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ASO Author Reflections: Surgical Decision-Making in Adrenocortical Carcinoma: When Less is More
Jesse E. Passman, MD, MPH®, and Heather Wachtel, MD
Department of Surgery, University of Pennsylvania Health System, Philadelphia
PAST
Adrenocortical carcinoma (ACC) is an aggressive cancer with poor outcomes.1 ACC is also rare, limiting the feasibil- ity of randomized prospective trials. In non-metastatic ACC, complete surgical resection is the only potentially curative therapy; however, controversy remains regarding the appro- priate surgical strategy. Universal open surgery and en bloc multiorgan resection are historically favored, although evi- dence on survival benefit is conflicting.2,3 Similarly, recent research seems to favor routine lymphadenectomy, although its role is not well defined.4
PRESENT
We utilized the National Cancer Database to perform a retrospective cohort study of patients undergoing surgery for non-metastatic ACC to assess the impact of surgical approach.5 Age, stage and positive surgical margins were the primary predictors of survival. While minimally invasive approach overall had worse outcomes, this effect was pri- marily driven by patients with stage III ACC, as those with stage I and II disease had equivalent survival regardless of surgical approach. Given there was no relationship between laparoscopy and surgical margins, this may be related to higher likelihood of intraoperative tumor spillage. En bloc
This article refers to: Passman JE, Ballester JMS, Ginzberg SP, Wachtel H. Defining optimal management of non-metastatic adrenocortical carcinoma. Ann Surg Oncol. (2023). https://doi. org/10.1245/s10434-023-14533-w.
@ Society of Surgical Oncology 2023
First Received: 2 November 2023
Accepted: 2 November 2023 Published online: 22 November 2023
J. E. Passman, MD, MPH e-mail: jesse.passman@pennmedicine.upenn.edu
multiorgan resection did not improve survival in any model, implying that such aggressive resections are likely unnec- essary if local invasion is not present. In contrast to other recent studies, lymphadenectomy did not improve overall survival. Adjuvant chemoradiation was only associated with survival in patients with positive resection margins.
FUTURE
These findings imply that while oncologic integrity of the resection is critical, the means by which it is attained can be left to surgeon preference and experience. The exception to this is in patients with stage III disease, for whom minimally invasive approach was associated with poorer outcomes. Lymphadenectomy, in contrast, offered no survival advan- tage at any stage, conflicting with recent research. The mech- anisms relating survival to lymphadenectomy are unclear. Our findings underscore the need for concerted efforts to develop multi-institutional longitudinal databases following patients with ACC. Such rich data sources would permit research determining what drives recurrence and disease- specific survival following apparent R0 resections, whether that is distant micrometastatic disease, microscopic tumor deposits in unresected lymph nodes, or tumor bed seeding from intraoperative spillage.
FUNDING H.W. received funding from the National Institutes of Health, NCI Grant K08 CA270385.
DISCLOSURE The authors have no conflicts of interest to disclose.
REFERENCES
1. Else T, Kim AC, Sabolch A, Raymond VM, Kandathil A, Caoili EM, Jolly S, Miller BS, Giordano TJ, Hammer GD. Adrenocorti- cal carcinoma. Endocr Rev. 2014;35:282-326.
2. Datta J, Roses RE. Surgical management of adrenocortical carcinoma: an evidence-based approach. Surg Oncol Clin. 2016;25:153-70.
3. Marincola Smith P, Kiernan CM, Tran TB, Postlewait LM, Maithel SK, Prescott J, Pawlik T, Wang TS, Glenn J, Hatzaras I. Role of additional organ resection in adrenocortical carcinoma: analysis of 167 patients from the US adrenocortical carcinoma database. Ann Surg Oncol. 2018;25:2308-15. https://doi.org/10. 1245/s10434-018-6546-y.
4. Hendricks A, Müller S, Fassnacht M, Germer C-T, Wiegering VA, Wiegering A, Reibetanz J. Impact of lymphadenectomy on the oncologic outcome of patients with adrenocortical
carcinoma-a systematic review and meta-analysis. Cancers. 2022;14:291.
5. Passman JE, Ballester JMS, Ginzberg SP, Wachtel H. Defin- ing optimal management of non-metastatic adrenocortical carcinoma. Ann Surg Oncol. 2023. https://doi.org/10.1245/ s10434-023-14533-w.
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