ODP597 Clinical case of uncomplicated pregnancy in a patient with adrenocortical carcinoma during treatment with mitotane

Abstract

Abstract Background Mitotane/o,p'DDD is adrenolytic and antitumor therapeutic agent used in the first line drug therapy of advanced adrenocortical carcinoma (ACC) as well as an adjuvant therapy after surgical resection of the primary tumor at moderate/high risk of recurrence. Mitotane is a metabolite of endocrine disruptor DDT and classified among teratogenic compounds. Preterm births and early pregnancy loss have been reported in female patients exposed to mitotane during pregnancy. Clinical Case At age 33, the patient underwent left adrenalectomy for "adrenocortical adenoma". Three years later, she was admitted to our Centre because of rapid development of Cushing's syndrome. Hormonal assessment revealed markedly increased urinary free cortisol level and abnormal overnight dexamethasone suppression test; ACTH was undetectable. Computed tomography revealed lungs and liver secondary masses, as well as tumor mass in the left adrenal bed. According to the above parameters, advanced ACC was suspected. During microscopy and immunohistochemistry of paraffin-embedded tissue blocks, tumor tissue after left adrenalectomy was identified as ACC. The patient started chemotherapy according to EDP-M (etoposide, doxorubicin, and cisplatin) protocol. Prior to chemotherapy initiation, mitotane and oral contraceptive pills were given. She also received glucocorticoid and mineralocorticoid replacement therapy. After three courses of chemotherapy, chest, abdomen and pelvis computed tomography disclosed complete regression of all the tumor masses. The patient continued mitotane, glucocorticoid and mineralocorticoid replacement drugs during the following year. Serial 18F-fluorodeoxyglucose-positron emission tomography scans were negative. One and a half years after cessation of chemotherapy, the patient chose to stop oral contraceptives. Several months later, the patient learned that she was pregnant (12 weeks of gestation) while on mitotane and adrenal replacement therapy. At this point, the patient and her partner were informed of the possible teratogenic effect of mitotane and strongly advised to terminate the pregnancy, but they decided to continue the pregnancy. Mitotane treatment was stopped immediately. The serum concentration of the drug was 16.8 mg/mL, within the therapeutic range (14–20 mg/mL). Glucocorticoid supplementation with hydrocortisone was continued. The course of the pregnancy was uncomplicated. A male infant was delivered breech by cesarean section at a gestation of 39 weeks. Birth weight was 3050 g, length 46 cm, and head circumference 36 cm. Apgar scores were 8, 9 and 9 at 1, 5 and 10 min, respectively. Newborn examination revealed no anomalies and no hyperpigmentation. Blood pressure, heart rate, and temperature were normal. Conclusion To our knowledge, we present the first case of uncomplicated pregnancy in a patient with adrenocortical carcinoma and therapeutic serum concentration of mitotane. Our report suggests that mitotane can not affect normal development of the fetus. Nevertheless, until more data are available, pregnancy should be avoided in women being treated with mitotane for ACC. Presentation: No date and time listed