Synthetic educational example. Do not self-treat: a qualified treating physician must verify the sources, patient data, contraindications, and final plan.
Patient
VERIFIED-ADRENOCORTICAL-CARCINOMA-L1-ACC_1L_MITOTANE_EDP · Algorithm: ALGO-ACC-1L
Clinical significance of mutations (ESCAT)
Tumor-board context — the engine does not use these tiers to rank tracks
| Biomarker | Variant | ESCAT | Evidence | Clinical significance | Drugs | Sources |
|---|
| No clinically actionable variants matched in this profile. |
Primary current-line option
- Indication
- IND-ACC-1L-MITOTANE-EDP
- Regimen
- EDP-M (etoposide + doxorubicin + cisplatin + mitotane) — FIRM-ACT regimen
- Drugs + NSZU
- Etoposide (DRUG-ETOPOSIDE) 100 mg/m²/day IV · Days 2, 3, 4 of each 28-day cycle · IV ⚠ NSZU — not for this indication
- Doxorubicin (DRUG-DOXORUBICIN) 40 mg/m² IV · Day 1 of each 28-day cycle · IV ⚠ NSZU — not for this indication
- Cisplatin (DRUG-CISPLATIN) 40 mg/m²/day IV · Days 3 and 4 of each 28-day cycle · IV ⚠ NSZU — not for this indication
- Mitotane (DRUG-MITOTANE) Continuous oral dosing, titrated toward a target blood level of 14-20 mg/L (see REG-MITOTANE-ADJUVANT-ACC for titration principles) · Continuous throughout chemotherapy and beyond, independent of the 28-day EDP cycle boundary · PO ✗ Not registered in UA
- Supportive care
- SUP-ANTIEMETIC-PREMED
- Reason
- Primary current-line option selected by ALGO-ACC-1L at step 3; branch-driving red flag: RF-FITNESS-ECOG-FIT.
Other current-line alternatives (1 tracks)
Same treatment line; review when biomarker, access, contraindication, or patient-context assumptions change.
- Indication
- IND-ACC-1L-RESECTION-MITOTANE
- Regimen
- Mitotane adjuvant monotherapy (ACC)
- Drugs + NSZU
- Mitotane (DRUG-MITOTANE) Starting dose 2-3 g/day PO in divided doses (up to 4-6 g/day if urgent disease control needed); titrate upward at approximately 2-week intervals (weekly if urgent) per tolerability and mitotane blood level, toward a target therapeutic blood level of 14-20 mg/L · Continuous daily dosing in 3-4 divided doses, taken with fatty meals to enhance absorption; no fixed cycle length — individualized, guided by blood-level monitoring · PO ✗ Not registered in UA
- Reason
- Current-line alternative presented for HCP consideration
Why this branch was chosen
Triggers from the patient profile that fired and drove the chosen branch.
Step 3 → branch IND-ACC-1L-MITOTANE-EDP
- RF-FITNESS-ECOG-FIT ★ winner: Fit performance status (ECOG 0-1): patient is fully active or restricted in physically strenuous activity but ambulatory and able to carry out light work. Eligible for full-dose chemotherapy and intensive regimens (CHOEP, BEACOPP-escalated, HD-MTX, ASCT consolidation, CAR-T).
SRC-NCCN-BCELL-2025SRC-ESMO-DLBCL-2024
Pre-treatment investigations
Investigations before treatment start · critical / standard / desired · merged across tracks
| ID | Name | Priority | Category | Where to order | Needed for |
|---|
| TEST-CBC | Complete Blood Count with Differential | Critical | lab | — | all tracks |
| TEST-CMP | Comprehensive Metabolic Panel | Critical | lab | — | all tracks |
| TEST-LFT | Liver Function Tests (ALT, AST, bilirubin, ALP, GGT, albumin) | Critical | lab | — | all tracks |
| TEST-CORTISOL-MORNING | Morning cortisol | Standard | lab | — | all tracks |
| TEST-CT-CAP | CT chest/abdomen/pelvis | Standard | imaging | — | all tracks |
| TEST-GERMLINE-MULTI-GENE-PANEL | Germline multi-gene hereditary cancer panel (NGS) | Standard | genomic | CSD Lab: M089 | all tracks |
| TEST-LVEF-ECHO | Echocardiogram with LVEF | Standard | clinical_assessment | — | all tracks |
What NOT to do
Explicit prohibitive rules, each grounded in a regimen / supportive care / contraindication entity
Standard plan (IND-ACC-1L-MITOTANE-EDP)
- Do not omit mitotane blood-level monitoring and a glucocorticoid (+/- mineralocorticoid) replacement plan before starting EDP-M — mitotane is continued concurrently throughout chemotherapy and causes near-universal drug-induced adrenal insufficiency.
- Do not exceed commonly-cited cumulative doxorubicin lifetime dose limits (~450-500 mg/m², cardiotoxicity risk) without cardio-oncology input.
- Do not interpret the non-significant FIRM-ACT overall-survival difference as evidence that EDP-M is not preferred over streptozocin+mitotane — response rate and PFS favored EDP-M significantly, and the OS analysis was confounded by permitted crossover.
Standard plan (IND-ACC-1L-RESECTION-MITOTANE)
- Do not offer adjuvant mitotane to every resected ACC patient regardless of recurrence risk — reserve for high-recurrence-risk stage I-III disease (stage III, Ki-67 >10%, or R1/RX margin); the randomized ADIUVO trial did not show benefit in lower/intermediate-risk disease.
- Do not initiate mitotane without a concurrent plan for glucocorticoid (+/- mineralocorticoid) replacement and mitotane blood-level monitoring — drug-induced adrenal insufficiency is near-universal.
- Do not omit discussion/offer of germline TP53 testing in pediatric ACC or adult ACC meeting Chompret criteria (Li-Fraumeni association).
- Do not favor a laparoscopic surgical approach over open adrenalectomy for large or higher-stage tumors without specific expert-center rationale — retrospective data associate laparoscopic resection with higher positive-margin/peritoneal-seeding risk in this setting.
Timeline
Treatment timeline — derived from regimen + monitoring schedule
Standard plan
Induction · EDP-M (etoposide + doxorubicin + cisplatin + mitotane) — FIRM-ACT regimen
28-day cycles × Until progression, unacceptable toxicity, or maximal response per treating team — FIRM-ACT protocol design; a fixed maximum cycle count is not specified in this KB pass, verify against the primary source/institutional protocol
MDT brief
Data quality
Usable with caveats. No critical default-track gap was found, but the MDT should review the listed caveats before final sign-off.
- Biomarker coverage: 0/0 known (100%), 0 missing, 0 default-track gaps
- Unevaluated RedFlags: RF-ACC-HIGH-RECURRENCE-RISK-BIOLOGY, RF-LI-FRAUMENI-CONFIRMED-CARRIER
Technical MDT skill metadata (0/16 activated in this plan)
All registered virtual specialists. ✓ — activated for this case; ○ — not activated (available for other clinical scenarios).
| Specialist | skill_id | Version | Last reviewed | Sign-offs | Domain |
|---|
| Cellular therapy specialist (CAR-T) | cellular_therapy_specialist | v0.1.0 | 2026-04-25 | 0 | cellular_therapy |
| Clinical pharmacist | clinical_pharmacist | v0.1.0 | 2026-04-25 | 0 | clinical_pharmacy |
| Hematologist / oncohematologist | hematologist | v0.1.0 | 2026-04-25 | 0 | hematology_oncology |
| Hematopathologist (lymphoma / leukemia / myeloma) | hematopathologist | v0.1.0 | 2026-04-25 | 0 | hematopathology |
| Infectious disease / hepatology | infectious_disease_hepatology | v0.1.0 | 2026-04-25 | 0 | infectious_diseases |
| Medical oncologist (solid-tumor chemotherapist) | medical_oncologist | v0.1.0 | 2026-04-25 | 0 | solid_oncology |
| Molecular geneticist / molecular oncologist | molecular_geneticist | v0.1.0 | 2026-04-25 | 0 | molecular_oncology |
| Palliative care | palliative_care | v0.1.0 | 2026-04-25 | 0 | palliative_care |
| Pathologist (general) | pathologist | v0.1.0 | 2026-04-25 | 0 | pathology |
| Primary care / family physician | primary_care | v0.1.0 | 2026-04-25 | 0 | primary_care |
| Psycho-oncologist | psychologist | v0.1.0 | 2026-04-25 | 0 | psychosocial |
| Radiation oncologist | radiation_oncologist | v0.1.0 | 2026-04-25 | 0 | radiation_oncology |
| Radiologist | radiologist | v0.1.0 | 2026-04-25 | 0 | diagnostic_imaging |
| Social worker / case manager | social_worker_case_manager | v0.1.0 | 2026-04-25 | 0 | psychosocial |
| Surgical oncologist | surgical_oncologist | v0.1.0 | 2026-04-25 | 0 | surgical_oncology |
| Transplant specialist (BMT) | transplant_specialist | v0.1.0 | 2026-04-25 | 0 | cellular_therapy |
Sources cited
- SRC-ADIUVO-TERZOLO-2023: Adjuvant mitotane versus surveillance in low-grade, localised adrenocortical carcinoma (ADIUVO); an international, multicentre, open-label, randomised, phase 3 trial and observational study (2023)
- SRC-ENSAT-ACC-2018: European Society of Endocrinology Clinical Practice Guidelines on the management of adrenocortical carcinoma in adults, in collaboration with the European Network for the Study of Adrenal Tumors (2018)
- SRC-ESMO-ACC-2020: Adrenocortical carcinomas and malignant phaeochromocytomas: ESMO-EURACAN Clinical Practice Guidelines for diagnosis, treatment and follow-up (2020)
- SRC-FIRM-ACT-FASSNACHT-2012: Combination chemotherapy in advanced adrenocortical carcinoma (2012)
- SRC-NCCN-NET-2025: NCCN Neuroendocrine and Adrenal Tumors (v.2.2025)
Experimental options (clinical trials)
Last synced: 2026-09-09 · ctgov.
No active trials matched this scenario in ctgov.
Option availability in Ukraine
Per-track UA registration · NSZU · cost · access pathway. Render-time metadata; engine selection does not depend on these fields (CHARTER §8.3).
| Option | UA registration | NSZU | Cost orientation | Access pathway |
|---|
| Standard plan EDP-M (etoposide + doxorubicin + cisplatin + mitotane) — FIRM-ACT regimen (REG-EDP-M-ACC) 1/4 component drug(s) not registered in Ukraine +1 | ✗ not registered | ✗ out-of-pocket | ₴-? — verify pathway | not recorded |
| Standard plan Mitotane adjuvant monotherapy (ACC) (REG-MITOTANE-ADJUVANT-ACC) 1/1 component drug(s) not registered in Ukraine +1 | ✗ not registered | ✗ out-of-pocket | ₴-? — verify pathway | not recorded |
Cost information is orientation. Verify with a specific pharmacy / foundation / trial site. Status updated: 2026-09-09.