Adrenal Cancer Treatment

If an adrenal nodule is found, the team wants as much information as possible to develop an individualized treatment plan. The team will evaluate the nodule by obtaining a CT scan or MRI done specifically to look at the adrenal glands. Our team prefers to investigate adrenal abnormalities using CT first, and MRI if a different type of study is needed. Patients also have blood drawn and submit urine samples (drawn over 24 hours) to test for excess amounts of adrenal hormones. Other laboratory studies may be obtained depending on individual patient findings.

In some instances, patients are referred to one of U-M's genetic counselors for potential further genetic testing. For more information, please visit the Cancer Genetics Clinic.

Surgery

Surgery is the treatment of choice if possible. In many cases, patients present after tumor has spread to other organs in the body or the tumor has invaded structures that cannot be removed and the tumor is considered inoperable. If patients are able to undergo surgery, it is extremely important that your surgery is performed by a surgeon experienced in the treatment of adrenal cancer (most surgeons see one adrenal cancer patient in a lifetime), as the covering of the tumor must not be penetrated during surgery and a wide margin of normal tissue around the tumor should be included to ensure complete resection and minimize the chance for local recurrence. At University of Michigan, our endocrine surgeons often operate on patients with advanced adrenal cancer, including patients who have been told by other health care teams that their tumor is unresectable. Appropriate preoperative evaluation and planning is of the utmost importance in adrenal cancer patients to assure optimal outcome. Adrenal cancer is a very rare cancer different from many other types of cancers. It must be carefully and completely removed. Based on experience and research done at the University of Michigan, we generally do not recommend removing adrenal cancer (or any mass/nodule suspected of potentially being malignant) using a laparoscopic approach as it often leads to early recurrence in the abdominal cavity due to microscopic tumor spillage. Often, the entire tumor is not resected when the procedure is performed laparoscopically, and the "margins" (edges of the tissue removed) are positive for tumor cells. An open approach (through a larger incision along the rib cage or along the midline of the abdomen) allows the surgeon to remove a rim of normal (benign) tissue around the tumor more easily to help decrease rates of local recurrence and spread within the abdomen and has been found to improve survival in patients with adrenal cancers which have not already spread outside the adrenal gland.

Unfortunately, even with pathologically documented complete resection of ACC, up to two-thirds of patients have recurrence of tumor at a locoregional or distant site, or both. Individual markers of tumor biology such as histologic grade (calculated by the number of cells seen to be multiplying within the tumor), length of time without evidence of measurable disease, and slow progression of tumor can be used as a guide when considering re-operation. If a recurrence is found where the original tumor previously was and there is no evidence of tumor elsewhere in the body (metastases), re-operation is associated with increased length of survival when compared to patients treated with mitotane and/or chemotherapy alone.

Treatment After Adrenal Cancer Surgery

After surgery, the U-M Multidisciplinary Endocrine Oncology Tumor Board reviews the surgeon’s operative report and the pathology report. Important aspects of the pathology report include completeness of resection and margin status (positive or negative), capsular or vascular invasion, tumor grade (a measurement of how fast the tumor cells are multiplying), evidence of tumor within lymph nodes, or invasion of nearby structures. Decisions regarding further treatment are made. Treatment may include one or more of the following:

If mitotane is started, labs to check mitotane levels, thyroid function and liver function will be checked frequently and replacement steroids will also be started. University of Michigan physicians are experienced in the administration of standard chemotherapy regimens for adrenal cancer patients and are also involved in finding new therapies. Often, physicians will discuss participation in ongoing studies for promising new medications to treat adrenal cancer.

Follow-up Care

Clinic visits, imaging studies, and blood work are generally obtained every three months to assess disease status and look for evidence of recurrence or disease progression. U-M physicians will work closely with a patient's primary care physician and other physicians (oncologists) near their home to ensure they are receiving optimal care. For those with persistent or recurrent disease, U-M physicians consider all treatment options and stay abreast of new clinical trials offered around the world.

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