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practical_care_model

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Practical Care Model

ACC overview

Adrenocortical carcinoma (ACC) is a rare endocrine malignancy whose evaluation and treatment typically require coordination across endocrinology, surgery, pathology, radiology, nuclear medicine, medical oncology, radiation oncology, and supportive care. Contemporary ACC care models are therefore organized less around a single intervention than around a structured pathway that spans initial suspicion, biochemical and imaging workup, expert pathologic review, stage-appropriate treatment planning, surveillance, and management of recurrence.123

Within the broader ACC care hierarchy, the practical care model is closely linked to referral-center management and multidisciplinary decision-making. Reviews, guidelines, and national network experiences consistently describe expert-center care as the preferred framework because diagnosis is uncommon, surgery is technically demanding, endocrine complications can be severe, and recurrence decisions are highly individualized.4567 The evidence base, however, is limited by the rarity of ACC: much of it comes from retrospective cohorts, registry analyses, and single-center experiences rather than randomized comparisons, and observed benefits of centralization may partly reflect selection and referral bias.8910

A practical ACC care model also includes recognition of its limits. Centralization may improve diagnostic consistency, operative planning, and access to multimodality care, but it does not eliminate uncertainty in prognostication or guarantee superior outcomes in every dataset.111213 In addition, regionalization can create travel burdens and access disparities, so implementation requires balancing concentration of expertise against timely, equitable delivery of surgery, systemic therapy, surveillance, and supportive care.14151617

Diagnostic and organizational context

Guidelines and major reviews place multidisciplinary review at the start of ACC care, ideally as soon as a lesion is suspected rather than after surgery alone.123 Core elements include hormonal evaluation, cross-sectional staging that includes the chest, assessment of resectability and vascular or adjacent-organ involvement, and expert pathologic interpretation when tissue is obtained.1863 Registry data suggest that these basics are often incompletely performed in routine practice, with gaps in endocrine testing, thoracic imaging, pathology reporting, and follow-up planning.19

What appears most reliable is that organized specialist review improves completeness of workup and reduces fragmentation of care.1920 What is less certain is the magnitude of any direct survival effect attributable to the meeting structure itself, since centers with multidisciplinary teams also differ in case mix, surgical expertise, and access to adjuvant therapy.211020 Clinically, the implication is that suspected or confirmed ACC is usually best reviewed early by an expert team, even when some components of care must remain local.223

Centralization and surgical pathway

From diagnostic organization, the care model typically progresses to decisions about surgery, which remains the main curative-intent treatment for localized ACC. Across reviews, consensus statements, and observational studies, referral to higher-volume surgeons and specialized centers is associated with more guideline-concordant operative planning, more frequent lymph node evaluation, and lower rates of some perioperative adverse outcomes or local recurrence.2311247 Network-based studies also report better survival for localized or locally advanced disease when primary surgery is performed in expert centers.2512

The most consistent finding is not that every high-volume analysis shows identical survival benefit, but that experienced centers manage a broader range of technically complex disease and more often deliver multimodality care around surgery.913 By contrast, retrospective datasets remain vulnerable to confounding because fitter patients, operable tumors, and patients able to travel may be overrepresented at referral centers.916 The practical implication is that potentially resectable ACC should generally be assessed by surgeons and teams familiar with adrenal cancer, while operative aggressiveness in metastatic disease should be individualized rather than assumed to be standard.266

Care across recurrence and advanced disease

As care shifts from initial treatment to recurrence or metastatic disease, coordination becomes even more important because surgery, mitotane, cytotoxic therapy, locoregional procedures, radiation, and endocrine symptom control may all be considered in varying combinations.1856 Reviews and consensus documents describe this phase as one of repeated reassessment, with management tailored to disease pace, hormone excess, technical resectability, prior treatments, and patient goals.13

Retrospective single-center data suggest that dedicated adrenal or ACC multidisciplinary teams may improve progression-free or overall survival in advanced disease, but these findings remain difficult to separate from era effects and broader improvements in systemic therapy and supportive care.2710 What appears reliable is that advanced ACC care benefits from coordinated review at major transition points, especially when considering repeat surgery, radiotherapy, or multiple lines of systemic treatment.53 Clinically, this favors a longitudinal model in which recurrence is re-presented to the multidisciplinary team rather than managed as a one-time postoperative problem.120

Supportive care, quality of life, and patient-centered coordination

The practical care model extends beyond tumor-directed treatment. ACC and its therapies may produce substantial physical symptoms, steroid-related complications, treatment toxicity, emotional distress, and social or functional disruption, and these burdens may not correlate closely with stage or treatment status alone.282930 Patient-reported outcome research suggests that communication, organization of care, and recognition of treatment-specific issues such as mitotane effects and adrenal insufficiency meaningfully shape patient experience.2829

The reliable conclusion is that psychosocial and supportive needs are common and often underdetected in ACC.30 Less certain is the best standardized model for delivering this support across different health systems, since evidence is drawn mainly from qualitative studies, questionnaire development, and single-center cohorts.2829 In practice, this supports integrating endocrine education, symptom management, psychosocial screening, and palliative care earlier than would be suggested by tumor status alone.3130

Access, disparities, and implementation limits

The organizational advantages of centralization must be interpreted alongside disparities in access. National database studies report variation in likelihood of surgery, timing of treatment, and use of multimodality care by race, insurance status, age, treatment setting, and geography.14153217 Longer travel distance to surgery may also be associated with lower use of adjuvant treatment and worse postoperative survival, illustrating that referral-center models can improve expertise while also increasing logistical barriers.16

These findings are probably reliable for identifying structural inequities, even if they do not fully explain outcome differences in all cohorts.1415 What remains less reliable is whether observed regional or institutional variation always reflects quality differences rather than differences in case mix or local resources.32 The practical implication is that expert-center care may need hub-and-spoke implementation, telemedicine consultation, and shared-care follow-up to preserve expertise without making care inaccessible.223

Role in management and research

Overall, the practical care model for ACC is best understood as a referral-centered, multidisciplinary framework designed to reduce variation in a rare and complex cancer. Its strongest support comes from guidelines, expert reviews, and convergent observational evidence showing improved completeness of evaluation, more specialized surgery, and greater access to multimodality treatment in experienced centers.33417 Because the disease is rare and the literature is dominated by retrospective analyses, the model is supported more by consistency of direction than by high-certainty comparative trials.89

For management, this means ACC care generally should be structured around early expert review, high-quality surgery when feasible, repeated multidisciplinary reassessment at recurrence, and routine attention to endocrine, psychosocial, and supportive needs.563 For research, the same model underpins registry development, pathology standardization, biobanking, and clinical trial enrollment, which remain especially important given the limits of single-center experience and the persistent heterogeneity of practice.33344

Included Articles

  • PMID 16570232: This review emphasizes that improving ACC outcomes requires structured multidisciplinary care through expert networks, national registries, reference pathology review, and coordinated European standards for diagnosis, treatment, and tumor banking. It also highlights trial enrollment as a key strategy for metastatic or unresectable disease.33
  • PMID 20658299: A Spanish national survey of adrenalectomy found better perioperative outcomes in higher-volume centers and surgeons, including more frequent laparoscopic use, shorter hospital stay, and lower in-hospital morbidity for high-volume surgeons. The findings support concentration of adrenal surgery in experienced multidisciplinary units.23
  • PMID 20668036: In adult stage II adrenocortical carcinoma, prospective follow-up and counseling by specialized centers soon after surgery were associated with markedly lower recurrence and higher 5-year survival than later registry referral, highlighting substantial referral bias in historical series and the value of early structured specialist care.8
  • PMID 21246024: A German registry analysis found major real-world deficits in ACC care, including incomplete preoperative hormonal testing, frequent omission of thoracic CT, pathology reporting gaps, and delayed or absent surveillance. The study emphasizes early coordination with specialized centers to improve diagnostic accuracy, perioperative safety, and follow-up quality.19
  • PMID 22069043: A multi-institutional comparative study found that ACC treated at higher-volume centers was associated with more lymph node dissection, more multiorgan resection, greater use of adjuvant therapy, lower local recurrence, and longer time to recurrence, supporting referral to experienced multidisciplinary centers.11
  • PMID 23253377: This letter argues that ACC outcomes improve with centralized surgery in high-volume or specialized centers and that national and international collaboration has enabled advances in stratification, lymphadenectomy, adjuvant treatment, and postoperative care. It advocates coordinated surgical networks and prospective collaborative studies to standardize operative management.34
  • PMID 23641018: A population-based Dutch registry study found that adults with ENSAT stage I-III adrenocortical carcinoma had longer survival when primary surgery was performed in Dutch Adrenal Network centers rather than non-network hospitals, supporting centralized multidisciplinary management for localized or locally advanced disease.25
  • PMID 24613316: This review emphasizes that suspected adrenocortical carcinoma should be managed through coordinated multidisciplinary care in expert networks, integrating endocrinology, oncology, surgery, radiology, nuclear medicine, pathology, and genetics. It also highlights referral-center surgery and national and international networks as means to improve care quality and research despite disease rarity.4
  • PMID 25069860: A U.S. National Cancer Database analysis found that high-volume centers treated a minority of ACC cases but used more aggressive management, including higher rates of surgery, radical resection, lymph node evaluation, open approach, and chemotherapy or mitotane. Despite these practice differences, short-term outcomes and overall survival were not significantly improved after adjustment.9
  • PMID 25244969: This editorial argues that resection of the primary tumor in metastatic ACC should not be treated as standard care and should be limited to carefully selected patients after prospective multidisciplinary review. It emphasizes recent, high-quality imaging with detailed assessment of vascular and organ involvement, clear palliative intent, and frank discussion of expected morbidity, recovery, and limited survival benefit.26
  • PMID 25319576: This multicenter Australian series found that older age, metastases at presentation, and extra-adrenal invasion predicted worse overall survival, while extra-adrenal invasion and absence of preoperative endocrine investigations predicted worse recurrence-free survival. The authors also observed a trend toward better margin status and recurrence outcomes with higher surgeon case volume, supporting management in specialized tertiary endocrine or surgical oncology units.35
  • PMID 26286367: In a multicenter cohort of 209 patients undergoing ACC resection, 18% were readmitted within 90 days. Higher ASA class and metastatic disease at presentation independently predicted readmission, with infections the most common cause, highlighting the need for risk-aware perioperative coordination and postoperative follow-up.36
  • PMID 28583923: This case report describes stage II nonfunctional adrenocortical carcinoma discovered synchronously with ovarian granulosa cell tumor and colon adenocarcinoma, managed through coordinated surgery by gynecologic oncology, urology, and general surgery. The report emphasizes multidisciplinary planning, genetic counseling, and close follow-up because no established guidelines exist for multiple synchronous primary malignancies.37
  • PMID 28601306: A National Cancer Database analysis found disparities in access to ACC surgery, with lower resection likelihood among older patients, men, African-American patients, those with government insurance, and those treated at community cancer centers. Among resected patients, worse overall survival was associated with older age and greater comorbidity burden.14
  • PMID 28614035: This review frames ACC care as individualized and multimodal, integrating biochemical, radiologic, genomic, surgical, systemic, and locoregional information to guide evaluation, treatment selection, surveillance, and management of recurrence according to stage and tumor behavior.18
  • PMID 30117750: This review emphasizes that ACC management should be concentrated in expert multidisciplinary centers because diagnosis, prognostication, surgery, systemic therapy, endocrine control, and recurrence decisions are all high-risk and interdependent. It recommends coordinated input from endocrinology, oncology, surgery, radiology, pathology, and related subspecialties at diagnosis and key disease transitions.5
  • PMID 30299884: These adult ACC guidelines emphasize a structured multidisciplinary expert-center care pathway spanning diagnosis, surgery, pathology review, staging, adjuvant decisions, recurrence management, and mitotane monitoring. They recommend expert team discussion for all suspected or proven cases and consideration of clinical trial enrollment throughout care.1
  • PMID 30473001: This French guideline update emphasizes that malignant adrenal tumors, including ACC, should be managed through multidisciplinary discussion and preferably in specialized adrenal cancer networks or expert centers because of disease rarity and the need to coordinate diagnostic workup, surgery, adjuvant therapy, and long-term follow-up.2
  • PMID 31331729: This review reports that adrenalectomy outcomes are better when operations are performed by higher-volume surgeons, with a data-derived threshold of about six adrenalectomies per year. For ACC, the article also notes evidence supporting benefit at higher-volume hospitals and recommends referral to experienced surgeons and dedicated multidisciplinary adrenal centers.24
  • PMID 32342024: A qualitative ACC study identified four major health-related quality-of-life domains: physical complaints, mental consequences, social consequences, and functional limitations. It also found that communication, organization of care, and partner perspectives meaningfully shape patients’ wellbeing, supporting more patient-centered multidisciplinary care.28
  • PMID 32700134: A single-center retrospective study of adrenal tumor multidisciplinary meetings described a coordinated workflow involving endocrinology, radiology, pathology, urology, anesthesiology, and postoperative review. ACC was among the adrenal cases discussed, illustrating a referral-style team model for integrated diagnosis, perioperative planning, pathology review, and follow-up.21
  • PMID 33400171: A small single-center ACC series during the COVID-19 pandemic reported symptomatic SARS-CoV-2 infection mainly in patients receiving mitotane, with treatment interruption during infection, increased steroid replacement when febrile, and emphasis on strict prevention, telemedicine, and individualized risk-benefit assessment for adjuvant or systemic therapy decisions.38
  • PMID 33875173: This clinical review emphasizes an ACC care pathway centered on prompt imaging and hormonal assessment, chest-abdomen-pelvis staging, expert open en bloc surgery for potentially resectable disease, and multidisciplinary decision-making for recurrent or advanced presentations. It also advocates referral-center management with coordinated input from endocrine, surgical, oncology, pathology, radiology, and genetics specialists.6
  • PMID 34032493: A large NCDB analysis found that ACC treatment at academic centers was associated with better overall survival than treatment at community programs, even after adjustment for treatment modality. Academic centers also showed different practice patterns, including more adrenalectomy or radical en bloc resection, more open surgery, more systemic therapy, and fewer positive margins.12
  • PMID 34307633: This case report highlights multidisciplinary coordination for giant ACC with renal vein tumor thrombus, including endocrine stabilization, ICU care, complex surgery with vascular involvement, postoperative steroid replacement, and subsequent radiotherapy and mitotane after early metastatic recurrence.39
  • PMID 35092681: In a large single-center retrospective ACC cohort spanning 1998 to 2019, clinical outcomes improved over time despite a higher proportion of stage IV presentations, coinciding with more complete primary resections and greater use of multiple systemic therapy lines. The report supports multidisciplinary referral-center management for this rare cancer.27
  • PMID 35151433: An NCDB analysis found that high-volume centers were more likely than low-volume centers to deliver surgery, chemotherapy, and lymph node evaluation for ACC, with lower readmission rates. Survival was similar for operated non-metastatic disease but improved for metastatic disease treated at high-volume centers.13
  • PMID 35177233: This discussion emphasizes that ACC is so rare that experience is dispersed across many centers, limiting single-center expertise. It highlights the value of multidisciplinary management, referral to higher-volume expertise, and telemedicine links to regional referral centers to support care coordination.22
  • PMID 35326518: This study developed and validated an ACC-specific quality-of-life questionnaire that captures disease- and treatment-related issues not covered by generic cancer instruments, including mitotane side effects, hypercortisolism or hydrocortisone effects, and emotional concerns. Registry findings suggest this tool may support side-effect monitoring, treatment guidance, and shared decision making in ACC care.29
  • PMID 35987166: This national database study found care-delivery disparities in ACC: minority patients and those without private insurance were less likely to undergo surgery, and privately insured patients more often received earlier surgery and additional multimodality care. Despite these treatment differences, 90-day mortality and overall survival were similar by race and insurance group.15
  • PMID 36010898: A retrospective single-center study found that advanced ACC patients managed after implementation of a dedicated adrenal multidisciplinary team had longer overall and progression-free survival than patients treated before that model. The report supports early referral to tertiary centers for coordinated endocrine, surgical, oncologic, imaging, pathology, and radiotherapy decision-making.10
  • PMID 37403612: In a national ACC cohort, surgery was associated with better overall survival, but longer travel distance to surgical care was linked to lower use of adjuvant chemotherapy and worse survival after surgery, especially among rural patients. The findings highlight care-access tradeoffs created by regionalized multidisciplinary referral models.16
  • PMID 37530661: A SEER analysis of 1275 adults with ACC found substantial regional variation in use of adrenalectomy, systemic therapy, and combined treatment across US registries, with differences persisting after adjustment for age, ENSAT stage, and year of diagnosis. The authors interpret this as potentially reflecting variation in ACC expertise or quality of care.32
  • PMID 39345031: A population-based inpatient analysis of metastatic ACC found inpatient palliative care use remained low overall at 12% but increased from 3.7% in 2007 to 19.1% in 2019, while in-hospital mortality stayed stable. Younger patients, those with a solitary metastatic site, and those without brain metastases were less likely to receive inpatient palliative care.31
  • PMID 39500005: A national cohort study of treated ACC found a median 27-day interval from diagnosis to first treatment, with slower care associated with non-Hispanic Black race and age 40-64 years, while female sex and metastatic disease were linked to faster treatment. These treatment delays were not associated with worse overall survival in this analysis.17
  • PMID 39661189: A single-center Canadian adrenalectomy series found similar indications and most perioperative outcomes across urology and general surgery, while suggesting lower 30-day readmission and ICU or stepdown use with urologists. The report emphasizes that adrenal surgery depends on multidisciplinary care, local expertise, and surgeon volume more than specialty label alone.40
  • PMID 40215284: This multidisciplinary Spanish consensus frames ACC care as expert-center management integrating prompt hormonal, radiologic, functional imaging, pathology, surgical, oncology, nuclear medicine, and follow-up decisions. It emphasizes coordinated evaluation of resectability, endocrine secretion, hereditary risk, and treatment planning across specialties.3
  • PMID 40496560: A tertiary endocrine multidisciplinary tumour board was associated with more frequent repeated discussion for adrenal masses and reported longer overall survival in ACC than an external matched control cohort. The board also commonly prompted imaging reinterpretation and additional hormonal investigations, underscoring coordinated specialist review in ACC care.20
  • PMID 41504709: In a single-centre observational ACC cohort, distress, fear of progression, and depressive symptoms were frequent and largely unrelated to tumour burden, hormone excess, or treatment status. The study found that 80% met criteria for psychosomatic counselling, supporting routine psychosocial assessment and integrated supportive care in ACC management.30
  • PMID 41765867: A nationwide Dutch cohort found stable ACC incidence over time but improved referral to expert centers after creation of the Dutch Adrenal Network. Care in an expert center was associated with better survival, supporting centralized multidisciplinary ACC management.7

PMID 35536657 is a published erratum to the multidisciplinary referral-center outcomes study and corrects the spelling of an author name in the original report. It does not change the study’s findings or interpretation regarding ACC care pathways, referral-center management, or temporal outcome trends.41

  • PMID 35536657: Published erratum for the 2022 multidisciplinary referral-center ACC outcomes study; it corrects an author name only and does not alter the article’s clinical conclusions or relevance to centralized multidisciplinary care.41

References

Footnotes

  1. 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.. Eur J Endocrinol. 2018. PMID: 30299884. Local full text: 30299884.md ↩ ↩2 ↩3 ↩4 ↩5 ↩6

  2. [RETRACTED: Recommandations françaises du Comité de Cancérologie de l’AFU — Actualisation 2018—2020 : tumeur de la surrénale French ccAFU guidelines — Update 2018—2020: Adrenal cancer].. Prog Urol. 2018. PMID: 30473001. Local full text: 30473001.md ↩ ↩2 ↩3

  3. Spanish consensus on the diagnosis and management of adrenocortical carcinoma.. Endocr Relat Cancer. 2025. PMID: 40215284. Local full text: 40215284.md ↩ ↩2 ↩3 ↩4 ↩5 ↩6 ↩7 ↩8 ↩9

  4. [Adrenocortical carcinoma: Update in 2014].. Presse Med. 2014. PMID: 24613316. Local full text: 24613316.md ↩ ↩2 ↩3 ↩4

  5. Decision-making for adrenocortical carcinoma: surgical, systemic, and endocrine management options.. Expert Rev Anticancer Ther. 2018. PMID: 30117750. Local full text: 30117750.md ↩ ↩2 ↩3 ↩4 ↩5

  6. American Association of Clinical Endocrinology Disease State Clinical Review on the Evaluation and Management of Adrenocortical Carcinoma in an Adult: a Practical Approach.. Endocr Pract. 2020. PMID: 33875173. Local full text: 33875173.md ↩ ↩2 ↩3 ↩4 ↩5 ↩6

  7. Time trends in incidence, treatment and survival of patients with adrenocortical carcinoma, a nationwide study.. J Clin Endocrinol Metab. 2026. PMID: 41765867. Local full text: 41765867.md ↩ ↩2 ↩3 ↩4

  8. Improved survival in patients with stage II adrenocortical carcinoma followed up prospectively by specialized centers.. J Clin Endocrinol Metab. 2010. PMID: 20668036. Local full text: 20668036.md ↩ ↩2 ↩3

  9. Treatment patterns and outcomes for patients with adrenocortical carcinoma associated with hospital case volume in the United States.. Ann Surg Oncol. 2014. PMID: 25069860. Local full text: 25069860.md ↩ ↩2 ↩3 ↩4 ↩5

  10. The Overall Survival and Progression-Free Survival in Patients with Advanced Adrenocortical Cancer Is Increased after the Multidisciplinary Team Evaluation.. Cancers (Basel). 2022. PMID: 36010898. Local full text: 36010898.md ↩ ↩2 ↩3 ↩4

  11. Adrenocortical carcinoma: effect of hospital volume on patient outcome.. Langenbecks Arch Surg. 2012. PMID: 22069043. Local full text: 22069043.md ↩ ↩2 ↩3

  12. Disparate Practice Patterns and Survival Outcomes: The Impact of Centralization of Cancer Care for Adrenocortical Carcinoma in the United States.. J Urol. 2021. PMID: 34032493. Local full text: 34032493.md ↩ ↩2 ↩3

  13. Treatment differences at high volume centers and low volume centers in non-metastatic and metastatic adrenocortical carcinoma.. Am J Surg. 2022. PMID: 35151433. Local full text: 35151433.md ↩ ↩2 ↩3

  14. Disparities in access to care and outcomes in patients with adrenocortical carcinoma.. J Surg Res. 2017. PMID: 28601306. Local full text: 28601306.md ↩ ↩2 ↩3 ↩4

  15. Treatment Differences for Adrenocortical Carcinoma by Race and Insurance Status.. J Surg Res. 2022. PMID: 35987166. Local full text: 35987166.md ↩ ↩2 ↩3 ↩4

  16. Association between travel distance and overall survival among patients with adrenocortical carcinoma.. J Surg Oncol. 2023. PMID: 37403612. Local full text: 37403612.md ↩ ↩2 ↩3 ↩4

  17. Demystifying delays: Factors associated with timely treatment of adrenocortical carcinoma.. Am J Surg. 2025. PMID: 39500005. Local full text: 39500005.md ↩ ↩2 ↩3

  18. PERSONALIZED CARE OF PATIENTS WITH ADRENOCORTICAL CARCINOMA: A COMPREHENSIVE APPROACH.. Endocr Pract. 2017. PMID: 28614035. Local full text: 28614035.md ↩ ↩2 ↩3

  19. Deficits in the management of patients with adrenocortical carcinoma in Germany.. Dtsch Arztebl Int. 2010. PMID: 21246024. Local full text: 21246024.md ↩ ↩2 ↩3

  20. Use and utility of endocrine multidisciplinary tumour board: an appraisal from a tertiary centre.. Front Endocrinol (Lausanne). 2025. PMID: 40496560. Local full text: 40496560.md ↩ ↩2 ↩3 ↩4

  21. The impact of adrenal tumor multidisciplinary team meetings on clinical outcomes.. Endocrine. 2020. PMID: 32700134. Local full text: 32700134.md ↩ ↩2

  22. Treatment differences at high volume centers and low volume centers IN NON -metastatic and metastatic adrenocortical carcinoma.. Am J Surg. 2022. PMID: 35177233. Local full text: 35177233.md ↩ ↩2 ↩3

  23. Results of adrenal surgery. Data of a Spanish National Survey.. Langenbecks Arch Surg. 2010. PMID: 20658299. Local full text: 20658299.md ↩ ↩2

  24. Volume-outcome relationship in adrenal surgery: A review of existing literature.. Best Pract Res Clin Endocrinol Metab. 2019. PMID: 31331729. Local full text: 31331729.md ↩ ↩2

  25. Surgery for adrenocortical carcinoma in The Netherlands: analysis of the national cancer registry data.. Eur J Endocrinol. 2013. PMID: 23641018. Local full text: 23641018.md ↩ ↩2

  26. A meaningful use of the phrase “appropriately selected patients”.. Surgery. 2014. PMID: 25244969. Local full text: 25244969.md ↩ ↩2

  27. Temporal Trends in Outcomes in Patients With Adrenocortical Carcinoma: A Multidisciplinary Referral-center Experience.. J Clin Endocrinol Metab. 2022. PMID: 35092681. Local full text: 35092681.md ↩ ↩2

  28. Patient and Partner Perspectives on Health-Related Quality of Life in Adrenocortical Carcinoma.. J Endocr Soc. 2020. PMID: 32342024. Local full text: 32342024.md ↩ ↩2 ↩3 ↩4

  29. Health-Related Quality of Life in Adrenocortical Carcinoma: Development of the Disease-Specific Questionnaire ACC-QOL and Results from the PROFILES Registry.. Cancers (Basel). 2022. PMID: 35326518. Local full text: 35326518.md ↩ ↩2 ↩3 ↩4

  30. Psychosocial burden in adrenocortical carcinoma patients.. Eur J Endocrinol. 2026. PMID: 41504709. Local full text: 41504709.md ↩ ↩2 ↩3 ↩4

  31. Inpatient palliative care in metastatic adrenocortical carcinoma: a retrospective analysis using the National Inpatient Sample database.. Minerva Endocrinol (Torino). 2025. PMID: 39345031. Local full text: 39345031.md ↩ ↩2

  32. Regional differences in stage distribution and rates of treatment for adrenocortical carcinoma across United States SEER registries.. Minerva Urol Nephrol. 2023. PMID: 37530661. Local full text: 37530661.md ↩ ↩2 ↩3

  33. Adrenocortical carcinoma — improving patient care by establishing new structures.. Exp Clin Endocrinol Diabetes. 2006. PMID: 16570232. Local full text: 16570232.md ↩ ↩2 ↩3

  34. The importance of national cooperation and centralized surgery for adrenocortical surgery.. Surgery. 2013. PMID: 23253377. Local full text: 23253377.md ↩ ↩2

  35. Improving Outcomes in Adrenocortical Cancer: An Australian Perspective.. Ann Surg Oncol. 2015. PMID: 25319576. Local full text: 25319576.md ↩

  36. Incidence and Risk Factors Associated with Readmission After Surgical Treatment for Adrenocortical Carcinoma.. J Gastrointest Surg. 2015. PMID: 26286367. Local full text: 26286367.md ↩

  37. Triple synchronous primary malignancies: a rare occurrence.. BMJ Case Rep. 2017. PMID: 28583923. Local full text: 28583923.md ↩

  38. Frequency and outcome of SARS-CoV-2 infection in patients with adrenocortical carcinoma followed at a reference center in Italy.. Endocrine. 2021. PMID: 33400171. Local full text: 33400171.md ↩

  39. Multidisciplinary team therapy for left giant adrenocortical carcinoma: A case report.. World J Clin Cases. 2021. PMID: 34307633. Local full text: 34307633.md ↩

  40. Perioperative outcomes of adrenal surgery Does surgical specialty matter?. Can Urol Assoc J. 2025. PMID: 39661189. Local full text: 39661189.md ↩

  41. Correction to: Temporal Trends in Outcomes in Patients with Adrenocortical Carcinoma: A Multidisciplinary Referral Center Experience.. J Clin Endocrinol Metab. 2022. PMID: 35536657. Local full text: 35536657.md ↩ ↩2

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