Popular science public health knowledge: pathological types, treatment and prognosis of tumors of adrenal glands (part 2)
Continuation of previous article, pathological types, treatment and prognosis of adrenal tumors!
PathologyHistological data. In absence of clinical signs of metastasis, a specific histological diagnosis may be difficult. Some macroscopic features indicative of malignancy include body weight greater than 500 g, areas of calcification or necrosis, and a strongly lobulated appearance. Most adrenocortical carcinomas are large, but their size has either little or no effect on survival time.
Adrenal adenomas are usually well encapsulated, uniform in cross section, and free of metastases; Adrenal neoplasms, in contrast, are large multilobular tumors with areas of necrosis and signs of capsular and vascular invasion.
There are various histological diagnostic systems for adrenocortical carcinoma, but system described by Medeiros and Weiss is most commonly used. Nine histological features are described:
A malignant neoplasm that meets four or more of these histological criteria. The three most common were mitotic rates greater than 5 mitoses/50 HPF, an atypical mitotic pattern, and venous invasion. The rate of mitosis is not only an important indicator for distinguishing malignant from benign tumors, but also an important indicator for predicting clinical toxicity of adrenocortical carcinoma.
Patients with a high mitosis rate (>20 mitosis/10 HPF) had a shorter disease-free survival than patients with a low mitosis rate (less than 20 mitosis/10 HPF).
Adrenocortical carcinoma is classified as either well-differentiated or anaplastic, depending on degree of cellular differentiation. Although well-differentiated carcinomas may have a less aggressive course than anaplastic tumors, cell differentiation cannot predict survival regardless of mitotic rate.
Microscopically, adrenocortical carcinoma is a malignant tumor of cells of adrenal cortex, showing partial or complete histological and functional differentiation.
Stages and prognostic factors
Setting technology
CT or MRI can show extent of disease and should include chest to rule out lung metastases.
If inferior vena cava is involved, either an examination of vena cava or ultrasound can help estimate size of tumor.
Partial Level Evaluation
See CT and MRI images in Diagnosis section to assess local extent of disease and regional lymph node involvement.
Metastases to lungs (45%)
1. Chest x-ray
Bilateral chest x-rays are commonly used to screen for primary tumors in patients with subsequent metastases, predominantly to lungs.
Benefits
2. Chest CT
If metastatic nodes are found, a spiral chest CT scan (CT) should be performed to assess their number and characteristics.
Benefits
The limitations of CT are mainly associated with pleural nodes and intrapulmonary nodes <6 mm.
Metastases in liver (40%)
1. Ultrasound of liver
Ultrasound is cheap and readily available, but its value compared to single layer helical CT (SCT), MSCT, and MRI results in reduced sensitivity and specificity. In general, sonographic manifestations of liver metastases are nonspecific.
Benefits
2. Abdominal CT
CT is most sensitive method for diagnosing liver metastases.
Benefits
Adrenal tumor staging
Prognostic factors (risk factors for relapse)
The two main prognostic factors in adrenal tumors are completeness of resection and stage of disease. Patients with evidence of invasion of local tissues or extension to lymph nodes had a worse prognosis.
Patients with a high mitosis rate (>20 mitosis/10 HPF) had a shorter disease-free survival than patients with a low mitosis rate (less than 20 mitosis/10 HPF).
Prognostic factors are currently being studied
address
For stages I-III, main treatment is complete surgical resection with or without regional lymph node dissection.
Stage 1 and 2
Current and complete resection of all cancers is key to long-term survival and potential cure. There is no consensus on effective adjuvant therapy.
Rationale
Tumor size, hemorrhage, and number of mitoses have been associated with survival in radical resection patients. Tumor size less than 12 cm, mitosis rate less than 6/high magnification field, and absence of intratumoral hemorrhage were associated with improved survival.
Unresectable localized disease can be treated with radiation therapy. Local lesions may also be amenable to palliative resection, especially if lesion is functional.
Third stage
The treatment of patients with locally invasive tumors but no clinical lymphadenopathy is complete surgical resection. In patients with regional lymphadenopathy, lymph node dissection should be performed during surgery. These patients are at high risk of disease recurrence and should be considered for inclusion in clinical trials.
Simultaneous nephrectomy may be required if cancer is closely associated with a nearby organ, such as kidney. Even a tumor thrombus in inferior vena cava is not a contraindication to resection.
Unresectable localized disease can be treated with radiation therapy. Local lesions may also be amenable to palliative resection, especially if lesion is functional.
Stage Four
Chemotherapy
Unresectable or widely disseminated tumors can be treated with antihormonal therapy and systemic chemotherapy with mitotane.
1. Single-dose chemotherapy: op-DDD (Mitotane) is most commonly used chemotherapy drug for treatment of adrenal tumors. 2 to 6 grams per day, divided into two or three doses, and increase dose. until side effects occur.
Adverse reactions include gastrointestinal toxicity, neuromuscular toxicity, and rash. Mitotane has been associated with increased bleeding time and abnormal platelet aggregation. Due to effect of 17-hydroxysteroids and 17-ketosteroids on steroid metabolism, majority of patients have decreased levels of 17-hydroxysteroids and 17-ketosteroids in urine.
Rationale
2. Combination chemotherapy: other chemotherapy combined with mitotane. The use of etoposide (VP-16) 100 mg/m2/day, cisplatin (100 mg/m2) once every 4 weeks, mitotane in advanced adrenocortical cancer.
Rationale
Surgery
Longer response times have been reported in adrenocortical carcinoma following resection of liver, lung, and brain metastases.
Radiation therapy
The softening of bone metastases can be achieved with radiotherapy.
Recurrent cancer
Surgery
Recurrent or metastatic adrenocortical carcinoma should also be resected, and radiofrequency ablation has been reported to control recurrent tumors within and outside liver.
Radiation
Radiofrequency ablation allows you to control tumor recurrence.
Abdominal radiotherapy may be helpful in 65% of unresectable local recurrences and may even reduce ileus.
Prediction and Survival
The overall 5-year survival rate for surgically treated tumors is about 40%. The median survival of patients with stage IV tumors is usually less than 9 months.
Popular science public health knowledge: pathological types, treatment and prognosis of tumors of adrenal glands (part 2)
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