Seven studies (869 participants) included in the review led to the conclusion that fewer people experienced POCD with total intravenous anaesthesia (TIVA) compared to inhalational anaesthesia. The conclusions, however, rated "low" on GRADE scoring (confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect). Assessment
Cognitive tests are given prior to operations to establish a baseline. The same tests are again given post-operatively to determine the extent and duration of the decline for POCD. "A project examining adults 55 and older who have major non-cardiac surgeries is finding that upward of 30 percent of patients is testing significantly worse than their baseline 3 months later". Epidemiology
POCD is common after cardiac surgery, and recent studies have now verified that POCD also exists after major non-cardiac surgery, although at a lower incidence. The risk of POCD increases with age, and the type of surgery is also important because there is a very low incidence associated with minor surgery. POCD is common in adult patients of all ages at hospital discharge after major noncardiac surgery, but only the elderly (aged 60 years or older) are at significant risk for long-term cognitive problems. Patients with POCD are at an increased risk of death in the first year after surgery. Research interest has increased since early 2000, especially as more elderly patients are able to undergo successful minor and major surgeries.POCD has been studied through various institutions since the inception of the IPOCDS-I study centred in Eindhoven, Netherlands and Copenhagen, Denmark.
Pathology
Adrenal tumors are often not biopsied prior to surgery, so diagnosis is confirmed on examination of the surgical specimen by a pathologist. Grossly, ACCs are often large, with a tan-yellow cut surface, and areas of hemorrhage and necrosis. On microscopic examination, the tumor usually displays sheets of atypical cells with some resemblance to the cells of the normal adrenal cortex. The presence of invasion and mitotic activity help differentiate small cancers from adrenocortical adenomas. Several relatively rare variants of ACC include:
Oncocytic adrenal cortical carcinoma
Myxoid adrenal cortical carcinoma
Carcinosarcoma
Adenosquamous adrenocortical carcinoma
Clear cell adrenal cortical carcinoma

Differential diagnosis
Differential diagnosis includes:
Adrenocortical adenoma
Renal cell carcinoma
Pheochromocytoma
Hepatocellular carcinomaAdrenocortical carcinomas are most commonly distinguished from adrenocortical adenomas (their benign counterparts) by the Weiss system, as follows:
Total score indicates:
0-2: Adrenocortical adenoma
3: Undetermined
4-9: Adrenocortical carcinoma

Treatment
The only curative treatment is complete surgical excision of the tumor, which can be performed even in the case of invasion into large blood vessels, such as the renal vein or inferior vena cava. The 5-year survival rate after successful surgery is 50–60%, but unfortunately, many patients are not surgical candidates. Radiation therapy and radiofrequency ablation may be used for palliation in patients who are not surgical candidates. Minimally invasive surgical techniques remain controversial due to the absence of long-term data, with a particular concern for rates of recurrence and peritoneal carcinomatosis.Chemotherapy regimens typically include the drug mitotane, an inhibitor of steroid synthesis, which is toxic to cells of the adrenal cortex, as well as standard cytotoxic drugs.