Current management options for recurrent adrenocortical carcinoma

Anthony R Glover,¹ Julian C Y Ip,¹ Jing Ting Zhao,¹ Patsy S H Soon,^1,4 Bruce G Robinson,^1,3 Stan B Sidhu<sup>1,2

1</sup>Kolling Institute of Medical Research, Cancer Genetics Laboratory, ²Endocrine Surgical Unit, ³Department of Endocrinology, Royal North Shore Hospital and University of Sydney, St Leonards, ⁴Department of Surgery, Bankstown Hospital and University of New South Wales, Bankstown, NSW, Australia

Abstract: Adrenal cortical carcinoma (ACC) is a rare cancer that poses a number of management challenges due to the limited number of effective systemic treatments. Complete surgical resection offers the best chance of long-term survival. However, despite complete resection, ACC is associated with high recurrence rates. This review will discuss the management of recurrent ACC in adults following complete surgical resection. Management should take place in a specialist center and treatment decisions must consider the individual tumor biology of each case of recurrence. Given the fact that ACC commonly recurs, management to prevent recurrence should be considered from initial diagnosis with the use of adjuvant mitotane. Close follow up with clinical examination and imaging is important for early detection of recurrent disease. Locoregional recurrence may be isolated, and repeat surgical resection should be considered along with mitotane. The use of radiotherapy in ACC remains controversial. Systemic recurrence most often involves liver, pulmonary, and bone metastasis and is usually managed with mitotane, with or without combination chemotherapy. There is a limited role for surgical resection in systemic recurrence in selected patients. In all patients with recurrent disease, control of excessive hormone production is an important part of management. Despite intensive management of recurrent ACC, treatment failure is common and the use of clinical trials and novel treatment is an important part of management.

Keywords: recurrence, surgery, chemotherapy, mitotane, treatment