Localised adrenocortical carcinoma: the decisions you may face
5 treatment settings, 4 with more than one named option. Each section lays out the options the standard of care names, what each is for, the trials behind them with their recorded results, the side effects and cautions on record, and questions to ask. Built from the cancer page's standard-of-care rows; nothing here is advice for your case.
Diagnosis and staging
Hormone work-up, contrast CT or MRI of the adrenal, chest CT and FDG-PET; no biopsy of a resectable adrenal mass; germline testing.
A CT scan is a fast 3D X-ray that shows the size and shape of tumours and whether they have spread.
- Fast, ubiquitous
- Sub-millimetre resolution
- Standard for RECIST response
MRI uses a strong magnet and radio waves, with no ionising radiation, to picture soft tissue in finer contrast than CT, so it is the standard scan for brain tumours, prostate, rectal cancer staging, liver lesions and breast screening in high-risk women. It is slow, expensive and blurred by movement.
- No ionising radiation
- Best soft-tissue and brain imaging
- Functional sequences (diffusion, perfusion)
FDG PET is the standard PET scan. A radioactive sugar shows which tissues are burning glucose fast, which most cancers do.
- Universal availability
- Decades of validation
A test of the DNA you were born with, to find inherited risk genes such as BRCA or Lynch syndrome.
- Actionable for patient and relatives
- Cheap
No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.
- Anatomic only; cannot distinguish scar from live tumour
- Radiation dose
- Poor for brain, marrow, and small peritoneal disease
- Slow and expensive
- Motion artefacts
- Gadolinium concerns in renal impairment
- Non-specific: infection and inflammation are also hot
- Brain background
- Poor in indolent tumours
- VUS burden
- Uptake and counselling capacity
- Between CT (computed tomography), MRI, FDG PET and the other options, which do you recommend for me, and what about my case would make you choose differently?Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- Does your recommendation follow the current guideline (ESE/ENSAT guideline on adrenocortical carcinoma 2018), and if it departs from it, why?Why: Departures from guidelines are sometimes right for an individual; they should be explained.
- For my situation (diagnosis and staging), which of the standard options do you recommend and why?Why: Guideline options include: Hormone work-up, contrast CT or MRI of the adrenal, chest CT and FDG-PET; no biopsy of a resectable adrenal mass; germline testing.
Add these to your appointment list, or take the full question set for this cancer.
Resectable disease
Open adrenalectomy with en bloc resection of adherent structures and locoregional lymphadenectomy by an experienced surgeon; laparoscopic surgery only for small tumours; perioperative hydrocortisone for cortisol-secreting tumours.
Surgeons operate through small incisions using robotic arms with tremor-free precision and 3D vision.
- Precision, shorter stay
- Enables complex minimally invasive resections
No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.
- Cost
- Loss of haptic feedback
- Not superior for every indication
- Is Robotic & minimally invasive surgery the only reasonable path for me, or is there a trial, a different sequence or a wait-and-see option?Why: A single standard does not mean a single choice; timing and trials are decisions too.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- Does your recommendation follow the current guideline (ESE/ENSAT guideline on adrenocortical carcinoma 2018), and if it departs from it, why?Why: Departures from guidelines are sometimes right for an individual; they should be explained.
- For my situation (resectable disease), which of the standard options do you recommend and why?Why: Guideline options include: Open adrenalectomy with en bloc resection of adherent structures and locoregional lymphadenectomy by an experienced surgeon; laparoscopic surgery only for small tumours; perioperative hydrocortisone for cortisol-secreting tumours.
Add these to your appointment list, or take the full question set for this cancer.
After complete resection, low risk
Observation with imaging every three months (ADIUVO showed no benefit from mitotane).
A relative of the insecticide DDT that is the only drug specific to adrenal cortex cancer; it needs blood-level monitoring and permanent steroid replacement.
A CT scan is a fast 3D X-ray that shows the size and shape of tumours and whether they have spread.
- Fast, ubiquitous
- Sub-millimetre resolution
- Standard for RECIST response
No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.
- Anatomic only; cannot distinguish scar from live tumour
- Radiation dose
- Poor for brain, marrow, and small peritoneal disease
- Between Mitotane and CT (computed tomography), which do you recommend for me, and what about my case would make you choose differently?Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- Does your recommendation follow the current guideline (ESE/ENSAT guideline on adrenocortical carcinoma 2018), and if it departs from it, why?Why: Departures from guidelines are sometimes right for an individual; they should be explained.
- For my situation (after complete resection, low risk), which of the standard options do you recommend and why?Why: Guideline options include: Observation with imaging every three months (ADIUVO showed no benefit from mitotane).
- Am I a candidate for Mitotane, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
Add these to your appointment list, or take the full question set for this cancer.
After resection, high risk
Adjuvant mitotane titrated to 14 to 20 mg/L for at least two years with glucocorticoid replacement; tumour-bed radiotherapy after incomplete resection; platinum-based chemotherapy considered for very high-risk tumours (ADIUVO-2).
A relative of the insecticide DDT that is the only drug specific to adrenal cortex cancer; it needs blood-level monitoring and permanent steroid replacement.
IMRT and IGRT shape the radiation beam to the tumour's outline from multiple angles and check the patient's position with a scan before every session, so surrounding organs receive less dose. Fewer, larger doses are now standard in breast and prostate cancer, but a low-dose bath still spreads across normal tissue.
- Conformal dose, fewer side effects
- Hypofractionation saves visits
Etoposide is a chemotherapy from the mayapple plant, essential to curing testicular cancer (BEP), treating small-cell lung cancer, lymphomas, childhood sarcomas and leukaemias, and used in transplant conditioning.
Cisplatin is the original platinum chemotherapy, discovered by accident in 1965; it cures testicular cancer and makes radiation work better in cervical and head and neck cancer.
No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.
- Low-dose bath to normal tissue
- Motion management
- Reduce to 75% for CrCl 15-50.
- Dose reduce or avoid for CrCl below 60 (carboplatin is the alternative).
- Between Mitotane, IMRT / IGRT (modern external beam), Etoposide and the other options, which do you recommend for me, and what about my case would make you choose differently?Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- Does your recommendation follow the current guideline (ESE/ENSAT guideline on adrenocortical carcinoma 2018), and if it departs from it, why?Why: Departures from guidelines are sometimes right for an individual; they should be explained.
- For my situation (after resection, high risk), which of the standard options do you recommend and why?Why: Guideline options include: Adjuvant mitotane titrated to 14 to 20 mg/L for at least two years with glucocorticoid replacement; tumour-bed radiotherapy after incomplete resection; platinum-based chemotherapy considered for very high-risk tumours (ADIUVO-2).
- Am I a candidate for Mitotane, Etoposide, Cisplatin, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
Add these to your appointment list, or take the full question set for this cancer.
Local recurrence
Repeat resection when feasible after a disease-free interval of a year or more, with mitotane; ablation or radiotherapy for small unresectable recurrences.
Thermal ablation kills a tumour with heat or cold delivered through a needle, with no incision required.
- Outpatient, repeatable
- Preserves organ function
Stereotactic body radiotherapy converges multiple beams with sub-millimetre accuracy to deliver tumour-destroying doses in one to five outpatient sessions, doing the job of surgery for inoperable early lung cancer and for metastases in liver, spine and brain. Tumour size and location limit its use, and late toxicity is a concern near the central airways.
- Ablative doses with minimal recovery
- Outpatient
A relative of the insecticide DDT that is the only drug specific to adrenal cortex cancer; it needs blood-level monitoring and permanent steroid replacement.
No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.
- Size limit ~3 cm
- Heat-sink near vessels
- Size and location limits
- Late toxicity near central airways
- Between Thermal ablation (RFA, microwave, cryo), SBRT / SABR (stereotactic radiotherapy) and Mitotane, which do you recommend for me, and what about my case would make you choose differently?Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- Does your recommendation follow the current guideline (ESE/ENSAT guideline on adrenocortical carcinoma 2018), and if it departs from it, why?Why: Departures from guidelines are sometimes right for an individual; they should be explained.
- For my situation (local recurrence), which of the standard options do you recommend and why?Why: Guideline options include: Repeat resection when feasible after a disease-free interval of a year or more, with mitotane; ablation or radiotherapy for small unresectable recurrences.
- Am I a candidate for Mitotane, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
Add these to your appointment list, or take the full question set for this cancer.