinium-DTPA)

is used, and axial, sagittal, and coronal projections local- ize the tumor and its invasion of adjacent structures better. On occasion, additional gradient-echo series can be used to visualize vessel structures and possible inva- sion of the inferior vena cava and renal veins. On T1- weighted images, adrenal carcinoma may have a heter- ogeneous or low signal appearance; however, on T2- weighted images, it may have a signal greater than that of fat.97 Heterogeneous enhancement after intravenous paramagnetic contrast also occurs.81,82, 90,98-106

Although MRI offers information contributing to tissue specific diagnosis among adrenal masses, dif- ferentiation between adrenal masses on the basis of signal-intensity ratios or T2 calculations remains con- troversial. A number of studies have shown that the accuracy of MRI in the differentiation of benign masses from malignant adrenal masses could be im- proved by using gadolinium with gradient-echo MRI. On MR images obtained after IV gadolinium, adeno- mas show mild enhancement with quick washout, whereas malignant tumors show strong enhancement and slower washout. However, even with the use of gadolinium, considerable overlap in the characteris- tics of benign and malignant masses remains.

Recent studies of chemical-shift MRI have shown that the technique had a very high accuracy in differ- entiating benign masses from malignant masses. Chemical-shift MRI with in-phase and opposed-phase pulse sequences currently is the most successful im- aging method for distinguishing benign adenoma from metastases, with a reported accuracy rate of 96- 100%. Whether chemical-shift imaging will allow the differentiation of benign masses from malignant ad- renal masses remains unsettled at present. Low atten- uation numbers on unenhanced CT scans of an adre- nal mass and relative loss in signal intensity on MRI both are associated with an increased likelihood of a benign adenoma. Both imaging methods have been advocated as noninvasive follow-up imaging protocols in patients without an extraadrenal primary neo- plasm.

Twelve patients from our series had MRI exami- nations. Both T1 and T2 signal intensities were studied as well as contour, size, enhancement after gadolin- ium, inferior vena cava invasion, and distal metasta- ses. Of the 12 adenocarcinomas studied with MRI, T1-weighted images showed low signal intensity in 6 tumors and heterogeneous signal intensity in the other 6 tumors (Fig. 5A). On T2-weighted images, there was high signal intensity in 3 tumors (Fig. 5B) and heterogeneous signal intensity in 9 neoplasms. There was no signal change on an echo time (TE) of 150 msec. Tumor contour was lobulated in 8 tumors and smooth in 4 tumors. The size of the tumors

ranged from 3 cm to 31 cm, and only one tumor was <5 cm. Gadolinium enhancement was present in 11 tumors. In these same 12 patients examined with CT, tumors presented heterogeneous density in 8 tumors, hypodensity in 2 tumors, and isodensity in 2 tumor.

Adrenal Cortical Scintigraphy

The adrenal cortical scintigraphy functional localiza- tion technique takes advantage of the accumulation of radiocholesterol into adrenal cortical tissues. The cur- rent cholesterol agent of choice is 131I-6-ß-iodom- ethyl-19-norcholesterol (NP-59), which has provided unique functional information about adrenal cortical, mineralocorticoid, and androgen secretion.107-109 Up- take of NP-59 was used to identify functioning adrenal cortical tissues and, ultimately, to distinguish benign masses from potentially malignant, space occupying, or destructive masses that may be silent clinically and may be discovered incidentally.110 The level of radio- cholesterol accumulation in adrenal cortical tissues also has been shown to represent a functional map of the magnitude of hormone-producing activity.111 Whereas CT and MRI are quite effective in identifying abnormal adrenal anatomy, radiocholesterol scintig- raphy, when used appropriately, can complement both the biochemical and radiologic imaging data to identify abnormal adrenal function in adenomas and can suggest the presence of adrenal carcinoma or delineate the functional status of adrenal masses iden- tified with CT or MRI.111,112

In adrenal carcinoma, the observed scintigraphic patterns are related directly to the functional status of the tumor. In patients with clinical features of CS, the tracer uptake per gram of tumor tissue usually is too low to permit visualization. Conversely, in patients with adrenal carcinoma associated with androgens or aldosterone excess, the nonneoplastic tissues concen- trate radiotracer. Thus, MRI plus adrenal functional data from scintigraphy could be more accurate than CT or MRI alone in the evaluation of patients with adrenal masses.

Imaging Assessment of IVC Invasion

IVC invasion by tumors occurs with reasonable fre- quency in adrenocortical carcinoma, and the diagno- sis can be established using US, CT, or MRI. Precise information regarding the presence and extent of IVC involvement is essential before deciding on surgical removal of thrombus.

US is considered a reasonably accurate procedure for evaluating vena caval extension. Cranial extension of a tumor thrombus usually is well demonstrated by US studies, which show echogenic endoluminal ma- terial within an enlarged bulging anterior wall113 but

FIGURE 5. (A) In this magnetic resonance image (MRI) (T1-weighted-gadolinium), a right adrenal mass is seen with heterogeneous enhancement after gadolinium and compression of the vena cava (surgical confirmation of carcinoma). The images in A and B are from the same patient shown in FIGURE 4. (B) In this MRI (T2-weighted), a right adrenal mass demonstrates high signal intensity and compression of the inferior vena cava. Arrows delineate the tumor.

TE TE

T I

25-

ALM

F 1

Mod PSe

R 2

TR: TE:

25€

FOY Thi

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FIGURE 6. In this magnetic resonance image (T1-weighted-gadolinium), a right adrenal carcinoma demonstrates inferior vena caval invasion.

may not be useful in obese or massively edematous patients. CT has proven helpful in demonstrating tu- mor thrombi as low-attenuating filling defects. Con- trast enhancement can help in delineating the ceph- alad extension of the thrombus. MRI has even better accuracy than CT in the preoperative assessment of IVC involvement. Using gradient and spin-echo im- ages, MRI can accurately delineate the presence and extent of the thrombus. In conventional spin-echo images (T1- and T2-weighted), the tumor thrombus is seen as an area of increased signal intensity, most frequently within an enlarged vena caval lumen (Fig. 6), and usually has contrast enhancement after gado- linium.81,82,114

We have compared retrospectively US, CT, and MRI results for the assessment of vena caval tumor thromboses in 9 patients from the current series with adrenal neoplasms. All patients underwent explora- tion with confirmation of the presence and extent of the vena caval tumor thrombus. No patients had su- prahepatic extension. The primary tumor and vena caval thrombus subsequently were excised in all pa- tients except in the youngest patient in our series, who

died during surgery due to massive pulmonary embo- lism. In 8 patients, US was performed and demon- strated the presence of vena caval involvement, and in vena caval involvement was demonstrated in 3 pa- tients with Doppler. CT scanning demonstrated vena caval thrombi in 5 of 9 of patients, whereas MRI ac- curately delineated vena caval invasion in all 4 pa- tients in whom it was done, including 1 patient who had negative CT scans. Thus, in the current series as well as in larger series reviewed from the literature,107 it can be concluded that MRI is the preferred vena caval imaging modality.

Imaging of Distant Metastases

The most common sites of metastases in our patients were the liver (85%), followed by lung (60%), bone (10%), and lymph nodes (10%), the latter more fre- quently in the retroperitoneum. For localization of liver metastases, US is a screening procedure that can show hypoechogenic rounded area(s); however, the best and most widely used imaging technique is CT, in which metastases usually are homogeneous, rounded, hypodense masses with variable sizes. For lung me-

tastases, chest X-rays can show metastases and medi- astinal lymph node enlargement, but CT scanning is a better way to demonstrate the metastatic disease.

PATHOLOGIC FINDINGS IN ADRENAL CARCINOMA Gross Anatomic Studies

Tang and Gray31 suggested that tumor weight was the most useful criterion to distinguish benign masses (< 50 g) from malignant adrenal tumors (>100 g). Several other studies suggested that tumor size alone cannot be utilized to indicate the biologic behavior of adrenal neoplasms.66,67,115-117 In the studies of Weiss66 and Weiss et al.,7º tumor size had a marginal effect on the survival of patients. In our series, tumor diameters in the adult group ranged from 4 cm to 21 cm (12.5 ± 4.4 cm), and the tumor weight ranged from 52 g to 1500 g (619 ± 474 g). The cut surface generally showed a variegated pattern, and many of the individual nod- ules were soft and friable. Areas of necrosis and hem- orrhage were frequent. The capsule often was infil- trated by tumor. In the children, tumor diameters ranged from 2 cm to 12 cm (6.1 ± 2.9 cm) and the tumor weight ranged from 10 g to 250 g (107 ± 86 g). Most authors concur that tumor size per se should not be used as the sole criterion to establish a benign or malignant diagnosis, because very large adrenocorti- cal neoplasms frequently have been observed with no metastases, whereas small tumors have been reported with metastases,117 as also noted in the current data.

Microscopic Evaluation Histologic analysis

Because of the relative rarity of adrenal cortical tu- mors, criteria to distinguish benign tumors from ma- lignant tumors were slow to be delineated. Except for those patients with metastases or local invasion in whom malignancy is obvious, it may be difficult his- tologically to differentiate between benign and malig- nant tumors. Early reports based on small numbers of patients30,64 proposed criteria of malignancy, includ- ing capsular and vascular invasion, mitotic activity, necrosis, hemorrhage, calcification, and nuclear poly- morphism.30,64,75 We have used the system proposed by Weiss.66 This classification lists 9 histologic criteria associated with adrenocortical neoplasms that metas- tasized or recurred locally. These features include 1) high nuclear grade using the criteria of Fuhrman et al.69; 2) mitotic rate > 5 per 50 high-power fields; 3) atypical mitotic figures; 4) eosinophilic tumor cell cy- toplasm (+75% of tumor cells); 5) diffuse architecture present in ≥ 33% of the tumor; 6) necrosis; 7) invasion of venous structures; 8) invasion of sinusoidal struc- tures; and 9) capsular invasion.

Using this system, Weiss66 found that all of 24

nonmetastasizing or recurring adrenal cortical neo- plasms had ≤ 2 of the histologic criteria described above. By contrast, 18 of 19 clinically malignant tu- mors exhibited ≥ 4 of the 9 features. In that study, all 43 patients were adults, with ages ranging from 20 years to 70 years. In a later study based on longer periods of follow-up, the criteria for malignancy were changed to include ≥ 3 of the above criteria.70

Histologic sections from 75 malignant and benign adrenocortical tumors in our series were reviewed by the same pathologist using the Weiss criteria.66,118 Thirty-eight tumors had a score of 0-3, 37 tumors had scores of 4-8, and no tumor exhibited all 9 criteria. Tumors with a total score ≤ 3 were considered “ade- nomas” and exhibited benign clinical courses. Those with a score ≥ 4 were classified as “carcinoma,” of whom 15 patients had metastases at the time of tumor resection. In the current series, the histologic features associated with malignant behavior in adults did not appear to have the same ominous prognosis when it was present in children.

Weiss et al.70 found that adult patients with adre- nal carcinoma tumors with a high mitotic rate had significantly shorter disease free survival than patients with a low mitotic rate. In their patients with tumors that had > 20 mitoses per 50 high-power fields, the median disease free survival was 14 months, whereas patients with tumors that had ≤ 20 mitoses per 50 high-power fields exhibited a mean disease free sur- vival of 58 months. In our series, there was no statis- tically significant difference in survival based on mi- totic rates within the tumors.

Immunohistochemical evaluation

Immunohistochemical studies have been used for identification of the pattern of differentiation in mor- phologically undifferentiated tumors. In this respect, identification of intermediate filament proteins, which are part of the cell cytoskeleton and are closely related to cell differentiation, have been emphasized as well as prognostic indicators, such as oncoproteins and proliferation markers. Among the intermediate fila- ments we studied were 1) cytokeratin expression, mostly restricted to epithelial cells and closely related to cell differentiation,119 for which only the low mo- lecular weight pair CK8/18 was examined, as identi- fied by the monoclonal antibody CAM 5.2, which has been reported consistently in the adrenal cortex; 2) vimentin, which is related to mesenchymal differenti- ation and has been reported consistently in some car- cinomas,119-122 was evaluated using the monoclonal antibody V9; 3) the monoclonal antibody, D11, which was characterized by Schröder et al.,120 has been re- ported to be specific for adrenocortical tissue, either

TABLE 4 Histogenesis Markers in Tumor Samples from Patients with Benign Adrenal Adenomas Localized Adrenocortical Carcinoma, and Metastatic Adrenocortical Carcinoma
Marker	Benign adenomas (n = 38)		Localized adrenal carcinoma (n = 21)		Adrenal carcinoma with metastasis (n = 14)		Nonneoplastic adrenal tissue adjacent to carcinoma
Marker	NEG	POS	NEG	POS	NEG	POS	NEG	POS
Cytokeratin (8/18)	23	15	16	5	10	4	0	9
Vimentin	11	27	0	21	0	14	3	40
D11	0	38	5	16	8	6	17	27
p53	36	2	15	6	8	6	0	19

NEG: negative; POS: positive.

normal, hyperplastic, or neoplastic (generous gift from Dr. S. Schröder); and 4) overexpression of a mutant p53 tumor suppressor gene associated with the malig- nant transformation in several lineages, including ad- renocortical epithelium. We used the epitope marked by the monoclonal DO-7 antibody.

The immunohistochemical data from tumor tis- sue in our series are presented in Table 4. We exam- ined staining characteristics of tissue from 38 benign adenomas, 21 localized adrenal carcinomas, 14 adre- nal carcinomas associated with metastases, and 44 samples of nonneoplastic adrenal tissue adjacent to adrenal carcinoma. Any degree of staining was con- sidered “positive.” The most common immunoprofile for an adrenocortical carcinoma was positive staining for vimentin, whether the tumor was localized or as- sociated with metastatic disease. The proportion of negative and positive staining for the other markers was not striking, although overexpression of p53 was present in adrenal carcinoma tissue with greater fre- quency compared with adenoma tissue or normal ad- jacent adrenal tissue. These studies are similar to re- ports of other laboratories.121-126 Thus, at present, immunohistologic markers are of limited use in char- acterizing adrenocortical carcinoma tissue.

DNA Analysis and Cell Proliferation

Failure of conventional microscopy to predict the clin- ical course of patients with adrenocortical tumors has stimulated several groups to look for other methods to improve the determination of biologic potential of this group of neoplasms. Among these new methodolo- gies, cell DNA content measurement using flow or image cytometry today is considered a powerful adju- vant diagnostic and prognostic tool when performed within strict guidelines.127 Despite conflicting results in the literature, the clinical utility of flow cytometry

has been established sufficiently for several groups of neoplasms, including breast, prostate, bladder, leuke- mias, and non-Hodgkin lymphoma. Tumor cell prolif- eration and its clinical assessment has been explored in adrenocortical tumors, as discussed below.

DNA ploidy in adrenocortical tumors

Cell DNA content measurements, including determi- nation of DNA ploidy and S-phase fraction, have been performed in a wide variety of human tumors using one of two methods: flow cytometry and image anal- ysis. Details of these methods have been published previously.127,128 A characteristic pattern is produced when DNA specific staining is measured by flow cy- tometry or image analysis, reflecting the cell cycle phases within the cell population (GO/G1 phase, S phase, and G2/M phase). The S-phase content and the proliferative activity (S and G2M phases) of the sample also can be determined by deconvoluting the DNA histogram. DNA ploidy in adrenal tumors has been studied actively in the last decade,129-142 although no particular differentiation has been made between tu- mors in children and tumors in adults. Table 5 pro- vides a summary showing that most studies have used paraffin embedded specimens and flow cytometric analysis. Only Padberg et al.138 used image analysis, and Zerbini et al.139 used both flow cytometry and image analysis as complementary methods. Because of the small number of cases, most series have grouped DNA tetraploid and DNA aneuploid tumors, although patients with aneuploid tumors have a dis- tinctly different prognosis. DNA tetraploidy has been found in 25% of adrenocortical adenomas134 and car- cinomas,132 whereas normal and hyperplastic adrenal glands usually are DNA diploid.129,131,132 Identification of hypodiploid tumors (DNA index [DI], 0.80-0.95) and aneuploid near-diploid tumors (DI, 1.05-1.30)

TABLE 5 DNA Ploidy Versus Histopathologic Diagnosis and Clinical Course of Adrenal Tumors
Reference	Technique specimen	No.	Age group (yrs)	Aneuploidy/total cases		Aneuploidy/total cases
Reference	Technique specimen	No.	Age group (yrs)	Adenoma	Carcinoma	Clinical benign	Clinical malignant
Klein et al., 1985129a	FCM/f	6	?Adults	0/2	4/4	1/3	3/3
Bowlby et al., 1986130	FCM/p	22	3-70	0/16	5/6	2/19	3/3
Amberson et al., 1987131	FCM/p	48	2.5-88	2/39b	6/6℃	3/31	4/5℃
Hosaka et al., 1987132a	FCM/p	52	1-75	—	30/52	—	—
Taylor et al., 1987133	FCM/p+f	10	Pediatric	—	—	1/6	4/4
Joensuu and Klemi, 1988134a	FCM/p	17	2-78	9/17	—	0/17	—
Rainwater et al., 1989135	FCM/p	26	Adults	3/20	6/6	6/23	2/2
Cibas et al., 1990136	FCM/p	43	5-78	6/30	9/13€	8/23	5/9ª
Camuto et al., 1991137	FCM/p	22	?Adults	—	21/22	—	21/22
Padberg et al., 1991138	IA	66	—	24/50	14/16	29/57	9/9
Zerbini et al., 1992139	FCM+IM/p	23	6 to 19	3/5℃	13/17ª	12/14	5/9ª
Suzuki et al., 1992140	FCM/p	14	17-75	0/6	7/8	3/9	4/5
Haak et al., 1993141	FCM/p+f	85	—	10/31	48/5ª	—	—

p: Paraffin embedded; f: fresh tissue; FCM: flow cytometry; IA: image analysis.

a DNA tetraploid cases excluded.

b One aneupolid case, unclassified.

c Statistically significant.

d Statistically nonsignificant.

also may be relevant. Although hypodiploid tumors are rare overall, they may be important in some tumor types (i.e., breast carcinoma). Hypodiploidy was not detected in studies of adrenocortical tumors using fresh tissue for flow cytometry, in DNA content, or in two studies that used image analysis.138,139

Multiploid aneuploidy (multiple aneuploid stem- lines) generally is associated with very aggressive neo- plasms and seems to be frequent in adrenocortical tumors, because it is present in ~25% of cases132,139 and in both clinically benign and malignant neo- plasms.134,139 Cibas et al.136 found 4 of 48 patients with multiploid adrenal tumors, 2 of whom exhibited an unfavorable prognosis. Hosaka et al.132 stratified pa- tients into two groups with respect to tumor resectibil- ity: curative and palliative operations. For patients with resectible tumors, the 5-year disease free survival rates for DNA diploid, tetraploid, aneuploid, and mul- tiploid were 80%, 33%, 67%, and 0%, respectively. Camuto et al.137 reported 96% aneuploidy rates in patients with clinically malignant tumors. By contrast, Joensuu and Klemi134 found that 53% of clinically be- nign adrenal tumors and other benign endocrine tu- mors were aneuploid. It is noteworthy that higher incidence rates of aneuploidy were found in a series of exclusively pediatric age group patients.

Table 5 reviews various attempts to correlate DNA ploidy with histopathologic classification and clinical outcome.129-142 The small number of cases precluded

statistical analyses in most of these studies; however, a significant correlation between DNA ploidy and his- topathologic classification and clinical outcome was found by Amberson et al.131 Cibas et al.136 found a strong correlation between ploidy and histopathologic diagnosis but not with clinical outcome. By contrast, Haak et al.141 found a correlation only between ploidy and clinical outcome. In that study, a favorable prog- nosis was associated with DNA aneuploid tumors in pediatric neoplasms. The two series of pediatric age group patients139,142 did not demonstrate any correla- tion between ploidy and clinical outcome of his- topathologic diagnosis.

The correlation between nuclear grade and DNA ploidy remains controversial.136 In our experience, the phenotype of nuclear atypia does not signify the pres- ence of an aneuploid stemline. Most atypical nuclei represent single events along the optical density axis of the image analysis histogram and are not able to replicate a stemline and define a peak on DNA histo- grams.143 Cibas et al.136 did not find an association between nuclear grade and DNA ploidy.

Cell proliferation measurements in adrenocortical tumors Measurement of tumor cell proliferation has been an area of interest in oncologic research, especially when considering the correlation between proliferative ac- tivity and clinical course. A variety of methods have been used to measure proliferative rates in tu-

mors,144-148 including: mitotic counting, S-phase de- termination by flow cytometry, AgNOR counting (sil- ver staining of nuclear organizing regions), and immu- nohistochemical detection of nuclear proteins.

To date, cell proliferation studies in normal and pathologic adrenal tissues are still controversial. Sazano et al.148 found no significant differences in proliferation fractions between normal adrenal glands compared with adrenal adenoma tissues using Ki-67. Klein et al.129 reported a small series of 10 patients in whom a higher proliferation fraction was noted in adenomas compared with normal adrenal glands, but no other series using flow cytometry has been able to demonstrate significant differences in proliferation fraction, histopathologic diagnosis, or clinical out- come.136,144 Furthermore, no significant difference be- tween proliferating cell nuclear antigen or labeling index was found in benign compared with malignant adrenocortical tumors.140,148 Conversely, monoclonal antibody studies using Ki-67 (MIB-1) have been found to exhibit a discriminant role in determining benign and malignant adrenocortical tumors.147,148 Immuno- staining for MIB-1 in paraffin embedded tissues sec- tions was performed in our series of tumors. Using a visual estimate of positivity, we found no significant correlation between mitotic count and clinical behav- ior of the tumor.

Data regarding AgNOR counting in adrenocortical carcinoma is still limited. According to Kida et al.,149 both the number and the total area of AgNOR per nucleus in adrenal carcinoma tissue were found to be greater than in adenomas or control tissues. Those authors also described different morphologic patterns of AgNOR dots in benign and malignant lesions. Sim- ilar significant results were obtained by Oz et al.150

Sazano et al.151 concluded that AgNOR numbers may be correlated with increased steroid hormone production and are of little value in discerning malig- nancy. At present, it appears that KI-67 immunostain- ing and AgNOR evaluation show a trend toward in- creased proliferative activity from normal adrenal glands to malignant tumors. This hypothesis needs to be confirmed by larger series using panels of methods for measuring cell proliferation.

In summary, pathologic criteria to diagnose and classify adrenocortical tumors have been slow to de- velop, and there still are no hard-and-fast criteria ac- cepted by all. Tumor size per se appears to carry prognostic significance. We have found that the Weiss histologic criteria offered a reliable guide to tumor prognosis. Immunohistologic profiles were interesting but unreliable markers of tumor prognosis, although overexpression of mutant p53 seems promising. Sim- ilarly, studies of DNA ploidy and cell cycle analyses

have not yet improved diagnostic criteria in assessing adrenal neoplasms.

MOLECULAR MECHANISMS OF HUMAN ADRENOCORTICAL TUMORIGENESIS

Our understanding of normal and malignant cell growth has advanced rapidly in the last two decades as new technologies have been accelerated by the ability to resolve the underlying molecular mechanisms. Studies targeting cellular oncogenes and tumor sup- pressor genes as well as genes involved in normal senescence, apoptosis, and differentiation may pro- vide not only knowledge of the molecular mechanisms of adrenocortical carcinoma but also a new generation of cancer markers that could help identify patients at high risk for malignancies of the adrenal cortex.

The pathogenesis of adrenocortical tumors is still not understood in the majority of cases, although the molecular mechanisms that lead to adrenocortical tu- mor formation are being studied increasingly.152,153 Recently, the clonal composition of adrenocortical tu- mors was established using X-chromosome inactivat- ing analysis.154,155 Like most tumors, adrenal adeno- mas and carcinomas most often were monoclonal, whereas ACTH-induced diffuse and macronodular hy- perplasias were polyclonal.152,154,155 These findings support the overwhelming evidence that cancer is generally the result of monoclonal expansion of a sin- gle cell, which becomes tumorous in response to a series of multistep genetic aberrations, including: overexpression of protooncogenes and/or inactivation of tumor suppressor genes, alterations of proteins in- volved in the normal progression of senescence, in- duction of apoptosis, and genomic instability in hu- man tumorigenesis. Mutations in oncogenes and tumor suppressor genes have been examined in adre- nocortical tumors, as shown in Table 6.

Oncogenes

G proteins are transmembrane signal transducers composed of three subunits, a, B, 8, which interact with specific receptors and effectors. Activating muta- tions of the a-subunit of Gs (gsp mutations) were identified in tissues from patients with McCune- Albright syndrome, and these included hyperfunction- ing adrenocortical adenomas.156 Constitutively acti- vating point mutations of the « chain of Gs and Gi2 were reported in 1 of 19 and 3 of 11 sporadic adreno- cortical carcinomas, respectively.157,158 However, in two series of adrenocortical tumors, no Gs or Gia2 mutations were found.159,160

Mutations of the ras oncogene in adrenocortical tumors have been explored but not found. Moul et al.161 analyzed 17 benign and malignant adrenal tu-

TABLE 6 The Frequency of Genetic Alterations in Sporadic Adrenocortical Tumors
Gene	Number of patients studied	Frequency (%)	References
11pLOH	17 (8 ad, 9 ca)	4 (23.5)	Yano et al., 1989181
11pLOH			Gicquel et al., 1995153
17pLOH	17 (8 ad, 9 ca)	6 (35.2)	Yano et al., 1989181
17pLOH	27 (16 ad, 11 ca)	13 (48)	Gicquel et al., 1995153
gip2	11 (5 ad, 6 ca)	3 (27)	Lyons et al., 1990158
gip2			Reincke et al.,
p53	18 (7 ad, 11 ca)	3 (16.6)	1994177
p53	15 (15 ad)	11 (73.3)	Lin et al., 1994178
ras	56 (32 ad, 24 ca)	7 (12.5)	Yashiro et al., 1994163
IGFII	23 (17 ad, 6 ca)	7 (30)	Gicquel et al., 1994156
	38 (23 ad, 15 ca)	14 (36.8)	Gicquel et al., 1995153

LOH: loss of heterozygosity, ad: adenoma, ca: carcinoma.

mors for the presence of activating mutations of the ras oncogene and failed to find it in any case. More recently, point mutations of N-ras were found in 12% of adrenocortical tumors but not K-ras or H-ras mu- tations.162 It is clear that mutations of the G proteins or ras oncogenes are rare events in the pathogenesis of these tumors.

The finding that hyperstimulation of the adrenals by ACTH could result in adrenocortical tumors was suggested directly by isolated case reports of adeno- mas and carcinomas arising 3-36 years after the diag- nosis of classic congenital adrenal hyperplasia.163,164 In addition, somatic mutations in the transmembrane domain of the thyrotropin receptor (TSH) recently were identified in hyperfunctioning thyroid adeno- mas, suggesting that G-protein-coupled receptors could play the role of protooncogenes in endocrine tissues.165,166 Recently, we analyzed 25 adrenocortical tumors for the presence of activating mutations of the ACTH receptor (ACTH-R), a member of the G-protein- coupled receptor superfamily.167 The direct sequenc- ing of the entire coding region of the ACTH-R gene did not reveal constitutively activating mutations in any of the sporadic adrenocortical tumors (17 adenomas and 8 carcinomas) or in 2 adrenal adrenocortical carci- noma cell lines.167 Seventeen of these patients are part of our current series. No mutations were noted in the ACTH-R gene in another study.168 These findings sug- gest that activating mutations of the ACTH-R gene do not represent a frequent mechanism of human adre- nocortical tumorigenesis. More recently, overexpres- sion of the structurally normal ACTH-R and Type 1 angiotensin II receptor (AT1) genes were observed in aldosterone secreting adenomas, suggesting a multi- ple and complex mechanism of growth in this subset

of adrenocortical tumors.169 Abnormalities in compo- nents of signal-transduction pathways, which control the intracellular production of phosphoinositol break- down products and diacylglycerol, may be implicated in adrenocortical tumorigenesis.170,171 Such proteins include G-protein-coupled receptors, phospholipase C, protein kinase C (PKC), and the rest of the cascade, including the transcription factors c-jun and c-fos, also may be implicated in adrenocortical tumorigen- esis.170,171 PKC represents a family of closely related isoenzymes with a critical role in signal-transduction pathways, including cellular growth regulation.171,172 We analyzed the expression of calcium-activated PKC in surgical specimens from human carcinomas, ade- nomas, hyperplasia, and normal tissues in an attempt to study the potential involvement of PKC activities in human adrenocortical tumorigenesis.171 All samples came from the current series. The calcium dependent total PKC activity was similar in the four groups stud- ied, suggesting that calcium dependent PKC activity is not elevated in adrenocortical tumors and is not a useful marker for adrenocortical malignancy.

Tumor Suppressor Genes

Molecular defects of tumor suppressor genes recently were demonstrated in hereditary and sporadic adre- nocortical neoplasms.143,172-174 The Li-Fraumeni syn- drome, a rare autosomal-dominant susceptibility to a variety of cancers, which include carcinoma of the adrenal cortex, breast, brain, muscle, and leukemias, has been associated with germ line mutations of the p53 tumor suppressor gene.172,173 The p53 tumor sup- pressor gene is composed of 11 exons and has been mapped on human chromosome 17p 13.1.143,174 Mu- tations of the p53 tumor suppressor gene have been identified in sporadic adrenocortical carcinomas and adenomas. Reincke et al.143 described p53 mutations in exons 5-8 in 27% of adrenocortical carcinomas and in two adrenal carcinoma cell lines but in none of the benign cortisol-secreting adrenal adenomas exam- ined. Lin et al.,175 demonstrated a high frequency p53 gene mutations in 11 of 15 adrenocortical adenomas (13 aldosterone-secreting adenomas and 2 cortisol- secreting adenomas). In 75% of their cases, these mu- tations were clustered on exon 4.175 These findings suggested that loss of the normal inhibitory function of the p53 tumor suppressor protein in the cell cycle may lead to the development of adrenocortical tu- mors.

The p16 tumor suppressor gene located on chro- mosome 9p21 encodes a protein that binds to and inhibits cyclin dependent kinase 4 (CdK4), one of sev- eral CdKs the activity of which propels cells through the cell cycle and into cell division.63,154,176,177 Biallelic

TABLE 7 Clinical and Molecular Features of Syndromes Associated with Benign and/or Malignant Adrenocortical Neoplasms
Syndrome	Clinical features	Chromosomal/molecular defects
Carney complex	PPNAD, atrial and other myxomas, swannomas, lentigines and blue nevi of the skin and mucosae	2p16 (Carney locus)
Congenital adrenal hyperplasia	Female and male pseudohermarphroditism, cortisol deficiency, mineralocorticoid deficiency, or excess	Inborn errors of cortisol biosynthesis enzymes resulting in chronic hypersecretion of ACTH
Li-Fraumeni syndrome	Familial susceptibility to a variety of cancers	Germ line mutations of p53 tumor suppressor gene
McCune-albright syndrome	Precocious puberty, cafe-au-lait spots, polyostotic fibrous dysplasia Hyperparathyroidism, pancreatic-dudoenal, and pituitary tumors Neonatal macrosomia, macroglossia, and omphalocele	Overactivity of the Gs protein signaling pathway 11q13 (MEN 1 locus) Allelic loss of 11p15
Multiple endocrine neoplasia type 1 (MEN 1)
Wiedemann-Beckwith syndrome

PPNAD: primary pigmented nodular adrenocortical disease; ACTH: corticotropic hormone.

lesions of the p16 gene have been observed in 50-85% of cell lines derived from a variety of human tu- mors.178 Moreover, in tumor cell lines that retain one allele of p16, sequence analysis has shown frequent nonsense, missense, or frame-shift mutations.178 We have investigated p16 abnormalities in our series of 20 adrenocortical tumors (10 adenomas and 10 carcino- mas) by using polymerase chain reaction, denaturing gradient gel electrophoresis (DGGE), and direct se- quencing; however, we were unable to detect any mu- tations or deletions in any cases studied (unpublished observations).

Chromosomal studies of individual adrenal tumors suggest that loss of heterozygosity at loci on the short arm of human chromosome 11 (11p) may be important in the pathogenesis of benign and malignant adrenocor- tical tumors.179,180 Consistent loss of alleles on chromo- somes 11p, 13q, and 17p were observed in primary ad- renocortical tumors and metastases but not in adrenocortical carcinomas.179 Particularly, uniparental disomy at the 11p 15.5 locus, which includes H-ras-1, IGF-II (an insulin gene), and overexpression of the IGF-II gene were observed in patients with adrenocortical car- cinoma.179 Using fluorescence in situ hybridization, chromosome numerical abnormalities also were de- tected in uncultured tumor cells from a patient with a secreting adrenocortical carcinoma from our series.

Elevated levels of IGF-II mRNA have been demon- strated frequently in malignant adrenocortical tumors by Northern blot analysis with a similar pattern of gene transcripts in adrenocortical tumors and normal tis- sue.154,178 Immunocytochemical studies showed overex- pression in adrenocortical tumors compared with con- trol adrenocortical tissue.154,178 These findings suggest an important role for IGF-II in tumor progression and/or acquisition of the malignant phenotype.180

Clinical Syndromes and Chromosomal Abnormalities Associated with Adrenocortical Neoplasms

Several recognized genetic syndromes have been as- sociated with adrenocortical neoplasms, as listed in Table 7.181-184 Children with Beckwith-Wiedman syn- drome, a growth disorder characterized by macroglos- sia, gigantism, omphalocele, hemihypertrophy, and allelic loss of 11q15, have an increased incidence of several tumors, including adrenocortical adenomas and carcinomas.181 Other familial syndromes, such as the Carney complex and multiple endocrine neo- plasms Type I (MEN-1), also may be associated with adrenocortical tumors.1 182-184

In summary, the pathogenesis of adrenocortical tumors may involve multiple genetic changes, such as activating mutations of the G-protein genes; inactivat- ing mutations of p53 tumor suppressor genes; overex- pression of IGF-II, ACTH-R, AT1; and chromosomal aberrations. A variety of genetic abnormalities may account for the phenotypic heterogeneity of adreno- cortical tumors. Furthermore, genes involved in telo- mere loss and cell senescence, in disruption of apo- ptosis associated with survival and expansion of malignant cells, and in genomic instability related to defective DNA repair all are potentially important con- siderations in understanding mechanisms of onco- genesis. These new molecular approaches may prove useful in elucidating the pathogenesis of adrenocorti- cal carcinoma.

TREATMENT OF ADRENAL TUMORS Surgery

The surgical treatment of patients with adrenocortical carcinoma is still a subject of some controversy. 185,186 Complete surgical excision is the best chance of cure for patients with Stage I and II tumors and in children. The presence of IVC invasion should not be consid-

ered as metastatic disease but, rather, as tumor exten- sion. In such cases, surgical procedure should be more aggressive, attempting to remove completely the in- travascular extension.187,188 The indication for total (or near-total) tumor excision in patients with Stage III and IV disease remains controversial. Some studies suggest a benefit from maximal debulking of the tu- mor mass when complete surgical excision of the tu- mor is not possible.189,190 Conversely, there some se- ries clearly indicate that surgical palliation does not influence the survival of the patients.10,14,28 The latter has been our experience at the Hospital das Clinicas. The survival rate of patients with adrenocortical car- cinomas 5 years after diagnosis and surgical resection is ~15-30%, with a high rate of recurrence after ap- parent complete tumor excision. When metastatic dis- ease is present at initial presentation, death usually occurs within a maximum period of 1 year.9,14,19,28,190 The results of surgery in these patients with more advanced stages of disease are questionable.

In the current series, 46 of 47 patients with a diagnosis of adrenal carcinoma underwent surgical procedures on the adrenal gland independent of the presence of metastases. In only 1 patient, who had pulmonary insufficiency due to lung metastases, sur- gery was withheld. This patient died 18 months after diagnosis. Approximately 50% of the operated patients underwent total ipsilateral adrenalectomy, 39% had adrenalectomy plus nephrectomy, and the remaining 15% underwent adrenalectomy, nephrectomy and splenectomy. A subcostal incision was performed in 35% of the patients, a thoracoabdominal laparotomy was performed in 49% of the patients, and abdominal median xyphoid-pubic incision was performed in the remaining 16% of the patients. Although laparoscopic surgery can be performed when dealing with small adrenal tumors with no invasion of adjacent struc- tures,186 we prefer the larger incisions, which allow for better exploration. More extensive surgical procedures were performed in >50% of the patients, reflecting the presence of large tumors in this group.

With regard to the surgical removal of tumor re- currences, two series compared the survival of pa- tients who underwent a second surgical excision with patients who received chemotherapy after their recur- rence. Those studies reported longer survival times in the surgical group and recommend surgical interven- tion whenever possible for tumor recurrence188,189 Against that reasoning is the fact that patients who were on chemotherapy usually were those with the most aggressive tumors for which primary or second- ary surgery was not possible.

In the current series, 13 patients had metastases at the time of primary surgery, and 6 patients developed

metastatic disease 3-48 months after primary surgery. Of these 19 patients, 15 died after a period of 21 ± 15 months, 3 are still alive with metastatic disease, and 1 is alive without metastases 84 months after surgery. In our patients who had only regional lymph node in- volvement, a lymphadenectomy was done but did not change their prognosis. Hepatic resection for liver me- tastases was performed in 4 patients but also was without significant effect of survival. Thus, the surgical removal of metastases did not seem to improve the prognosis for patients with widespread disease in our experience. Our data show that extensive surgery to reduce tumor mass was of no great benefit to the patients. We suggest that, in patients with metastatic disease, chemotherapy prior to surgery may be bene- ficial. Patients who have objective tumor regression with chemotherapy may benefit from surgical debulk- ing of the tumor. Patients who have no response to chemotherapy will not benefit from debulking sur- gery.

Twenty-seven patients with adrenal carcinoma in our series did not develop metastases within a post- surgical follow-up period of 6 ± 45 months. Of this group, 21 underwent “curative” surgery (adrenalecto- my), 4 had undergone adrenalectomy, and the re- maining 2 underwent adrenalectomy and splenec- tomy. This group of patients had a better natural history and were subjected to less extensive surgery. This group of patients with nonmetastatic carcinoma had smaller primary tumors than those with metasta- ses (7 ± 4 cm vs.14 ± 6 cm), which determined less extensive surgery.

Medical Therapy

Inhibitors of the adrenal cortex

Of the pharmacologic agents reported to suppress ad- renal function, mitotane (o,p’-DDD) appears to be the only one that both inhibits corticoid biosynthesis and destroys adrenocortical cells. Mitotane acts on adre- nocortical cell mitochondria, not only inhibiting 11-ß hydroxylase and cholesterol side chain cleavage en- zymes but also leading to the destruction of the mito- chondria with necrosis of the adrenal cortex.191,192 The zona reticularis of the adrenal cortex appears to be the most sensitive area to the action of mitotane followed by the fasciculata, whereas the zona glomerulosa ap- pears to be the least sensitive. In small doses ≤ 3 g per day, mitotane results primarily in the suppression of adrenal steroid secretion; in doses > 3 g per day, an adrenolytic effect is observed. In treating patients with adrenocortical carcinoma, doses usually range from 6-15 mg./Kg/body weight given in 3 or 4 doses per day. Blood levels of mitotane reach a plateau after the eighth week. Accordingly, patients receiving the drug

should have hormonal replacement after 2-4 weeks.193 Mitotane can alter peripheral metabolism of cortisol and androgens with an early fall in urinary excretion of 17-hydroxycorticoids, which occurs be- fore the suppressive effects of mitotane in cortisol secretion. Thus, changes in the cortisol secretion rate, urinary free cortisol levels, and plasma cortisol levels are useful for determining the biochemical response to mitotane.193 Furthermore, the drug significantly in- creased cortisol-binding globulin, sex-hormone bind- ing globulin, thyroxin-binding globulin, and vitamin D-binding protein in peripheral blood. It is necessary to increase the cortisol substitution requirement dur- ing prolonged mitotane therapy.194,195

To date, mitotane has been the only drug that has proven effective in treating patients with metastatic adrenocortical carcinoma. Most of the experience with mitotane comes from its use in patients with recurring metastatic disease or unresectable tu- mors,9,10,14,16,190,195-199 but its effectiveness under those conditions has been disputed.191 Hutter and Kayhoe197 reviewed 138 patients, noting objective tu- mor regression in 34% of patients with evaluable dis- ease. The mean duration of tumor regression was only 10.2 months, and those authors were unable to dem- onstrate a significant prolongation of survival. Lubitz et al.198 reported that 46% of their 75 patients experi- enced measurable tumor regression, but the median duration of survival was only slightly better than the 3-month median survival of nonresponders. Hoffman and Mattox196 questioned both the quality and quan- tity of life in 19 patients, only 4 of whom had measur- able tumor regression. At doses of 6-10 g per day, mitotane is most effective; however only 3 of 19 pa- tients were sufficiently free of side effects to carry out normal work or leisure activities. Most patients suf- fered lassitude and apathy ranging from a mild dulling of interest to profound psychotic depression. Those authors196 reported no significant difference in the duration of survival between those patients with mea- surable tumor response compared with those whose tumors failed to respond to mitotane. Luton et al.9 treated 59 patients with adrenocortical carcinoma, 20 of whom were started on the drug before surgery, 25 after “curative” surgery, and the remaining 14 on tu- mor recurrence. Those authors concluded that mito- tane controlled hormone hypersecretion but did not prolong survival significantly. Luton et al.9 reported that the side effects of mitotane were minimal, in disagreement with most investigators. Potential differ- ences in patient tolerance may be explained by differ- ences in medicinal preparation. Cellulose actylphtha- late was present in the capsule used by Luton et al.9 This agent acts to inhibit the absorption of mitotane

from the stomach, thus allowing the use of higher doses for a prolonged time.

In general, mitotane treatment for adrenal carci- noma is limited by frequent serious side effects, mak- ing it intolerable for many patients. Gastrointestinal symptoms of nausea, vomiting, anorexia, and diarrhea occur in >80% of patients. Neuropsychiatric symp- toms, especially lethargy and somnolence, occur in >25%, and skin rash occurs in 10% of patients. Other infrequent side effects include eye, genitourinary sys- tem, and dose related hepatotoxicity. All side effects can be reversed by reducing the dose of mitotane or by interrupting therapy. In general, there appears to be little correlation between drug dosage and its effec- tiveness. After the discontinuation of the drug, blood levels fall but persist for 6-9 weeks because of drug storage in adipose tissue.193

Although isolated case reports have described im- pressive remissions in patients with adrenocortical carcinoma after mitotane therapy,199-201 the majority of reports of sustained response to mitotane were in the pediatric age group.202-208 In large series197,209,210 that included both children and adults, the response to mitotane did not seem to be influenced by the age of the patient. Because survival appears to depend on the size of the primary lesion and the degree of local and distal extension of the tumor at the time of the initial surgery, it has been suggested that, if mitotane therapy is to be effective, it should be instituted early as adjuvant therapy after resection of the primary tumor and before local extension or distant metasta- ses occur. Even here, the existing data are contradic- tory, with some publications indicating encouraging results,9,10,209-211 whereas other studies did not show any beneficial effect from the use of mitotane in pre- venting tumor recurrence.17,209,212 The disabling side effects and the lack of ability to predict which patients will respond to mitotane are major deterrents to the use of this drug in the early postoperative period.213

Titration of blood levels of mitotane may have use, because 7 of 8 patients with objective tumor re- gression had levels > 14 µg/mL, whereas 19 of 20 patients with no response had levels < 10 µg/mL. This experience was confirmed later by Haak et al.,209 who mentioned that an important reason for not reaching therapeutic levels may be undertreatment with ste- roids, resulting in signs and symptoms of adrenocor- tical insufficiency that are accentuated by increased cortisol binding capacity during mitotane therapy. The replacement with glucocorticoids and mineralo- corticoids must be higher than normal doses, and this has not always been done.

Mitotane was used in 15 of our patients with met- astatic adrenal carcinoma in doses of 3-13 g for a

period of 1-17 months. In only 1 adult patient was there regression of the metastases after 2 months on a dose of 6 g per day. The administration of mitotane in the other 14 patients, 3 of whom were children (ages 3, 5, and 9 years), did not have any effect on metastases or survival. All patients developed side effects with the use of the drug, including nausea, emesis, and myal- gia. Thus, the overall results of mitotane therapy in patients with metastatic adrenal carcinoma have been fairly uniform from one group to the next and show a partial or complete response to therapy in 34% of patients, the duration of treatment varying from 1 month to 190 months.9,16,196-199,208-214

Chemotherapy

In patients who do not respond to mitotane or in whom side effects forced its discontinuation or when the tumor is poorly differentiated, other chemothera- peutic agents have been tried.

Cisplatin

Cisplatin administered to 13 patients with metastatic adrenal carcinoma2º was found to result in a partial response in 5 patients, had a minimal effect in 2 pa- tients, and resulted in disease stabilization in 3 pa- tients. Cisplatin combined with etoposide was used in 2 patients and resulted in a partial response of the metastases. This regimen was utilized in 8 patients in the current series. In 1 patient with local recurrence and regional lymph node metastases, there was a complete response after the first course of the drug; however, after 2 months, the tumor became nonre- sponsive. Two patients with pulmonary metastases had partial responses to this drug combination but refused additional courses of therapy. The remaining 5 patients did not show any response to chemotherapy.

Cyclophosphamide, doxorubicin, and cisplatin

The combination of cyclophosphamide, doxorubicin, and cisplatin was administered to 11 patients with partial response in 2 patients and stabilization of dis- ease in 6 patients.21

5-Flurouracil, doxorubicin, and cisplatin

The 5-flurouracil, doxorubicin, and cisplatin chemo- therapy regimen was administered by Schlumberger et al.215 to 5 patients with advanced adrenal carci- noma with 1 complete response, 1 minimal response, and stabilization of disease in the remaining 3 pa- tients. The effectiveness of moderate doses of mito- tane (6 g per day) plus doxorubicin hydrochloride (Adriamycin) in the treatment of patients with ad- vanced adrenocortical carcinoma was evaluated in a multicenter, prospective, nonrandomized trial in 52

patients. Mitotane was effective in reducing tumor regression in 22% of the patients, but the effect ap- peared to be limited to the well-differentiated or FT tumors. As a first-line agent, doxorubicin was effective in 19% of the poorly differentiated, nonhormone pro- ducing adrenocortical carcinomas, but it was not ef- fective as second-line therapy for patients with well- differentiated tumors for whom mitotane had failed.213

Suramin

Suramin, a polysulfated naphthylurea that has been used successfully against African trypanosomiasis and onchocerciasis, has also shown antitumor activity in patients with several types of cancers, including adre- nocortical carcinoma.216,217 Suramin decreased basal and ACTH-stimulated cortisol secretion in cultured adrenocortical cells in a dose dependent manner. Fur- thermore, the proliferation of adrenocortical cells in response to fetal calf serum was inhibited by high suramin concentrations. Thus, a likely explanation for the antitumor activity of suramin may be its interac- tion with growth factors that promote tumor growth by autocrine or paracrine stimulation. Dorfinger et al.216 reviewed 23 published case reports of advanced adrenal carcinomas treated with suramin. In 15 of 22 evaluable patients, there was some degree of tumor shrinkage. Arlt and coworkers217 reported data from 9 adults with metastatic carcinoma of the adrenal who were treated with suramin in four centers in Germany between 1987 and 1992. Three of 9 patients achieved a partial response, 2 of 9 patients exhibited disease sta- bilization, and 4 of 9 patients experienced progressive disease. Tumor responses were transient, and there were serious side effects, including coagulopathy (6 of 9 patients), thrombocytopenia (6 of 9 patients), poly- neuropathy (2 of 9 patients), and allergic skin reac- tions (4 of 9 patients). Thus, the clinical use of suramin is limited by the narrow therapeutic window with the risk of serious and possible lethal toxicity. Strict mon- itoring of suramin levels is mandatory, aiming at levels between 200 mg/L and 250 mg/L. It can be concluded that suramin should not be considered as first-line treatment for patients with metastatic adrenocortical carcinoma.

Gossypol

A biphenolic derivative extracted from cottonseeds, gossypol initially was demonstrated to exhibit an an- titumor effect on human adrenocortical cells in vitro218 and was used subsequently orally in the treat- ment of 21 patients with metastatic adrenal carci- noma. Eighteen patients completed at least 6 weeks of gossypol treatment. Three of those patients, who had

tumors that were refractory to other chemotherapeu- tic agents, had a partial tumor response that lasted from several months to >1 year. One patient had a minor response, 1 patient had stable disease, and 13 patients exhibited disease progression. The side ef- fects of gossypol were well tolerated: The only serious side effect was abdominal ileus, which resolved when the drug was withheld and restarted at a lower level. The authors concluded that gossypol can be used rel- atively safely on an outpatient basis for the treatment of metastatic adrenal carcinoma.219

Radiotherapy

The role of external radiotherapy in the treatment of patients with adrenocortical carcinoma has been doc- umented only infrequently in the literature. Percapio and Knowlton220 reported 14 patients with metastatic adrenal carcinoma who were given 3000-4000 rads of external radiation. Those authors reported that pain associated with metastases, particularly in the bones, and intestinal obstruction due to tumor growth could be reduced greatly with the treatment. Occasional lo- cal control of nonresectable lesions was observed.218 Other authors have described excellent responses to radiotherapy in patients with bony metastases and called attention to the possible prophylactic use of radiotherapy after surgery in patients with adrenal carcinoma.11,13,185,209 However, the majority of reports indicate that radiotherapy is ineffective in the treat- ment of patients with adrenocortical carcinoma and should be considered only as palliation for patients with bone involvement.10,21,28,211

CONCLUSIONS

The age incidence of adrenocortical carcinoma ap- pears to be bimodal, with a peak occurring in the first decade and a second peak occurring in the fourth decade. In the current series, adrenocortical carci- noma was far more prevalent in women than in men (4:1). Adrenocortical carcinoma occurring in children appears to have a less ominous prognosis and more often presents as pure VS. By contrast, adrenal carci- noma in adults usually presents with large masses, advanced stage of disease, a mixed CVS picture, and generally with a more aggressive picture with shorter life expectancy.

Modern-day imaging methods using CT, MRI, and US scanning have been quite successful in locating and staging adrenocortical carcinoma. Of the various pathologic methods used to classify adrenal tumors, we have found that the Weiss histologic criteria offer the most accurate assessment of tumor prognosis. A variety of immunologic markers, DNA ploidy, and cell phase markers have been explored in adrenal carci-

noma, but results to date have be inconsistent. In this regard, we are hopeful that the overexpression of mu- tant p53 will prove to be a useful marker of tumor prognosis.

Molecular genetic studies of patients with adreno- cortical carcinoma have suggested several potential abnormalities leading to aberrant and uncontrolled growth. Mutations of G-protein genes, mutations of p53 suppressor genes, overexpression of growth fac- tors, disrupted apoptosis, defective DNA repair, and linkage to chromosome abnormalities may offer fu- ture explanations for uncontrolled growth leading to tumor formation. With regard to the treatment of pa- tients with adrenocortical carcinoma, little has changed over the past generation. Surgical excision of the tumor and en bloc local extension offer the best prognosis. Patients with tumor invasion of venous structures do not appear to have an ominous progno- sis. Mitotane remains the mainstay of therapy, but the usefulness of this drug is limited by its severe toxicity and the lack of clear-cut evidence that it can prolong life.

REFERENCES

1. Brennan MF, MacDonald JS. Cancer of the endocrine sys- tem. In: De Vita VT Jr., Hellman SA, Rosenberg JB, editors. Cancer. Principles and practice of oncology. ed 2, vol 2, chapter 35. Philadelphia: Lippincott Co., 1985:1179-242.

2. . Cagle PT, Hough AJ, Pysher J, et al. Comparison of adrenal cortical tumors in children and adults. Cancer 1986;57:2235-7.

3. Steiner PE. Cancer: race and geography: some etiological, environmental, ethnological, epidemiological, and statisti- cal aspects in caucasoids, mongoloids, negroids and mexi- cans. Baltimore: Williams and Wilkins, 1954:25.

4. Brennan MF. Adrenocortical carcinoma. Cancer 1987;37:348- 65.

5. . Public Health Service, National Cancer Institute. Third Na- tional Cancer Survey: incidence data [National Cancer In- stitute monograph]. Bethesda, MD: United States Depart- ment of Health, Education, and Welfare; Public Health Service, National Institutes of Health, National Cancer In- stitute, 1975.

6. Jadpour N, Woltering EA, Brennan MF. Adrenal neoplasms. Curr Prob Surg 1980;17:1-52.

7. Plager JE. Carcinoma of the adrenal cortex: clinical descrip- tion, diagnosis, and treatment. Int Adv Surg Oncol 1984;7: 329-53.

8. Bertagna C, Orth D. Clinical and laboratory findings and results of therapy in 58 patients with adrenocortical tumors admitted to a single medical center. Am J Med 1981;71:855- 75.

9. Luton J-P, Cerdas S, Billaud L, et al. Clinical features of adrenocortical carcinoma, prognostic factors, and the effect of mitotane therapy. N Engl J Med 1990;322:1195-201.

10. Bodie B, Novick AC, Pontes JE, et al. The Cleveland Clinic experience with adrenal cortical carcinoma. J Urol 1989;141: 257-60.

11. Nader S, Hickey RC, Sellin RV, et al. Adrenal cortical carci- noma. A study of 77 cases. Cancer 1983;52:707-11.

12. Cohn K, Gottesman L, Brennan M. Adrenocortical carci- noma. Surgery 1986;100:1170-7.

13. King DR, Lack EE. Adrenal cortical carcinoma. A clinical and pathologic study of 49 cases. Cancer 1979;44:239-44.

14. Henley DJ, van Heerden JA, Grant CS, et al. Adrenal cortical carcinoma. A continuing challenge. Surgery 1983;94:926-31.

15. Karakousis CP, Rao V, Moore R. Adrenal adenocarcinomas: histologic grading survival. J Surg Oncol 1985;29:105-11.

16. Venkatesh S, Hickey RC, Sellin RV, et al. Adrenal cortical carcinoma. Cancer 1989;64:765-9.

17. Pommier RF, Brennan MF. An eleven-year experience with adrenocortical carcinoma. Surgery 1992;112:963-71.

18. Icard PH, Louvel A, Chapuis Y. Survival rates and prognostic factors in adrenocortical carcinoma. World J Surg 1992;16: 753-8.

19. Zografos GC, Driscoll DL, Karakousis CP, et al. Adrenal carcinoma: a review of 53 cases. J Surg Oncol 1994;55:160-4.

20. Kasperlik-Zakuska AA, Migdalska BM, Zgliczynski S, et al. Adrenocortical carcinoma. A clinical study and treatment results of 52 patients. Cancer 1995;75:2587-91.

21. Wooten MD, King DK. Adrenal cortical carcinoma. Epide- miology and treatment with mitotane and a review of the literature. Cancer 1993;72:3145-55.

22. Margio C, Muller H, Davies JND. Survey of cancer in chil- dren admitted to a Brazilian charity hospital. J Natl Cancer Inst 1969;43:1231-9.

23. Ribeiro RN, Sandrini RN, Schell ML, et al. Adrenocortical carcinoma in children: a study of 40 cases. J Clin Oncol 1990;8:67-74.

24. Sandrini R, Ribiero RC, DeLacerda L. Extensive personal experience-childhood adrenocortical tumors. J Clin En- docr Metabol 1997;82:2027-31.

25. Mendonça BB, Lucon AM, Menezes CAV, et al. Clinical, hormonal and pathological findings in a comparative study of adrenal cortical neoplasms in childhood and adulthood. J Urol 1995;154:2004-9.

26. Sabbaga CC, Avilla SG, Shultz C, et al. Adrenocortical carci- noma in children: clinical aspects and prognosis. J Pediatr Surg 1993;28:841-3.

27. Soreide JA, Brabrand K, Thorensen SO. Adrenal cortical car- cinoma in Norway. 1970-1984. World J Surg 1992;16:663-8.

28. Hogan TF, Gilchrist KW, Westring DW, et al. A clinical and pathological study of adrenocortical carcinoma. Therapeu- tic implications. Cancer1980;45:2880-3.

29. Ahlman H, Jansson S, Wängberg B, et al. Adrenocortical carcinoma-diagnostic and therapeutical implications. Eur J Surg 1993;159:149-58.

30. Schteingart DE, Oberman HA, Friedman BA, et al. Adrenal cortical neoplasms producing Cushing’s syndrome. A clini- copathologic study. Cancer 1968;22:1005-13.

31. Tang CK, Gray GF. Adrenocortical neoplasms. Prognosis and morphology. Urology 1975;5:691-5.

32. Rapaport E, Goldberg MB, Gordan GS, et al. Mortality in surgically treated adrenocortical tumors: II. Review of cases reported for the 20 year period 1930-1949, inclusive. Post- grad Med 1952;11:325-53.

33. Hutter AM Jr., Kayhoe DE. Adrenal cortical carcinoma: clin- ical features of 138 patients. Am J Med 1966;41:572-80.

34. Müller J. Adrenocortical tumors: clinical and diagnostic findings. Results Cancer Res 1990;118:106-12.

35. Grumberg SM. Development of Cushing’s syndrome and virilization after presentation of a nonfunctioning adreno- cortical carcinoma. Cancer 1982;50:815-6.

36. Halmi KA, Lascaria AD. Conversion of virilization to femi-

nization in a young girl with adrenal cortical carcinoma. Cancer 1971;27:931-5.

37. Lanes R, Gonzalez S, Obreson O. Adrenal cortical carcinoma in a 4-year-old child: temporal changes in steroid secretion. Clin Pediatr 1982;21:164-6.

38. Steward DR, Jones PHM, Jolleys A. Carcinoma of the adrenal gland in children. J Pediatr Surg 1974;9:59-67.

39. Holcombe JH, Physher TJ, Kirkland RT. Functioning adre- nocortical tumors in childhood. In: Humphrey GB: Grindey GB, Dehner LP, Acton RT, Pysker TJ, editors. Adrenal and endocrine tumors in children. Boston: Martinus Nijhoff Publishers, 1983:277-90.

40. Brooks RV, Felix-Davies D, Lee MR, et al. Hyperaldosteron- ism from adrenal carcinoma. Br Med J 1972;1:220-1.

41. Filipecki S, Feltynowski T, Poplawska W, et al. Carcinoma of the adrenal cortex with hyperaldosteronism. J Clin Endocri- nol Metabol 1972;35:225-9.

42. Salassa TM, Weeks RE, Northcutt RC, et al. Primary aldoste- ronism and malignant adrenocortical neoplasia. Trans Am Clin Climatol Assoc 1975;86:163-72.

43. Hyodo T, Megyesi K, Kahn CR, et al. Adrenocortical carci- noma and hypoglycemia: evidence for production of non- suppressible insulin-like activity by the tumor. J Clin Endo- crinol Metabol 1977;44:1175-84.

44. Zapz J, Futo E, Peter M, et al. Can “big” insulin-like growth factor II in serum of tumor patients account for the devel- opment of extrapancreatic tumor hypoglycemia? J Clin In- vest 1992;90:2574-84.

45. Falchuk KR. Inappropriate antidiuretic hormone-like syn- drome associated with an adrenocortical carcinoma. Am J Med Sci 1973;266:393-5.

46. Prinz RA, Brooks MH, Churchill R, et al. Incidental asymp- tomatic adrenal masses detected by computed tomographic scanning. Is operation required? JAMA 1982;248:701-4.

47. Lewinsky BS, Grigor KM, Symington T, et al. The clinical and pathologic features of “non-hormonal” adrenocortical tu- mors. Report of twenty new cases and review of the litera- ture. Cancer 1974;33:778-90.

48. Vandergrind AJ, Seshul R, Uhrich EC. Nonfunctional adeno- carcinoma of the adrenal cortex. J LA State Med Soc 1964; 116:130-3.

49. Weiss M, Margolis J, Zinn HJ, et al. Necrotizing adenocarci- noma of the adrenal as a cause of prolonged pyrexia-case report. J Am Geriatr Soc 1970;18:428-30.

50. Wood KF, Lees F, Rosenthal FD. Carcinoma of the adrenal cortex without endocrine effects. Br J Surg 1957;45:41-8.

51. Mossler JA, Woodard BH, Tannenbaum SI, et al. Cryptococ- cal meningitis in a patient with functioning adrenal cortical adenoma. Arch Pathol Lab Med 1981;105:276-7.

52. Dupuy R, Vallin J, Bontelier D, et al. Syndrome de Budd- Chiari par tumeur surrénale. Rev Int Hepatol 1964;14:672- 86.

53. Carbonnel F, Valla D, Menu Y, et al. Acute Budd-Chiari syndrome as first manifestation of adrenocortical carci- noma. J Clin Gastroenterol 1988;10:441-4.

54. Nicholls K. Massive adrenal hemorrhage complicating adre- nal neoplasm. Med J Aust 1979;2:560-2.

55. Francios J, Boels W, Rabaecy M. Cancers métastatiques de la choroide, dont un d’origine corticosurrénalienne. Ann Ocul (Paris) 1952;185:497-514.

56. Hirsch-Hoffman HV. Diagnose eines bosärtigen neben- nierentumors aus einer vaginalmetastase. Zentralbl Gynaekol 1928;52:1970-7.

57. Lipsett MB, Hertz R, Ross GT. Clinical and pathophysiologic aspects of adrenal carcinoma. Am J Med 1963;35:374-83.

58. Lynch HT, Mulcahy GM, Harris RE, et al. Genetic and patho- logic findings in a kindred with hereditary sarcoma, breast cancer, brain tumor, leukemia, lung, laryngeal, and adrenal cortical carcinoma. Cancer 1978;41:2055-64.

59. Li FP, Tudser MA, Fraumeni JF Jr. Childhood cancer in sibs. J Pediatr 1976;88:419-23.

60. Mark S, Clark OH, Kaplan RA. A virilized patient with con- genital hemihypertrophy. Postgrad Med 1994;70(J):752-5.

61. MacFarlane DA. Cancer of the adrenal cortex. The natural history, prognosis and treatment in a study of fifty-five cases. Ann R Coll Surg Engl 1958;23:155-86.

62. Sullivan M, Boileau M, Hodges CV. Adrenal cortical carci- noma. J Urol 1978;120:660-5.

63. Ritchie JP, Gittes RF. Carcinoma of the adrenal cortex. Can- cer 1980;45:1957-64.

64. Heinbecker P, O’Neil LW, Ackerman LV. Functional and nonfunctional adrenal cortical tumor. Surg Gynecol Obstet 1957;105:21-33.

65. O’Hare MJ, Monaghan P, Nevile AM. The pathology of ad- renocortical neoplasia: a correlated structural and func- tional approach to the diagnosis of malignant disease. Hum Pathol 1979;10(2):137-54.

66. Weiss LM. Comparative histologic study of 43 metastasizing and nonmetastasizing adrenocortical tumors. Am J Surg Pathol 1984;8:163-9.

67. Gandour ML, Grizzle WE. A small adrenocortical carcinoma with aggressive behavior. An evaluation of criteria for ma- lignancy. Arch Pathol Lab Med 1986;110:1076-9.

68. van Slooten H, Schaberg A, Smeenk D, et al. Morphologic characteristic of benign and malignant adrenocortical tu- mors. Cancer 1985;55:766-73.

69. Fuhrman SA, Lasky LC, Limas C. Prognostic significance of morphologic parameters in renal cell carcinoma. Am J Surg Pathol 1982;6:655-63.

70. Weiss LM, Medeiros LJ, Vickery AL Jr. Pathologic features of prognostic significance in adrenocortical carcinoma. Am J Surg Pathol 1989;13:202-6.

71. Ross EJ, Marshall-Jones P, Friedman M. Cushing’s diagnos- tic criteria. Q Med 1996;35:149-92.

72. Nader S, Hickey RC, Sellin RV, et al. Adrenal cortical carci- noma. A study of 77 cases. Cancer 1983;52:707-11.

73. Lack EE, Mulvihill JJ, Travis WD, et al. Adrenal cortical neoplasms in the pediatric and adolescent age group. Pathol Ann 1992;27:1-53.

74. Hayles AB, Hahn HB Jr., Sprague RG. Hormone-secreting tumors of the adrenal cortex in children. Pediatrics 1966;37: 19-25.

75. Sakai Y, Yanase T, Hara T, et al. Mechanism of abnormal production of adrenal androgens in patients with adreno- cortical adenomas and carcinomas. J Clin Endocrinol Metabol 1994;78:36-9.

76. Martin JF. Suprarenal calcification. Radiol Clin North Am 1965;3:129-38.

77. Yeh HC, Milly HA, Rose J, et al. Ultrasonography of adrenal masses: usual features. Radiology 1978;127:467-74.

78. Abrams HL, Siegelman SS, Adams DF, et al. Computed to- mography versus ultrasound of the adrenal gland: a pro- spective study. Radiology 1982;143:121-8.

79. Bernardino ME, Goldstein HM, Green B. Gray scale ultra- sonography of adrenal neoplasms. Am J Roentgenol 1978; 130:741-4.

80. Ferruci JT Jr. Body ultrasonography (medical progress). N Engl J Med 1979;300:590-602.

81. Lee JK, Sagel SS, Stanley RJ. Adrenal glands. In: Computed body tomography with MRI correlation. ed 2. New York: Raven Press, 1989:827-49.

82. Edelman RR, Hesselink JR. Adrenal glands. In: Clinical mag- netic resonance imaging. Philadelphia: W.B. Saunders Co., 1990:888-94.

83. Shultz CL, Haaga JR, Fletcher BD, et al. MRI of the adrenal glands: a comparison with CT. Am J Roentgenol 1984;143: 1235-40.

84. Falke THM, te Strake L, Shaff MJ, et al. MR imaging of the adrenals: correlation with computed tomography. J Comput Assist Tomogr 1986;10:242-53.

85. Bernardino ME. Management of the asymptomatic patient with a unilateral adrenal mass. Radiology 1988;166:121-3.

86. Davis PL, Hricak H, Bradley WG Jr. Magnetic resonance imaging of the adrenal glands. Radiol Clin North Am 1984; 22:891-5.

87. Van Erkel AR, van Gils APG, Lequin M, et al. CT and MR distinction of adenomas and nonadenomas of the adrenal glands. J Comput Assist Tomogr 1994;18:432-8.

88. McLoughlin RF, Bilbey JH. Tumors of the adrenal gland: findings on CT and MR imaging. Am J Roentgenol 1994;163: 1413-8.

89. Reinig JW, Doppman JL, Dwyer AJ, et al. MRI of indetermi- nate adrenal masses. AJR 1986;147:493-6.

90. Lee MJ, Hahn PF, Papanicolau N, et al. Benign and malignant adrenal masses: CT distinction with attenuation coefficients, size and observer analysis. Radiology 1991;179:415-8.

91. Reinig JW. MR imaging differentiation of adrenal masses: has the time finally come? Radiology 1992;185:339-40.

92. Bilbey JH, McLoughlin RF, Kurkjian PS, et al. MR imaging of adrenal masses: value of chemical-shift imaging for distin- guishing adenomas from other tumors. Am J Roentgenol 1995;164:637-44.

93. Copeland PM. The incidentally discovered adrenal mass. Ann Intern Med 1983;98:940-5.

94. Krestin GP, Friedmann G, Fischbach R, et al. Evaluation of adrenal masses in oncologic patients: dynamic contrast- enhanced MR vs CT. J Comput. Assist Tomogr 1991;15:104- 10.

95. Korobkin M, Brodeur FJ, Yutzy GG, et al. Differentiation of adrenal adenomas from nonadenomas using CT attenua- tion values. Am J Roentgenol 1996;166:531-6.

96. Lee MJ, Mayo-Smith WW, Hahn PF, et al. State-of-art MR imaging of the adrenal gland. Radiographics 1994;14:1015- 29.

97. Chang A, Glazer HS, Lee JKT, et al. Adrenal gland: MR imaging. Radiology 1987;163:123-8.

98. Doppman JL, Reinig JW, Dwyer AJ, et al. Differentiation of adrenal masses by magnetic resonance imaging. Surgery 1987;102:1018-26.

99. Baker ME, Blinder R, Spritzer C, et al. MR evaluation of adrenal masses at 1.5T. Am J Roentgenol 1989;153:307-12.

100. Glazer GM, Woolsey EJ, Borrello J, et al. Adrenal tissue char- acterization using MR imaging. Radiology 1986;158:73-9.

101. Chezmar JL, Robbins SM, Nelson RC, et al. Adrenal masses: characterization with T1-weighted MR imaging. Radiology 1985;166:357-9.

102. Korobkin M, Lombardi TJ, Aisen AM, et al. Characterization of adrenal masses with chemical shift and gadolinium-en- hanced MR imaging. Radiology 1995;197:411-8.

103. Reinig JW, Stutley JE, Leonhardt CM, et al. Differentiation of adrenal masses with MR imaging: comparison of tech- niques. Radiology 1994;192:41-6.

104. Kier R, McCarthy S. MR characterization of adrenal masses: field strength and pulse sequence considerations. Radiology 1989;171:671-4.

105. Outwater EK, Siegelman ES, Radecki PD, et al. Distinction between benign and malignant adrenal masses: value of T1-weighted chemical-shift MR imaging. Am J Roentgenol 1995;165:578-83.

106. Schwartz LH, Panicek DM, Koutcher JA, et al. Echoplanar MR imaging for characterization of adrenal masses in pa- tients with malignant neoplasms: preliminary evaluation of calculated T2 relaxation values. Am J Roentgenol 1995;164: 911-5.

107. Gross M, Valk TW, Freitas JE, et al. The relationship of adrenal iodomethylnorcholesterol uptake to indices of ad- renal cortical function in Cushing’s syndrome. J Clin Endo- crinol Metabol 1981;52:1062-6.

108. Gross MD, Shapiro B, Grekin RJ, et al. The relationship of adrenal gland iodomethylnorcholesterol uptake to zona glo- merulosa function in primary aldosteronism. J Clin Endo- crinol Metabol 1983;57:477-81.

109. Gross MD, Shapiro B, Freitas JE. The relationship of 13l I-6-beta-iodomethyl-norcholesterol (NP-59) adrenal corti- cal uptake to indices of androgen secretion in women with hyperandrogenism. Clin Nucl Med 1984;9:264-70.

110. Gross MD, Shapiro B, Bouffard JA, et al. Distinguishing benign from malignant euadrenal masses. Ann Intern Med 1984;109:613-8.

111. Fig LM, Gross MD, Shapiro B, et al. Adrenal localization in the adrenocorticotropic hormone-independent Cushing’s syndrome. Ann Intern Med 1988;109:547-53.

112. Thrall JH, Freitas JE, Beierwaltes WH. Adrenal scintigraphy. Semin Nucl Med 1978;8:23-41.

113. Didier D, Racle A, Etievent JP, et al. Tumor thrombus of the inferior vena cava secondary to malignant abdominal neo- plasms: US and CT evaluation. Radiology 1987;162:83-9.

114. Goldfarb DA, Novick AC, Lorig R, et al. Magnetic resonance imaging for assessment of vena caval tumor thrombi: a comparative study with vena cavography and computerized tomography scanning. J Urol 1990;144:1100-4.

115. Hough AJ, Hollifield JW, Page DL, et al. Prognostic factors in adrenal cortical tumors: a mathematical analysis of clinical and morphologic data. Am J Pathol 1979;72:390-9.

116. Nakano M. Adrenal cortical carcinoma. A clinicopathologi- cal and immunohistochemical study of 91 autopsy cases. Acta Pathol Jpn 1988;38:163-80.

117. Gandour MJ, Grizzle WE. A small adrenocortical carcinoma with aggressive behavior. An evaluation of criteria for ma- lignancy. Arch Pathol Lab Med 1986;110:1076-9.

118. Medeiros LJ, Weiss LM. New developments in the patho- logic diagnosis of adrenal cortical neoplasms. A review. Am J Surg Pathol 1992;97(1):73-83.

119. Azumi N, Battifora H. The distribution of vimentin and keratin in epithelial and non-epithelial neoplasms. A com- prehensive immunohistochemical study on formalin- and alcohol-fixed tumors. Am J Clin Pathol 1987;88:286-96.

120. Schröder S, Niendorf A, Achilles E, et al. Immunocytochem- ical differential diagnosis of adrenocortical neoplasms using the monoclonal antibody D11. Virchows Arch A Pathol Anat 1990;417:89-96.

121. Henzen-Logmans SC, Stel HV, Van-Muijen GNP, et al. Ex-

pression of intermediate filament proteins in adrenal cortex and related tumours. Histopathology 1988;12:359-72.

122. Cote RJ, Cordon-Cardo C, Reuter VE, et al. Immunopathol- ogy of adrenal and renal cortical tumors: coordinated change in antigen expression is associated with neoplastic conversion in the adrenal cortex. Am J Pathol 1990;136: 1077-84.

123. Edgren M, Eriksson B, Wilander E, et al. Adrenocortical carcinoma: a clinical and immunohistochemical study. Int J Oncol 1985;6:825-31.

124. Komminoth P, Roth J, Schröder S, et al. Overlapping expres- sion of immunohistochemical markers and synaptophysin mRNA in pheochromocytomas and adrenocortical carcino- mas. Implications for the differential diagnosis of adrenal gland tumors. Lab Invest 1995;72:424-31.

125. Schröder S, Padberg BC, Achilles E, et al. Immunocytochem- istry in adrenocortical tumours: a clinicomorphological study of 72 neoplasms. Virchows Arch A Pathol Anat 1992; 420:65-70.

126. Gaffey MJ, Traweek ST, Mills SE, et al. Cytokeratin expres- sion in adrenocortical neoplasia: an immunohistochemical and biochemical study with implications for the differential diagnosis of adrenocortical, hepatocellular, and renal cell carcinoma. Hum Pathol 1992;23:144-53.

127. Darzinkiewicz Z. The cell cycle: application of flow cytom- etry in studies of cell reproduction. In: Bauer KD, Duque RE, Shankey TV, editors. Clinical flow cytometry principles and application. Baltimore: William and Wilkins, 1993:13-40.

128. Shankey TV, Rabinovitch PS, Bagwell B, et al. Guidelines for implementation of clinical DNA cytometry. Cytometry 1993; 14:472-7.

129. Klein FA, Kay S, Radcliff JE, et al. Flow cytometric determi- nations of ploidy and proliferation patterns of adrenal neo- plasms: an adjunct to histologic classification. J Urol 1985; 135:862-6.

130. Bowlby LS, DeBault LE, Abraham SR. Flow cytometric anal- ysis of adrenal cortical tumor DNA. Relationship between cellular DNA and histopathologic classification. Cancer 1986;58:1499-505.

131. Amberson JB, Vaughan E, Gray GF, et al. Flow cytometric analysis of nuclear DNA from adrenocortical neoplasms. A retrospective study using paraffin-embedded tissue. Cancer 1987;59:2091-5.

132. Hosaka Y, Rainwater LM, Grant CS, et al. Adrenocortical carcinoma: nuclear deoxyribonucleic acid ploidy studied by flow cytometry. Surgery 1987;102:1027-34.

133. Taylor SR, Roederer M, Murphy RF. Flow cytometric DNA analysis of adrenocortical tumors in children. Cancer 1987; 59:2059-63.

134. Joensuu H, Klemi PJ. DNA aneuploidy in adenomas of en- docrine organs. Am J Pathol 1988;132:145-51.

135. Rainwater LM, Young WF Jr., Farrow FM, et al. Flow cyto- metric analysis of deoxyribonucleic acid ploidy in benign and malignant aldosterone-producing neoplasms of the ad- renal gland. Surg Gynecol Obstet 1989;168:491-6.

136. Cibas ES, Medeiros LJ, Weinberg DS, et al. Cellular DNA profiles of benign and malignant adrenocortical tumors. Am J Surg Pathol 1990;14:948-55.

137. Camuto P, Schinella R, Gilchrist K, et al. Adrenocortical carcinoma: flow cytometric study of 22 cases, an ECOG study. Urology 1991;37:380-4.

138. Padberg BC, Lauritzen I, Achiles E, et al. DNA cytophotom- etry in adrenocortical tumors: a clinicomorphological study of 66 cases. Virchows Arch A Pathol Anat 1991;419:167-70.

139. Zerbini C, Lozakewich PW, Weinberg DS, et al. Adrenocor- tical neoplasms in childhood and adolescence: analysis of prognostic factors including DNA content. Endocr Pathol 1992;3:116-28.

140. Suzuki T, Sasano H, Nisikawa T, et al. Discerning malig- nancy in adrenocortical neoplasms: utility of DNA flow cy- tometry and immunohistochemistry. Mod Pathol 1992;5: 224-31.

141. Haak HR, Cornelisse CJ, Hermans J, et al. Nuclear DNA content and morphological characteristics in the prognosis of adrenocortical carcinoma. Br J Cancer 1993;68:151-5.

142. Bugg MF, Ribeiro RC, Roberson PK, Lloyd RV, et al. Corre- lation of pathologic features with clinical outcome in pedi- atric adrenocortical neoplasia. Am J Clin Pathol 1994;101: 625-9.

143. Reincke M, Karl M, Travis WH, et al. p53 mutations in human adrenocortical neoplasms: immunohistochemical and molecular studies. J Clin Endocrinol Metabol 1994;78: 790-4.

144. Quinn CM, Wright NA. The clinical assessment of prolifer- ation and growth in human tumors: evaluation of methods and application as prognostic variables. J Pathol 1990;160: 93-102.

145. Woosley JT. Measuring cell proliferation. Arch Pathol Lab Med 1991;115:555-7.

146. Linden MD, Torres FX, Kubus J, et al. Clinical application of morphologic and immunocytochemical assessments of cell proliferation. Am J Clin Pathol 1992;97 (Suppl 1):S4-13.

147. Goldblum JR, Shannon RS, Kaldjian EP, et al. Immunohis- tochemical assessment of proliferative activity in adreno- cortical neoplasms. Mod Pathol 1992;6:63-8.

148. Sazano H, Itamani A, Shizawa S, et al. Cell proliferation and apoptosis in normal and pathologic human adrenal glands. Mod Pathol 1995;8:11-7.

149. Kida Y, Takano Y, Okudaira M. Argyrophilic nucleolar orga- nizer regions in human adrenocortical neoplasms. J Cancer Res Clin Oncol 1992;119:49-54.

150. Oz B, Dervisoglu S, Dervisoglu M, Oz O. Silver binding nucleolar organizer regions in adrenocortical neoplasia. Cy- topathology 1992;3:93-9.

151. Sazano H, Saito Y, Sato I, Sazano N, et al. Nucleolar orga- nizer regions in human adrenocortical disorders. Mod Pathol 1990;3:591-5.

152. Gicquel C, Bertagna X, Le Bouc Y. Recent advances in the pathogenesis of adrenocortical tumours. Eur J Endocrinol 1995;133:133-44.

153. Latronico AC, Chrousas GP. Neoplasms of the adrenal cor- tex. Clinical and basal aspects. In: Arnold A, editor. Endo- crine neoplasms. Kluwer Academic Publishers, 1997:217-37.

154. Beuschlein F, Reincke M, Travis WD, et al. Clonal composi- tion of human adrenocortical neoplasms. Cancer Res 1994; 54:4927-32.

155. Gicquel C, Leblond-Francillard M, Bertagna X, et al. Clonal analysis of human adrenocortical carcinomas and secreting adenomas. Clin Endocrinol (Oxford) 1994;40:465-77.

156. Weinstein LS, Shenker A, Gejman PV, et al. Activating mu- tations of the stimulatory G protein in the McCune-Albright syndrome. N Engl J Med 1991;325:1688-95.

157. Lyons J, Landis CA, Harsh G, et al. Two G protein oncogenes in human endocrine tumors. Science 1990;249:655-9.

158. Yoshimoto K, Iwahana H, Fukuda A, et al. Rare mutations of the Gs alpha subunit in human endocrine tumors. Cancer 1993;72:1386-93.

159. Reincke M, Karl M, Travis W, et al. No evidence for onco-

genic mutations in guanine nucleotide-binding proteins of human adrenocortical neoplasms. J Clin Endocrinol Metabol 1993;77:1419-22.

160. Gicquel C, Dib A, Bertagna X, et al. Oncogenic mutations of a-Gi2 protein are not determined for human adrenocortical tumourigenesis. Eur J Endocrinol 1995;133:166-72.

161. Moul JW, Bishoff JT, Theune SM, et al. Absent ras gene mutations in human adrenal cortical neoplasms and pheo- chromocytomas. J Urol 1993;149:1389-94.

162. Yashiro T, Hara H, Fulton NC, et al. Point mutations of ras genes in human adrenal cortical tumors: absence in adre- nocortical hyperplasia. World J Surg 1994;18:455-61.

163. Bauman A, Bauman CG. Virilizing adrenocortical carcino- ma: development in a patient with salt-losing congenital adrenal hyperplasia. JAMA 1982;248:3140-1.

164. Barzilay JI, Pazianos AG. Adrenocortical carcinoma. Urol Clin North Am 1989;16:457-68.

165. Parma J, Duprez L, Van Sande J, et al. Somatic mutations in the thyrotropin receptor gene cause hyperfunctioning thy- roid adenomas. Nature 1993;365:649-51.

166. Tsigos C, Arai K, Latronico AC, et al. Receptors for melano- cortin peptides in the hypothalamic-pituitary-adrenal axis and skin. Ann NY Acad Sci 1995;771:352-63.

167. Latronico AC, Reincke M, Mendonça BB, et al. No evidence for oncogenic mutations in the adrenocorticotropin recep- tor gene in human adrenocortical neoplasms. J Clin Endo- crinol Metabol 1995;80:875-7.

168. Nawata H, Takayanagi R, Ohnaka, Sakai Y, et al. Type 1 angiotensin II receptors of adrenal tumors. Steroids 1995;60: 28-34.

169. Nishizuka Y. The role of protein kinase C in cell surface signal transduction and tumour promotion. Nature 1984; 308:693-8.

170. Castagna M, Takai Y, Kaibuichi K, et al. Direct activation of calcium-activated, phospholipid-dependent protein kinase by tumor-promoting phorbol esters. J Biol Chem 1982;257: 7847-51.

171. Latronico AC, Mendonça BB, Bianco AC, et al. Calcium- dependent protein kinase-C activity in human adrenocorti- cal neoplasms, hyperplastic adrenals, and normal adreno- cortical tissue. J Clin Endocrinol Metabol 1994;79:736-9.

172. Li FP, Fraumeni, JF. Prospective study of a family cancer syndrome. JAMA 1982;247:2692-4.

173. Malkin D, Li FP, Strong LC, Fraumeni JF, et al. Germ line p53 mutations in a familial syndrome of breast cancer, sarco- mas, and other neoplasms. Science 1990;250:1233-8.

174. Roemer K, Friedmann T. Mechanisms of action of the p53 tumor suppressor and prospects for cancer gene therapy by reconstitution of p53 function. Ann NY Acad Sci 1994;716: 265-82.

175. Lin SR, Lee YJ, Tsai JH. Mutations of the p53 gene in human functional adrenal neoplasms. J Clin Endocrinol Metabol 1994;78:483-91.

176. Serrano M, Hannon BJ, Beach D. A new regulatory motif in cell-cycle control causing specific inhibition of cyclin D/CDKY. Nature 1993;366:704-7.

177. Kamb A, Gruis NA, Weaver-Feldhaus J, et al. A cell cycle regulator potentially involved in genesis of many tumor types. Science 1994;264:436-40.

178. Yano T, Linehan M, Anglard P, et al. Genetic changes in human adrenocortical carcinoma. J Natl Cancer Inst 1989; 81:518-23.

179. Gicquel C, Bertagna X, Schneid H, et al. Rearrangement at the 11p15 locus and overexpression of insulin-like growth factor-II gene in sporadic adrenocortical tumors. J Clin En- docrinol Metabol 1994;78:1444-53.

180. Rosenberg C, Della-Rosa VA, Latronico AC, et al. Selection of adrenal tumor cells in culture demonstrated by interphase cytogenetics. Cancer Genet Cytogenet 1995;79:36-40.

181. Ping AP, Reeve AE, Law DJ, et al. Genetic linkage of Beck- with-Wiedmann syndrome to 11p15. Am J Hum Genet 1989; 44: 720-3.

182. Stratakis CA, Carney JA, Lin JP, et al. Carney complex, a familial multiple neoplasia and lentiginosis syndrome. J Clin Invest 1996;97:699-705.

183. Thakker RV. The role of molecular genetics in screening for multiple endocrine neoplasia type I. Endocrinol Metabol Clin North Am 1994;23:117-35.

184. Skogseid B, Larsson C, Lindgren PG, et al. Clinical and genetic features of adrenocortical lesions in multiple endo- crine neoplasia type 1. J Clin Endocrinol Metabol 1992;75: 76-81.

185. Jensen JC, Harvey IP, Sindelar WF, et al. Recurrent or met- astatic disease in select patients with adrenocortical cancer. Arch Surg 1991;126:457-61.

186. Weisnagel JS, Gagner M, Breton G, et al. Laparoscopic ad- renalectomy. Endocrinologist 1996;6:169-78.

187. Cheung PS, Thompson NW. Right atrial extension of adreno- cortical carcinoma. Surgical management using hypothermia and cardiopulmonary bypass. Cancer 1989;64:812-25.

188. Geelhoed GW, Dunnick NR, Doppman JL. Management of intravenous extensions of endocrine tumors and prognosis after surgical treatment. Ann J Surg 1980;139:844-8.

189. Grondal S, Adermark B, Eriksson B, et al. Adrenocortical carcinoma: a retrospective study of a rare tumor with a poor prognosis. Eur J Surg Oncol 1990;16:500-6.

190. Thompson NW, Cheung PSY. Diagnosis and treatment of functioning and nonfunctioning adrenocortical neoplasms in- cluding incidentalomas. Surg Clin North Am 1987;67:423-36.

191. Schteingart DE. Cushing’s syndrome. Endocrine Metabol Clin North Am 1989;18:311-38.

192. Luton J-P, Mahoudeau JA, Bouchard P, et al. Treatment of Cushing’s disease by o,p’-DDD. Survey of 62 cases. N Engl J Med 1979;300:459-64.

193. Van Seters AP, Moolenaar AJ. Mitotane increases the blood level of hormone-binding proteins. Acta Endocrinol (Copen- hagen) 1991;124:526-33.

194. Moolenaar AJ, van Slooten H, van Seters AP, et al. Blood levels of o,p’-DDD following administration in various ve- hicles after a single dose and during long- term treatment. Cancer Chemother Pharmacol 1981;7:51-4.

195. Hajjar RA, Hickey RC, Samaan NA. Adrenal cortical carci- noma. A study of 22 patients. Cancer 1975;35:549-54.

196. Hoffman DL, Mattox VL. Treatment of adrenocortical carci- noma with o,p’-DDD. Med Clin North Am 1972;6:999-1012.

197. Hutter AM Jr., Kayhoe DE. Adrenal cortical carcinoma. Re- sults of treatment with o,p’-DDD in 138 patients. Am J Med 1966;41:581-92.

198. Lubitz JA, Freeman L, Okun R. Mitotane use in inoperable adrenal cortical carcinoma. JAMA 1973;223:1109-12. 1993. Becker D, Schumacher OP. O,p’-DDD therapy in invasive adrenocortical carcinoma. Ann Intern Med 1975;82:677-9.

200. Downing V, Eule J, Huseby RA. Regression of an adrenal cortical carcinoma and its neovascular bed following mito- tane therapy: a case report. Cancer 1974;34:1882-7.

201. Jaraback J, Rice K. Metastatic adrenocortical carcinoma. Prolonged regression with mitotane therapy. JAMA 1981; 246:1706-7.

202. Coelho Netto AS, Wajchenberg BL, Ravaglia C, et al. Treat- ment of adrenocortical cancer with o,p’-DDD. Ann Intern Med 1963;59:74-8.

203. Fisher DA, Panos TC, Melby JC. Therapy of adrenocortical cancer with o-p’-DDD in two children. J Clin Endocrinol Metabol 1963;23:218-21.

204. Helson L, Wollner N, Murphy ML, et al. Metastatic adrenal cortical carcinoma: biochemical changes accompanying clinical regression during therapy with o,p’-DDD. Clin Chem 1971;17:1191-3.

205. Ostuni JA, Roginsky MS. Metastatic adrenal cortical carci- noma: documented cure with combined chemotherapy. Arch Intern Med 1975;135:1257-8.

206. Benaily M, Schweisguth O, Job J-C. Les tumeurs cortico- surrenales de l’enfant. Etude retrospective de 34 cas ob- serves de 1954 a 1973. Arch Franç Pediatr 1975;32:441-54.

207. Rappaport R, Schweisguth O, Cachin O, et al. Corticosurre- nalome malin avec metastases Exerese et traitment par o,p’- DDD survi de guerison. Arch Franç Pediatr 1978;35:551-4.

208. Greig F, Oberfield SE, Levine LS, et al. Recovery of adrenal function after treatment of adrenocortical carcinoma with o,p’-DDD. Clin Endocrinol 1984;20:389-99.

209. Haak HR, Hermans J, van de Velde CJH, et al. Optimal treatment of adrenocortical carcinoma with mitotane re- sults in a consecutive series of 96 patients. Br J Cancer 1994;69:947-51.

210. Kasperlik-Zaluska AA, Migdalska B, et al. Impact of adjuvant mitotane on the clinical course of patients with adrenocor- tical cancer. Cancer 1994;73:1533-4.

211. Schteingart DE, Motazedi A, Noonan RA, et al. Treatment of adrenal carcinomas. Arch Surg 1982;117:1142-6.

212. Vassilopoulou-Sellin R, Guinee VF, Klein MJ, et al. Impact of adjuvant mitotane on the clinical course of patients with adrenocortical cancer. Cancer 1993;71:3119-23.

213. Decker RA, Elson P, Hogan TF, et al. For the Eastern Coop- erative Oncology Group study 1879: mitotane and Adriamy- cin in patients with advanced adrenocortical carcinoma. Surgery 1991;110:1006-13.

214. van Slooten H, Moolenaar AJ, van Seters AP, et al. The treatment of adrenocortical carcinoma with o,p’-DDD: prognostic implications of serum level monitoring. Eur J Cancer Clin Oncol 1984;20:47-53.

215. Schlumberg M, Ostronoff M, Bellaiche M, et al. 5-Fluorou- racil, doxorubicin and cisplatin in adrenal cortical carci- noma. Cancer 1988;61:1492-4.

216. Dorfinger K, Niederle B, Vierhapper H, et al. Suramin and the human adrenocortex: results of experimental and clini- cal studies. Surgery 1991;110:1100-5.

217. Arlt W, Reineke M, Siegmann L, et al. Suramin in adreno- cortical cancer: limited efficacy and serious toxicity. Clin Endocrinol 1994;41:199-307.

218. Wu YW, Chick CL, Knazek RA. An in vitro and in vivo study of antitumor effects of gossypol on human SW-13 adreno- cortical carcinoma. Cancer Res 1989;49:3754-8.

219. Flack MR, Pyle RG, Mullen NM, et al. Oral gossypol in the treatment of metastatic adrenal cancer. J Clin Endocrinol Metabol 1993;76:1019-24.

220. Percarpio B, Knowlton AH. Radiation therapy of adrenal cortical carcinoma. Acta Radiol Ther Phys Biol 1976; 15:288-92.

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Adrenocortical Carcinoma Clinical and Laboratory Observations

KEYWORDS: adrenal carcinoma, adrenocortical carcinoma, virilization, childhood virilization, mitotane.

Epidemiologic Features: Age, Gender and Race

Clinical Features of Patients with Adrenal Carcinoma

Natural History of Adrenal Cortical Carcinoma Subtypes

Tumor Staging and Prognosis

BIOCHEMICAL AND HORMONAL FINDINGS IN CHILDREN AND ADULTS

Biochemical Abnormalities

Hormonal Findings

Children with adrenocortical carcinoma

Adults with adrenocortical carcinoma

IMAGING STUDIES

Ultrasonography

Computerized tomography

Magnetic Resonance Imaging

Adrenal Cortical Scintigraphy

Imaging Assessment of IVC Invasion

Imaging of Distant Metastases

PATHOLOGIC FINDINGS IN ADRENAL CARCINOMA Gross Anatomic Studies

Microscopic Evaluation Histologic analysis

Immunohistochemical evaluation

DNA Analysis and Cell Proliferation

DNA ploidy in adrenocortical tumors

MOLECULAR MECHANISMS OF HUMAN ADRENOCORTICAL TUMORIGENESIS

Oncogenes

Tumor Suppressor Genes

Clinical Syndromes and Chromosomal Abnormalities Associated with Adrenocortical Neoplasms

TREATMENT OF ADRENAL TUMORS Surgery

Medical Therapy

Inhibitors of the adrenal cortex

Chemotherapy

Cisplatin

Cyclophosphamide, doxorubicin, and cisplatin

5-Flurouracil, doxorubicin, and cisplatin

Suramin

Gossypol

Radiotherapy

CONCLUSIONS

REFERENCES

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