Case Report
Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Oncol. Feb 10, 2018; 9(1): 20-25
Published online Feb 10, 2018. doi: 10.5306/wjco.v9.i1.20
Yttrium-90 microsphere selective internal radiation therapy for liver metastases following systemic chemotherapy and surgical resection for metastatic adrenocortical carcinoma
Mina S Makary, Lawrence S Krishner, Evan J Wuthrick, Mark P Bloomston, Joshua D Dowell
Mina S Makary, Joshua D Dowell, Division of Vascular and Interventional Radiology, Department of Radiology, the Ohio State University Comprehensive Cancer Center, Columbus, OH 43210, United States
Lawrence S Krishner, Division of Medical Oncology, Department of Internal Medicine, the Ohio State University Comprehensive Cancer Center, Columbus, OH 43210, United States
Evan J Wuthrick, Department of Radiation Oncology, the Ohio State University Comprehensive Cancer Center, Columbus, OH 43210, United States
Mark P Bloomston, Division of Surgical Oncology, Department of Surgery and James Cancer Hospital and Richard Solove Research Institute, the Ohio State University Comprehensive Cancer Center, Columbus, OH 43210, United States
Author contributions: Makary MS, Krishner LS, Wuthrick EJ, Bloomston MP, and Dowell JD performed the research and analyzed the data; Makary MS and Dowell JD wrote the paper.
Informed consent statement: The study participant provided written informed consent for release of their information and publication of this paper.
Conflict-of-interest statement: The authors confirm that they do not have any conflict of interest.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Mina S Makary, MD, Division of Vascular and Interventional Radiology, Department of Radiology, the Ohio State University Comprehensive Cancer Center, 395 W. 12th Ave, 4th Floor, Columbus, OH 43210, United States. mina.makary@osumc.edu
Telephone: +1-614-2938000
Received: September 4, 2017
Peer-review started: September 7, 2017
First decision: October 30, 2017
Revised: November 5, 2017
Accepted: December 4, 2017
Article in press: December 4, 2017
Published online: February 10, 2018
Processing time: 157 Days and 3.5 Hours
ARTICLE HIGHLIGHTS
Case characteristics

A 60-year-old female patient with a past medical history significant only for poorly controlled hypertension despite medical therapy presented with a large left adrenal mass incidentally discovered on MRA during workup for renal artery stenosis.

Clinical diagnosis

The clinical examination of the patient revealed elevated blood pressure and abdominal pain.

Differential diagnosis

The differential diagnosis includes renal artery stenosis, adrenal phenochromcytoma, adrenocortical carcinoma, hyperaldosteronism, and hyperthyroidism.

Laboratory diagnosis

Serology values revealed normal urine cortisol [14.1 mcg/24 h (normal range: 3-22)], low adrenocorticotropic hormone (ACTH) [5.1 pg/mL (normal range: 9-50)], normal plasma metanephrines [0.20 nmol/L (normal range < 0.50)] and high aldoesterone [38.8 ng/dL (normal range: 1-16)].

Imaging diagnosis

Abdominal MR imaging revealed a heterogeneous, partially necrotic left adrenal mass measuring 5.6 cm × 8.9 cm as well as multiple bilobar enhancing liver metastases.

Pathological diagnosis

Histologic and immunologic evaluation of a biopsied hepatic lesion showed metastatic carcinoma positive for inhibin, melan-A, and CKAE1/3 with an immunohistochemical staining profile consistent with metastatic adrenocortical carcinoma.

Treatment

We present the first reported case of utilizing yttrium-90 microsphere selective internal radiation therapy (SIRT) in combination with first line EDP-M (Etoposide, Doxorubicin, Cisplatin, Mitotane) chemotherapy and debulking surgical primary tumor resection for treatment of metastatic adrenocortical carincoma.

Related reports

While surgical resection can be curative for early local disease, most patients present with advanced ACC owing to nonspecific symptoms. For those patients, previous reports studied treatment options including systemic chemotherapy and locoregional therapies including radiofrequency ablation and transarterial chemoembolization.

Term explanation

Adrenocortical carcinoma (ACC) is a rare malignancy that constitutes less than 5% of all adrenal incidentalomas and has an estimated annual incidence of 1-2 cases per million people. EDP-M (etoposide, doxorubicin and cisplatin plus mitotane) is first line chemotherapy for advanced adrenocortical carcinoma demonstrating an overall response rate of 49%, a median time to progression of 9.1 mo, and an overall survival of 28.5 mo in prior studies.

Experiences and lessons

This case study presents the successful treatment of metastatic ACC by combining Y-90 locoregional therapy for bilobar liver disease with first line EDP-M chemotherapy and debulking surgery. This strategy allowed for disease management for at least 12 mo following a single outpatient Y-90 treatment for each hepatic lobe rather than the repeated inpatient treatments required previously through TACE with possibly superior results.