Date:
Patient:
主诉 (zhǔ訴) (Chief Complaint):
Describe the patient’s main reason for presentation, which can vary but may include:
Abdominal or flank pain
Easy bruising
Central obesity with thin extremities (Cushingoid features)
Muscle weakness
Excessive sweating or heart palpitations
Unexplained weight gain or loss
Fatigue
In some cases, no specific symptoms (incidental finding on imaging)
History of Present Illness:
Onset, duration, and severity of symptoms
Past medical history (hypertension, diabetes, other endocrine disorders)
Past surgical history (adrenal surgery)
Family history (multiple endocrine neoplasia (MEN) syndromes)
Physical Examination:
Vital signs (temperature, heart rate, blood pressure, respiratory rate) – May be normal or show signs of hypertension.
General examination: Assess for signs of Cushing syndrome (central obesity, easy bruising, plethora – reddish skin).
Look for evidence of virilization (masculinization) in females or feminization in males (acne, facial hair growth, breast development).
Laboratory Findings:
Serum electrolytes: May reveal hypokalemia (low potassium) and hyponatremia (low sodium) in patients with Cushing syndrome.
24-hour urine cortisol: Elevated levels strongly suggest Cushing syndrome.
Plasma metanephrines and normetanephrines: Elevated levels may indicate pheochromocytoma (adrenal tumor secreting catecholamines), which can be a component of some ACC cases.
Other hormone tests (depending on suspected hormonal syndrome): Plasma ACTH (adrenocorticotropic hormone), testosterone, DHEA-S (dehydroepiandrosterone sulfate)
Serum cortisol: May be suppressed or elevated depending on the hormonal activity of the tumor.
Adrenocortical carcinoma markers: Plasma ACTH, inhibin B, SDHB (succinate dehydrogenase B) – May be elevated in some cases of ACC.
Imaging Studies:
CT scan with contrast: To assess the size, location, and characteristics of the adrenal mass.
MRI scan: May be helpful in further evaluating the tumor and surrounding tissues.
PET scan (positron emission tomography): May be useful for staging the cancer and identifying distant metastases.
Bone Scan (if metastases are suspected): May be used to detect cancer spread to the bones.
Biopsy: Tissue diagnosis by core needle biopsy, fine-needle aspiration, or surgical resection is crucial for definitive diagnosis of ACC.
Assessment:
Diagnose adrenocortical carcinoma based on clinical features, hormonal testing, imaging studies, and positive biopsy results.
Determine the stage of the cancer using the AJCC (American Joint Committee on Cancer) staging system, which considers tumor size, invasion into surrounding tissues, lymph node involvement, and distant metastases.
Evaluate for hormonal activity of the tumor and associated syndromes (Cushing syndrome, virilization, feminization).
Plan:
Surgical resection: The primary treatment for localized, resectable ACC is complete surgical removal of the adrenal gland and surrounding tissues.
Minimally invasive laparoscopic surgery may be preferred for smaller tumors.
Adjuvant Mitotane Therapy: A medication that can help destroy remaining cancer cells after surgery and may also be used in some cases before surgery to shrink the tumor.
Chemotherapy: May be used in combination with Mitotane or for patients with advanced or unresectable tumors.
Targeted therapy: Newer targeted therapies are being investigated for ACC, but their role is still evolving.
Management of hormonal syndromes: Medications can help control symptoms caused by excess hormone production.
Supportive care: Pain management, nutritional support, and psychological counseling are important aspects of care.
Prognosis:
The prognosis for ACC depends on the stage of the cancer at diagnosis. Early-stage, completely resected tumors have a better prognosis than advanced or metastatic disease.
Consultations (may be needed depending on the plan):
Endocrinologist (specialist in hormonal disorders)
Endocrine surgeon
Medical oncologist
Radiation oncologist (if considering radiotherapy)
Genetic counselor (if family history suggests a hereditary syndrome)
Progress Notes:
Document the details of the surgical procedure (extent of resection, complications).
Monitor response to adjuvant Mitotane therapy, including