OpenOnco · Treatment Plan

Treatment plan — Adrenocortical carcinoma

PLAN-VERIFIED-ADRENOCORTICAL-CARCINOMA-L1-ACC_1L_MITOTANE_EDP-V1 · v1 · 2026-07-15

Patient

VERIFIED-ADRENOCORTICAL-CARCINOMA-L1-ACC_1L_MITOTANE_EDP · Algorithm: ALGO-ACC-1L

DiagnosisAdrenocortical carcinoma

MOH / ICD-10C74.0

ICD-O-38370/3; C74.0

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

Standard plan

★ DEFAULT

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.

Standard plan

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	Domain
Cellular therapy specialist (CAR-T)	`cellular_therapy_specialist`	v0.1.0	2026-04-25	cellular_therapy
Clinical pharmacist	`clinical_pharmacist`	v0.1.0	2026-04-25	clinical_pharmacy
Hematologist / oncohematologist	`hematologist`	v0.1.0	2026-04-25	hematology_oncology
Hematopathologist (lymphoma / leukemia / myeloma)	`hematopathologist`	v0.1.0	2026-04-25	hematopathology
Infectious disease / hepatology	`infectious_disease_hepatology`	v0.1.0	2026-04-25	infectious_diseases
Medical oncologist (solid-tumor chemotherapist)	`medical_oncologist`	v0.1.0	2026-04-25	solid_oncology
Molecular geneticist / molecular oncologist	`molecular_geneticist`	v0.1.0	2026-04-25	molecular_oncology
Palliative care	`palliative_care`	v0.1.0	2026-04-25	palliative_care
Pathologist (general)	`pathologist`	v0.1.0	2026-04-25	pathology
Primary care / family physician	`primary_care`	v0.1.0	2026-04-25	primary_care
Psycho-oncologist	`psychologist`	v0.1.0	2026-04-25	psychosocial
Radiation oncologist	`radiation_oncologist`	v0.1.0	2026-04-25	radiation_oncology
Radiologist	`radiologist`	v0.1.0	2026-04-25	diagnostic_imaging
Social worker / case manager	`social_worker_case_manager`	v0.1.0	2026-04-25	psychosocial
Surgical oncologist	`surgical_oncologist`	v0.1.0	2026-04-25	surgical_oncology
Transplant specialist (BMT)	`transplant_specialist`	v0.1.0	2026-04-25	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)

Third plan track — open-enrollment trials from ClinicalTrials.gov. Render-time metadata; engine selection is not affected by this block (CHARTER §8.3). Last synced: 2026-07-15.

NCT	Title	Phase	Status	Sponsor	UA	Signals
NCT03050268	Familial Investigations of Childhood Cancer Predisposition	N/A	RECRUITING	St. Jude Children's Research Hospital	—	Single country
NCT03583710	Mitotane With or Without Cisplatin and Etoposide After Surgery in Treating Patients With Stage I-III Adrenocortical Cancer With High Risk of Recurrence	PHASE3	RECRUITING	M.D. Anderson Cancer Center	—	—
NCT00453674	German Adrenocortical Carcinoma Registry	N/A	RECRUITING	University of Wuerzburg	—	Single country
NCT06487481	Study of Preoperative Radiation Therapy in Participants With Resectable Recurrent Abdominal Adrenocortical Carcinoma	PHASE1	RECRUITING	National Cancer Institute (NCI)	—	Phase 1 only Small N (<50) Single country
NCT06831175	Phase II Study of PD-1 Inhibitor Combined With Apatinib and Mitotane in the Treatment of Advanced Adrenal Cortical Carcinoma	PHASE2	RECRUITING	West China Hospital	—	Small N (<50) Surrogate endpoint only Single country
NCT06006013	Cabozantinib in Combination With Pembrolizumab for the Treatment of Patients With Locally Advanced, Metastatic, or Unresectable Adrenal Cortical Cancer	PHASE2	RECRUITING	Emory University	—	Small N (<50) Surrogate endpoint only Single country
NCT06066333	Study of Radiotherapy and Pembrolizumab in People With Adrenocortical Carcinoma	PHASE2	RECRUITING	Memorial Sloan Kettering Cancer Center	—	Small N (<50) Single country
NCT07085572	Cemiplimab as Maintenance Treatment for Advanced Adrenocortical Cancer	PHASE2	RECRUITING	Azienda Socio Sanitaria Territoriale degli Spedali Civili di Brescia	—	Small N (<50) Surrogate endpoint only Single country
NCT06900595	Testing the Addition of an Anti-Cancer Drug, Cabozantinib to the Immunotherapy Drug Cemiplimab (REGN2810), in Adolescents and Adults With Advanced Adrenocortical Cancer	PHASE2	RECRUITING	National Cancer Institute (NCI)	—	Small N (<50) Surrogate endpoint only Single country
NCT05286814	PDS01ADC in Combination With Hepatic Artery Infusion Pump (HAIP) and Systemic Therapy for Subjects With Metastatic Colorectal Cancer, Intrahepatic Cholangiocarcinoma, or Metastatic Adrenocortical Carcinoma	PHASE2	RECRUITING	National Cancer Institute (NCI)	—	Surrogate endpoint only Single country

Verify recruitment status directly with the trial site. ctgov data can lag behind current UA-site status.

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
Trial · NCT03050268 Familial Investigations of Childhood Cancer Predisposition No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT03583710 Mitotane With or Without Cisplatin and Etoposide After Surgery in Treating Patients With Stage I-III Adrenocortical Cancer With High Risk of Recurrence No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT00453674 German Adrenocortical Carcinoma Registry No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT06487481 Study of Preoperative Radiation Therapy in Participants With Resectable Recurrent Abdominal Adrenocortical Carcinoma No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT06831175 Phase II Study of PD-1 Inhibitor Combined With Apatinib and Mitotane in the Treatment of Advanced Adrenal Cortical Carcinoma No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT06006013 Cabozantinib in Combination With Pembrolizumab for the Treatment of Patients With Locally Advanced, Metastatic, or Unresectable Adrenal Cortical Cancer No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT06066333 Study of Radiotherapy and Pembrolizumab in People With Adrenocortical Carcinoma No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT07085572 Cemiplimab as Maintenance Treatment for Advanced Adrenocortical Cancer No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT06900595 Testing the Addition of an Anti-Cancer Drug, Cabozantinib to the Immunotherapy Drug Cemiplimab (REGN2810), in Adolescents and Adults With Advanced Adrenocortical Cancer No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT05286814 PDS01ADC in Combination With Hepatic Artery Infusion Pump (HAIP) and Systemic Therapy for Subjects With Metastatic Colorectal Cancer, Intrahepatic Cholangiocarcinoma, or Metastatic Adrenocortical Carcinoma No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor

Cost information is orientation. Verify with a specific pharmacy / foundation / trial site. Status updated: 2026-07-15.

plan_id: PLAN-VERIFIED-ADRENOCORTICAL-CARCINOMA-L1-ACC_1L_MITOTANE_EDP-V1 | version: 1 | generated: 2026-07-15T13:33:22.734175+00:00

Per FDA non-device CDS positioning (CHARTER §15): Outpatient oncology treatment planning to support tumor-board discussion. Not a medical device; not for autonomous clinical decision-making.

Per FDA non-device CDS positioning (CHARTER §15): Both treatment options below are presented for review. The engine's selection of a 'recommended' default does not constitute a clinical decision. Final treatment selection requires HCP judgment incorporating information not available to the system.

This document is an informational resource supporting tumor-board discussion (per CHARTER §11). It is not a system that makes clinical decisions. Every recommendation must be verified by the treating physician.