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O,P'-DDD and Aminoglutethimide R Postgrad Med J: first published as 10.1136/pgmj.51.591.35 on 1 January 1975. Downloaded from Postgraduate Medical Journal (January 1975) 51, 35-37. Treatment of an adrenal cortical carcinoma with a combination of o,p'-DDD and aminoglutethimide R. D. M. SCOTT M.B., M.R.C.P.E., M.R.C.P. Department of Medicine, Western General Hospital, Edinburgh EH4 2XU Summary tures of several vertebrae. Intravenous pyelography A patient with Cushing's syndrome due to an adreno- showed depression of the left kidney, and left renal cortical carcinoma is described. Treatment of residual arteriography demonstrated an enlarged left adrenal disease and functional metastases was attempted with with several abnormal vessels surrounding it. At o,p'-DDD and later aminoglutethimide. Aminoglute- operation (Mr J. E. Newsam), an adrenal carcinoma thimide in a daily dose of 1 g appeared to have little invading the left renal pedicle was found. Left effect additional to o,p'-DDD. It is important to adrenalectomy and nephrectomy were performed maintain replacement therapy with cortico-steroids with removal of some but not all of the involved throughout the use of these drugs. paraaortic lymph nodes. The diagnosis was confirmed Introduction histologically. The of adrenal carcinoma TABLE 1. Plasma and urinary steroid prognosis inoperable measurements before treatment has altered since the introduction of 1,1-dichloro-2- copyright. (o-chlorophenyl)-2-(p-chlorophenyl)-ethane-o,p'- Plasma 11 -hydroxycorticosteroids DDD-which has been demonstrated to have a (11-OHCS) cytotoxic action on the adrenal cortex (Vilar and at 2300 hr 45 ,g/100 ml Its use has been limited the at 0800 hr 32 ,tg/100 ml Tullner, 1959). by high 30 minutes after tetracosactrin 39 ,tg/100 ml incidence of toxic effects on the gastrointestinal 250 (.g i.v. tract and central nervous system(Hutter and Kayhoe, Cortisol production rate (CPR) 182 mg/24 hr 1966b; Bergenstal et al., 1960). Aminoglutethimide has no cytotoxic activity but reduces output of Urinary steroid response to dexamethasone: active steroids by inhibiting the enzymatic production http://pmj.bmj.com/ of the precursor pregnenolone (Cash et al., 1967). It Dexamethasone dose might therefore be expected that the actions of 0 2 mg/24 hr 8 mg/24 hr o,p'-DDD and aminoglutethimide would be com- 17-hydroxycorticosteroids 99 91 104 plementary but their combined use appears to have (17-OHCS) mg/24 hr been reported previously in only a single case of 17-oxosteroids 124 80 95 metastatic adrenal carcinoma (Bochner et al., 1969). (17-OS) mg/24 hr A second case is now described. 11-hydroxycorticosteroids 3-9 2-9 4-0 (11-OHCS) mg/24 hr on October 1, 2021 by guest. Protected Clinical course A 44-year-old man presented with a history of At the time of operation treatment was started severe persistent backache of sudden onset 1 month with betamethasone 2 mg/24 hr and this was con- previously. He had gained 20 lb in weight in the tinued thereafter. Serial measurements were made of previous 6 months. plasma 11-OHCS, urinary 11-OHCS, 17-OHCS, He was typically Cushingoid in appearance. There 17-OS, and CPR. The results are shown in Fig. 1, was localized tenderness over the lower thoracic with the exception of the urinary 11-OHCS, which vertebrae. His blood pressure was 200/120 mmHg. closely paralleled urinary 17-OHCS excretion. The diagnosis of Cushing's syndrome was established There was an immediate postoperative reduction and the probability of an autonomous adrenal cause in plasma and urinary steroid levels and the CPR indicated by measurements of plasma and urinary fell to within the high normal range, at 28 mg/24 hr, steroids (Table 1), using standard methods. Radio- but as the patient was still receiving betamethasone logically moderate osteoporosis was observed, with 2 mg/24 hr, a dose normally sufficient to suppress several healed rib fractures and compression frac- the adrenals, it was clear that hyperfunction was Postgrad Med J: first published as 10.1136/pgmj.51.591.35 on 1 January 1975. Downloaded from 36 Case reports -Adrenotectomy 50 -' / U O.. .4 .o ,, -'- '- 90"- ·:[s t; t . , :. -'"'.-. 80 t3 71c tn n '4 J *r - < 24 1 , 60 -Rodiotheropy4.50 x..x=x,:, ..i · so ' x : X.A:'- oI X ...ho M-th aftL ?:/o.-. T.. - *- .- .( .. i. :*..*. ;. J:: ,.'. .t . -,- M70ths cftfr opea.t.on FIG. 1. Plasma and urinary steroid measurements with variations in drug therapy. Lower graph: broken line, 17-OHCS; solid line, 17-OS mg/24 hr. Upper graph: plasma 11-OHCS, 9 a.m. copyright. still present. A 4-week course of radiotherapy was measurements it was considered that treatment with given to the left renal area, but during this period a betamethasone was probably superfluous and might mass developed in the left supraclavicular fossa. be contributing to the progression of his bone This rapidly enlarged until treatment with o,p'-DDD disease, so this was withdrawn. Ten days later, after was introduced. With doses of this drug increasing a single treatment with radiotherapy to the left supra- to 9 g daily, steroid excretion was markedly re- clavicular mass, he collapsed suddenly and died. duced within 2 weeks, but, owing to the develop- At post mortem (Dr J. M. Drennan) metastatic ment of intolerable side carcinoma was at effects, namely nausea, identified only the site of the left http://pmj.bmj.com/ vomiting and diarrhoea, the dose had to be reduced adrenal, in the mediastinum and lungs, and in the to 3 g daily. Despite an increase in steroid excretion left supraclavicular area. Histologically the meta- the drug was withdrawn at the patient's request. stases were of uniform appearance, with predomi- The swelling in the neck began to enlarge further, nant coagulative necrosis interspersed with clumps accompanied by a progressive rise in steroid excre- of nuclear debris, granules of calcification and islets tion. Reintroduction of the drug at a dose which of degenerating tumour cells. The right adrenal was could be tolerated had little effect on steroid levels, atrophic. The thyroid gland was normal. but the patient was able to return to light work for on October 1, 2021 by guest. Protected 10 months. Discussion Aminoglutethimide was introduced in a dose of This patient's prognosis was poor from the time 250 mg q.i.d. 15 months after operation, in an he was first seen because he had high urinary steroid attempt to suppress cortisol production which had levels and because metastases were evident (Hutter increased to 120 mg/24 hr. Four subsequent attempts and Kayhoe, 1966a; Thorn and Lauler, 1972). That to measure the CPR were technically unsatisfactory, he survived for 2 years after the discovery of func- and no clinical or biochemical improvement was tional metastases and was able to work for part of observed. this time might be attributed to the use of o,p'-DDD After 6 months' combined treatment with o,p'- and aminoglutethimide. His failure to respond to DDD and aminoglutethimide there was a rapid radiotherapy is in accordance with published deterioration in his condition with further enlarge- experience (Hutter and Kayhoe, 1966b; Thorn and ment of the supraclavicular mass. Diplopia had Lauler, 1972). developed with nystagmus and slight cerebellar O,p'-DDD was poorly tolerated in this patient ataxia. In view of the high plasma 11-OHCS although the symptoms of gastro-intestinal and Postgrad Med J: first published as 10.1136/pgmj.51.591.35 on 1 January 1975. Downloaded from Case reports 37 central nervous system dysfunction did not differ Brown and Dr K. Fitzpatrick for CPR measurements, and encountered and Dr D. M. Burley (Ciba Laboratories) for the supply of from those usually (Hutter Kay- aminoglutethimide. hoe, 1966b). The maximum reduction in steroid Professor J. A. Strong kindly gave permission to publish levels was achieved with a daily dose of 9 g sup- details of the case, and offered much helpful criticism. porting the suggestion that 10 g daily is the optimum dose (Cope, 1972; Geyer, 1967). Although steroid References excretion was not suppressed, the growth rate of BERGENSTAL, D.M., HERTZ, R., LIPSETT, M.B. & MAY, R.H. the metastasis in the supraclavicular fossa appeared (1960) Chemotherapy of adrenocortical carcinoma with to have been retarded, and the cytotoxic activity of o,p'-DDD. Annals of Internal Medicine, 53, 672. at BOCHNER, F., LLOYD, H.M., ROESER, H.P. & THOMAS, M.J. o,p'-DDD was demonstrated histologically (1969) Effects of o,p'-DDD and aminoglutethimide on autopsy. metastatic adrenal carcinoma. Medical Journal ofAustralia, Aminoglutethimide in the conventional dose of 1, 809. 1 g daily was well tolerated and at autopsy the CASH, R., BROUGH, A.J., COHEN, M.N.P. & SATOH, P.S. in contrast to the occa- (1967) Aminoglutethimide as an inhibitor of adrenal thyroid gland was normal, steroidogenesis: Mechanism of action and therapeutic sional finding of goitre (Rallison, Kumagai and trial. Journal of Clincal Endocrinology and Metabolism, 27, Tyler, 1967). After the introduction of aminoglute- 1239. thimide, steroid excretion did not fall rapidly (Phil- COPE, C.L. (1972) Adrenal Steroids and Disease, 2nd edition, bert et from the p. 697. Pitman Medical: London. al., 1966), apart slight predictable FISHMAN, L.M., LIDDLE, G.W., ISLAND, D.P., FLEISCHER, N. decline in urinary 17-OHCS excretion (Fishman & KUCHEL, 0. (1967) Effects of aminoglutethimide on et al., 1967; Schteingart and Conn, 1967). It is adrenal function in man. Journal of Clinical Endocrinology possible, however, that there was a rapid decline and Metabolism, 27, 481. in steroid after the withdrawal of GEYER, G. (1967) Behandlung des Nebennierenrindenkar- production zinoms mit o,p'-DDD.
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