Author Manuscript
SERVICES . USA \\TMENT OF HEALTH & HOME
Published in final edited form as: Urol Oncol. 2022 October ; 40(10): 455.e19-455.e25. doi:10.1016/j.urolonc.2022.05.021.
Association of Tumor Size and Surgical Approach with Oncological Outcomes and Overall Survival in Patients with Adrenocortical Carcinoma
Kevin B. Ginsburg, MD, MS1,2, Alberto A. Castro Bigalli, MD, MS1, Jared P. Schober, MD1, David Perlman, MD2, Elizabeth A. Handorf, PhD, MD3, David YT Chen, MD1, Richard E. Greenberg, MD1, Rosalia Viterbo, MD1, Robert G. Uzzo, MD1, Alexander Kutikov, MD1, Marc C. Smaldone, MD, MHSP1, Andres F. Correa, MD1
1Department of Surgical Oncology, Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia PA
2Wayne State University Department of Urology, Detroit, MI
3Biostatistics and Bioinformatics Facility, Fox Chase Cancer Center, Philadelphia PA
Abstract
Objectives: To investigate the association of surgical approach with outcomes in patients with adrenocortical carcinomas smaller and larger than 6 cm in size.
Methods: We reviewed the national cancer database for patients undergoing minimally invasive adrenalectomy (MIA) and open adrenalectomy (OA) from 2010-2017. To adjust for differences between patients undergoing MIA and OA, we performed propensity score matching within each size strata of ≤6 cm, 6.1-10 cm, and 10.1-20 cm. We fit a generalized estimating equation with a logit link function to assess for the association of surgical approach with positive surgical margins and a Cox proportional hazards model to assess for the association of surgical approach with overall survival.
Corresponding Author: Kevin B. Ginsburg, MD, MS, Department of Surgical Oncology, Division of Urologic Oncology Fox Chase Cancer Center, Temple University Health System, 333 Cottman Avenue, Philadelphia, PA 19111, kevin.ginsburg@fccc.edu, Tel: 412-414-1862.
Conflicts of Interest:
KBG - None
ACB - None
AAC - None
EH - None
JPS - None
AM - None
MS - None
RV - None
RU - None
RG - None
DC - None
AK - None
AFC - None
Kevin Ginsburg attests to the accuracy of the references and all statements made in the following documents.
Results: We identified 364 patients that underwent MIA (182) and OA (182) in the matched cohort. We noted 21% and 18% of patients undergoing MIA and OA had a positive surgical margin, respectively. We did not identify a significant association between surgical approach and positive surgical margins in the cohort as a whole or within each of strata. Furthermore, we did not appreciate a significant association between surgical approach and overall survival in the cohort as a whole or within each size strata.
Conclusion: In the NCDB, patients undergoing MIA had similar positive surgical margins and overall survival compared with OA for masses ≤6 cm, 6-10cm, and >10 cm in size. Patients undergoing MIA should be carefully selected with surgical oncologic integrity being the primary determinants of surgical approach.
Keywords
Adrenocoritcal carcinoma; laparoscopy; survival; margins of excision
1.1 Introduction
Adrenocortical carcinoma (ACC) is a rare malignancy, affecting less than 2 people per million each year worldwide.1 While the outcomes of patients with localized ACC are favorable, the survival of patients with metastatic ACC is poor, with a median survival of 17 months.2
As metastatic ACC remains incurable, an R0 resection with negative surgical margins remains paramount to the treatment of patients with clinically localized ACC.2-4 Initial experiences with minimally invasive adrenalectomy (MIA) for the treatment of localized ACC generated concerns regarding the oncological efficacy of laparoscopic surgery for the treatment of this malignancy. These studies suggested patients treated with MIA had increased risk of tumor spillage, local recurrence, and worse survival.5-7 As a result, guideline organizations have taken a opposition to MIA most patients with adrenal tumors, especially tumors which are concerning for malignancy.2, 3
Currently, the National Comprehensive Cancer Network (NCCN) recommends that open adrenalectomy (OA) is preferred for patients with resectable disease but “the decision for open versus minimally invasive surgery is based on tumor size and degree of concern regarding potential malignancy, and local surgical expertise.”2 The European Society of Endocrinology and European Network for the Study of Adrenal Tumors (ESE/ENSAT) guidelines state that for tumors <6 cm in size, laparoscopy is reasonable given surgeon expertise. However, within the Management for Adrenal Incidentalomas guidelines, the ESE/ENSAT state that this cut off of 6 cm is arbitrary and not evidence based but based off the concern for positive surgical margins and tumor spillage with larger size masses treated with MIA.3, 8
Herein, we aimed to investigate the recommendation against the use of laparoscopy for masses >6cm in size. We tested for an association between tumor size and surgical approach with positive surgical margins and overall survival in patients with ACC.
1.2 Materials and Methods
1.2.1 Study Design
We conducted a retrospective review of patients undergoing adrenalectomy for adrenocortical carcinoma (ACC) in the National Cancer Database (NCDB) from 2010 to 2017. The NCDB, a hospital-based registry, harnesses clinical data from more than 1,500 Commission on Cancer (CoC) accredited institutions in the United States and Puerto Rico.9-12 The NCDB is a joint project of the CoC of the American College of Surgeons and the American Cancer Society. The data analyzed in the study was obtained from a de- identified NCDB file. The American College of Surgeons and the CoC have not verified and are not responsible for the analytic or statistical methodology employed nor the conclusions drawn from this data by the investigators. This study was deemed exempt from IRB review by the Fox Chase Cancer Center Institutional Review Board.
1.2.2 Study Population
Patients from the NCDB were included in this study if they underwent adrenalectomy with non-metastatic ACC (histology code 8370) during the period 2010 to 2017 with clinically localized disease (cT1-3NOMO). Patients with concern for distant metastasis (cM+ or AJCC stage IV disease) or nodal metastasis (cN+) were excluded. Patients with missing or incomplete information for independent variables, covariates, or outcomes of interested were excluded. Patients which received preoperative RT or systemic therapy were excluded. Furthermore, we excluded patients with clinical T4 tumors and limited the cohort to masses smaller than 20 cm in size. The analytic cohort prior to matching consisted of 698 patients.
1.2.3 Study Outcomes
The aim of this study was 1) to test for an association of surgical approach and oncological outcomes and 2) to test if the size of the adrenal tumor modified the association of surgical approach and oncological outcomes in order to identify if patients with ACCs of certain sizes (≤6 cm, 6.1-10 cm, and 10.1-20 cm) were at increased risk of worse oncological outcomes if treated with a minimally invasive adrenalectomy compared with open adrenalectomy. The outcomes of interest were positive surgical margins and overall survival. OS was calculated from the date of diagnosis to the date of death for patients which died or the date of last clinical contact for patients which remained alive at last follow up. Patients that underwent a robotic or laparoscopic surgery were classified as the MIA group. For patients that began with robotic or laparoscopic surgeries and were converted to open, these operations classified as MIA utilizing the intention to treat principle to account for the potential morbidity of attempting a minimally invasive approach. Secondary objectives were to test for an association between surgical approach (MIA vs. OA) and overall survival in patients with negative surgical margins and positive surgical margins.
1.2.4 Statistical Analysis
Clinical, demographic, and oncological parameters were compared between patients treated with MIA vs OA with the chi-squared test and Wilcoxon rank sum test. A multivariable logistic regression model with robust standard errors clustered by hospital was fit to
calculate the adjusted odds ratio of factors associated with MIA vs OA. Variables of interest included in the model were: clinical T stage (cT1 vs. cT2 vs. cT3 vs. missing), age (continuous per year), race (white vs. non-white), sex (male vs. female), Charlson comorbidity score (0 vs. 1 vs. ≥2), and insurance type (private, public, uninsured/unknown). The multivariable logistic regression model was used to estimate the probability of MIA vs OA. Nearest neighbor propensity score matching was performed within each size strata (≤6 cm, 6.1-10 cm, and 10.1-20 cm) with a caliper of 0.01. Balance between covariates was assessed in the propensity score matched cohort and within each size strata using the chi-squared test and Wilcoxon rank sum test as appropriate. We calculated the proportion of patients with positive surgical margins in the matched cohort and within each size strata. We used logistic regression to estimate the association between surgical approach and positive surgical margins in the matched cohort and within each size strata. These models used robust standard errors via generalized estimating equations (GEE) to account for cases clustering within hospitals. The model for the whole (matched) cohort was fit with and without categorical size as a covariate for adjustment. OS survival probability was estimated using the Kaplan-Meier method. As the log rank test should not be used for hypothesis testing in matched data, a Cox proportional hazards models with robust standard errors clustered by hospital were fit to test to an association of surgical approach and OS in the matched cohort, within each size strata, and by surgical margin status. The model for the whole cohort was fit with and without categorical size as a covariate for adjustment. Statistical analysis was performed with Stata version 15.1 with statistical significance set at a threshold of 0.05.
1.3 Results
1.3.1 Demographics
From 2010 to 2017, we identified 698 patients that underwent surgical resection for ACC in the NCDB (Supplemental Figure 1). Median age of the cohort was 56 (IQR: 44-67, Table 1). Most patients (n=421, 60%) patients underwent an OA surgical approach compared with 277 (40%) which underwent MIA. Prior to propensity score matching, we noted patients that underwent MIA tended to have smaller masses (median 7 cm) compared with patients that underwent OA (median 10.9 cm).
1.3.2 Propensity Score Matching
We fit a multivariable logistic regression model to test for an association of clinical, demographic, and oncological parameters associated with surgical approach (Supplemental Table 1). The model had modest predictive capability (AUC: 0.634, Supplemental Figure 2) and good fit (Hosmer-Lemeshow Goodness of Fit, p=0.5712). We used the multivariable logistic regression model to estimate a propensity score for surgical approach for each patient and performed nearest neighbor propensity score matching within each size strata (≤6 cm, 6.1-10 cm, and 10.1-20 cm). We identified 364 (182 MIA and 182 OA) patients in the propensity score matched cohort, with 86 patients with masses ≤6 cm, 168 patients with masses 6.1-10 cm, and 110 patients with masses 10.1-20 cm in size. Median follow up in the propensity score matched cohort was 37.8 months (IQR 17.5-60.7). Measured covariates including adrenal mass size, clinical T stage, age, race, sex, comorbidity score, and insurance type were well balanced between patients treated with OA and MIA in the
entire cohort and within each size strata (Table 1 and Supplemental Table 2). The data presented in the following sections for the primary and secondary objectives refers to the analysis of the propensity score matched cohort.
1.3.3 Positive Surgical Margins
Overall, 71 patients (19.5%; 95% CI 15.7%-23.9%) had a positive surgical margin. Patients that underwent MIA and OA had similar incidence of positive surgical margin (21% and 18%, respectively, Figure 1). We did not identify an association between surgical approach and positive surgical margins in the logistic regression GEEs without (OR 1.20, 95% CI 0.71-2.00, p=0.495) and with (OR 1.20, 95% CI 0.71-2.00, p=0.499) the inclusion of size as a covariate in the models (Table 2a, Model 1 and 2). Furthermore, when stratified by ACC size strata, we noted similar proportion of patients with positive surgical margins when treated with MIA (≤6 cm: 21%; 6.1-10 cm: 17%; 10.1-20 cm: 27%) compared with OA (≤6 cm: 16%; 6.1-10 cm: 19%; 10.1-20 cm: 18%, Figure 1). Additionally, we did not appreciate a significant relationship with surgical approach and positive surgical margins in the logistic regression GEE when stratified by size category/strata (Table 2a, Models 3-5). Although the relationship did not reach conventional statistical significance, the proportion of patients masses 10.1-20.0 cm in size with positive surgical margins treated was notably higher in patients treated with MIA compared with OA (27% vs. 18%, respectively, Table 2A, Model 5 - OR: 1.47, 95% CI 0.73-2.98, p=0.284)
1.3.4 Overall Survival
There were 175 deaths during study follow up. Kaplan-Meier curves of OS probability for the matched cohort and stratified by size are shown in Figure 2. We noted similar OS for patients treated with MIA and OA, regardless of ACC size. We did not appreciate a significant relationship between surgical approach and OS without (HR 1.11, 95% CI 0.82-1.50, p=0.501) and with (HR 1.13, 95% CI 0.83-1.52, p=0.438) size included as a covariate for adjustment in the Cox proportional hazards models (Table 2b, Models 1 and 2). Similarly, we did not appreciate a significant relationship between surgical approach and OS in the regression models when stratified by ACC size category/strata (Figure 2B-D, Table 2b, Models 3-5).
1.3.5 Impact of Surgical Margin Status on Survival
We did not appreciate a significant difference in OS for patients treated with MIA vs. OA when stratified by negative or positive surgical margin status (Figure E and F, respectively). Among patients with negative surgical margins, we did not identify a significant association between surgical approach and overall survival (MIA vs. OA: HR: 1.06, 95% CI 0.74-1.50, p=0.762). Additionally, among patients with positive surgical margins, we did not appreciate a significant association between surgical approach and OS (MIA vs. OA: HR 1.12, 95% CI 0.64-1.97, p=0.685).
1.4 Discussion:
Due to the poor prognosis of patients with recurrent or metastatic ACC, complete surgical resection is of paramount importance. Due to concerns regarding the inferior oncological
effectiveness of MIA, mainly, the increase in positive surgical margins and risk for tumor spillage, guidelines organizations have suggested masses >6cm in size undergo OA. Herein, we demonstrated that patients that underwent MIA did not have statistically significant difference in positive surgical margins or OS compared with patients undergoing OA. Additionally, when stratified by size, we did not appreciate a significant difference in positive surgical margins and OS for patients with masses ≤6 cm, 6.1-10 cm, and 10.1-20 cm in size.
Several groups reporting their initial experience with MIA raised concerns regarding this technique in the treatment of ACC. One of the first studies to investigate the oncological safety of MIA, Miller and colleagues reported on their single institutional experience of 88 patients undergoing adrenalectomy from 2003 to 2008, of which 17 had a MIA.5 The authors noted increase incidence of positive surgical margin, tumor spillage, and shorter time to recurrence for patients who underwent MIA compared with OA. Additional studies raise similar concerns regarding worse prognosis after MIA in a variety of outcomes: positive surgical margins, tumor spillage, local recurrence, peritoneal carcinomatosis, cancer specific survival and overall survival.6, 7, 13, 14 However, the full body of literature on this subject signals a clinical principle fraught with controversy. There are several single and multi-institutional retrospective cohorts demonstrating oncologic equivalency in each of the previously mentioned outcomes noted above: R0 resection, tumor spillage, disease free survival, cancer specific survival, and overall survival.15-19 Furthermore, meta-analysis and systemic review data tend to demonstrate oncological equivalency of MIA and OA.20, 21
The present study adds to the current literature by reporting specifically on the relationship of MIA with oncological outcomes by tumor size using comparative effectiveness techniques, which has not been reported in the literature previously. We did not appreciate a significant difference in positive surgical margins and overall survival for masses <6cm in size, in which guideline organizations report MIA is a reasonable option, as well as for masses larger than 6 cm in size, in which guideline organizations would recommend against the use of laparoscopy. These data suggest size may not be the most important driver of operative oncological integrity. The nuanced ability of surgeons to select patients in which they believe MIA offers an R0 resection and the technical ability to perform an oncological sound resection, regardless of surgical approach, may influence operative outcomes more than what can explained by a simple relationship between a size threshold and surgical approach. As demonstrated in our subgroup analysis, among patients with a negative surgical margin, MIA did not have significantly different OS compared with OA.
There are several limitations of this study worth noting which are inherent to the retrospective trial design and use of registry data. Despite covariate balance after propensity score matching, there remains the concern for residual and unmeasured confounding. Surgical expertise and the decision making process as to why certain patient were treated with MIA vs. OA is not discernable in these data and may introduce selection bias. The inclusion of other outcomes such as recurrence free survival and cancer specific survival would be beneficial but are not available within the dataset. Nonetheless, given the poor survival of patients with recurrent and metastatic ACC, OS is likely an acceptable surrogate22. Certain prognostic variables, such as hormonal status, Ki-67 expression, and
other molecular markers are not available within the NCDB for adjustment. Finally, for this rare disease, sample sizes were small, which limits statistical power to detect modest effects, specifically among the subgroup analysis.
It is important to note that the evidence for and against the use of MIA, and conversely the evidence to suggest the superiority of OA for larger adrenal masses, is weak, conflicting, and inconsistent. Given the concern for inferior outcomes, guideline organizations rightfully have taken a more conservative approach to the recommended treatment for patients with larger adrenal lesions concerning for ACC. Nonetheless, patients undergoing MIA should be carefully selected with surgical oncologic integrity, not necessarily size, being the primary determinants of surgical approach.
1.5 Conclusion:
In the NCDB, we did not find a significant difference in positive surgical margins and overall survival for patients with masses ≤6 cm, 6-10, and >10 cm in size undergoing MIA and OA. As current guidelines recommend OA for masses >6cm in size, OA should remain the preferred strategy, but for appropriately selected patients in which the oncological principles of surgery can be respected and negative surgical margins can be achieved, MIA may result in similar oncological outcomes.
Supplementary Material
Refer to Web version on PubMed Central for supplementary material.
Funding:
None
References:
1. Bilimoria KY, Shen WT, Elaraj D et al. : Adrenocortical carcinoma in the United States: treatment utilization and prognostic factors. Cancer, 113: 3130, 2008 [PubMed: 18973179]
2. Shah MH, Goldner WS, Benson AB et al. : Neuroendocrine and Adrenal Tumors, Version 2.2021, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw, 19: 839, 2021 [PubMed: 34340212]
3. Fassnacht M, Dekkers OM, Else T et al. : 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, 179: G1, 2018 [PubMed: 30299884]
4. Ginsburg KB, Chandra AA, Schober JP et al. : Identification of oncological characteristics associated with improved overall survival in patients with adrenocortical carcinoma treated with adjuvant radiation therapy: Insights from the National Cancer Database. Urol Oncol, 2021
5. Miller BS, Ammori JB, Gauger PG et al. : Laparoscopic resection is inappropriate in patients with known or suspected adrenocortical carcinoma. World J Surg, 34: 1380, 2010 [PubMed: 20372905]
6. Miller BS, Gauger PG, Hammer GD et al. : Resection of adrenocortical carcinoma is less complete and local recurrence occurs sooner and more often after laparoscopic adrenalectomy than after open adrenalectomy. Surgery, 152: 1150, 2012 [PubMed: 23158185]
7. Huynh KT, Lee DY, Lau BJ et al. : Impact of Laparoscopic Adrenalectomy on Overall Survival in Patients with Nonmetastatic Adrenocortical Carcinoma. J Am Coll Surg, 223: 485, 2016 [PubMed: 27238874]
Urol Oncol. Author manuscript; available in PMC 2023 October 01.
8. Fassnacht M, Arlt W, Bancos I et al. : Management of adrenal incidentalomas: European Society of Endocrinology Clinical Practice Guideline in collaboration with the European Network for the Study of Adrenal Tumors. Eur J Endocrinol, 175: G1, 2016 [PubMed: 27390021]
9. Boffa DJ, Rosen JE, Mallin K et al. : Using the National Cancer Database for Outcomes Research: A Review. JAMA Oncol, 3: 1722, 2017 [PubMed: 28241198]
10. Bilimoria KY, Stewart AK, Winchester DP et al. : The National Cancer Data Base: a powerful initiative to improve cancer care in the United States. Ann Surg Oncol, 15: 683, 2008 [PubMed: 18183467]
11. Merkow RP, Rademaker AW, Bilimoria KY: Practical Guide to Surgical Data Sets: National Cancer Database (NCDB). JAMA Surg, 153: 850, 2018 [PubMed: 29617542]
12. Mohanty S, Bilimoria KY: Comparing national cancer registries: The National Cancer Data Base (NCDB) and the Surveillance, Epidemiology, and End Results (SEER) program. J Surg Oncol, 109: 629, 2014 [PubMed: 24464362]
13. Wu K, Liu Z, Liang J et al. : Laparoscopic versus open adrenalectomy for localized (stage 1/2) adrenocortical carcinoma: Experience at a single, high-volumecenter. Surgery, 164: 1325, 2018 [PubMed: 30266443]
14. Maurice MJ, Bream MJ, Kim SP et al. : Surgical quality of minimally invasive adrenalectomy for adrenocortical carcinoma: a contemporary analysis using the National Cancer Database. BJU Int, 119: 436, 2017 [PubMed: 27488744]
15. Kastelan D, Knezevic N, Zibar Tomsic K et al. : Open vs laparoscopic adrenalectomy for localized adrenocortical carcinoma. Clin Endocrinol (Oxf), 93: 404, 2020 [PubMed: 32421867]
16. Porpiglia F, Fiori C, Daffara F et al. : Retrospective evaluation of the outcome of open versus laparoscopic adrenalectomy for stage I and II adrenocortical cancer. Eur Urol, 57: 873, 2010 [PubMed: 20137850]
17. Brix D, Allolio B, Fenske W et al. : Laparoscopic versus open adrenalectomy for adrenocortical carcinoma: surgical and oncologic outcome in 152 patients. Eur Urol, 58: 609, 2010 [PubMed: 20580485]
18. Donatini G, Caiazzo R, Do Cao C et al. : Long-term survival after adrenalectomy for stage I/II adrenocortical carcinoma (ACC): a retrospective comparative cohort study of laparoscopic versus open approach. Ann Surg Oncol, 21: 284, 2014 [PubMed: 24046101]
19. Lee CW, Salem AI, Schneider DF et al. : Minimally Invasive Resection of Adrenocortical Carcinoma: a Multi-Institutional Study of 201 Patients. J Gastrointest Surg, 21: 352, 2017 [PubMed: 27770290]
20. Autorino R, Bove P, De Sio M et al. : Open Versus Laparoscopic Adrenalectomy for Adrenocortical Carcinoma: A Meta-analysis of Surgical and Oncological Outcomes. Ann Surg Oncol, 23: 1195, 2016 [PubMed: 26480850]
21. Langenhuijsen J, Birtle A, Klatte T et al. : Surgical Management of Adrenocortical Carcinoma: Impact of Laparoscopic Approach, Lymphadenectomy, and Surgical Volume on Outcomes-A Systematic Review and Meta-analysis of the Current Literature. Eur Urol Focus, 1: 241, 2016 [PubMed: 28723392]
22. Li Y, Bian X, Ouyang J et al. : Nomograms to predict overall survival and cancer-specific survival in patients with adrenocortical carcinoma. Cancer management and research, 10: 6949, 2018 [PubMed: 30588100]
Highlights
· Due to the concern of surgical quality, guideline organizations recommend open adrenalectomy for masses larger than 6cm in size.
· In the NCDB, patients treated with minimally invasive adrenalectomy had similar incidence of positive surgical margins and similar overall survival regardless of mass size compared with open adrenalectomy.
· Overall survival was similar between minimally invasive vs. open adrenalectomy for patients with negative and positive surgical margins.
· These data suggest oncological integrity of the resection influences outcomes more than surgical approach for patients with adrenocortical carcinoma.
Positive Surgical Margins
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
All Patients
≤6 cm
6.1-10 cm
10.1-20 cm
Open
MIS
A)
1.00
Kaplan-Meier Survival Estimates
0.75
HR: 1.11, 95% CI 0.82-1.50, p=0.501
Overall Survival
0.50
0.25
0.00
0
12
24
36
48
60
Time from Diagnosis (Months)
Number at risk
OA 182
133
93
52
MIA 182
129
76
41
OA
MIA
B)
1.00
Kaplan-Meier Survival Estimates
Overall Survival Probability
0.75
HR: 0.77, 95% CI: 0.38-1.53, p=0.454
0.50
0.25
0.00
0
12
24
36
48
60
Time from Diagnosis (Months)
Number at risk
OA
43
31
25
15
MIA 43
39
23
14
OA
MIA
C)
1.00
Kaplan-Meier Survival Estimates
Overall Survival Probability
0.75
HR: 1.27, 95% CI: 0.84-1.92, p=0.264
0.50
0.25
0.00
0
12
24
36
48
60
Time from Diagnosis (Months)
Number at risk
OA 84
59
38
23
MIA 84
54
32
18
OA
MIA
D)
1.00
Kaplan-Meier Survival Estimates
Overall Survival Probability
0.75
HR 1.19, 95% CI: 0.72-1.97, p=0.495
0.50
0.25
0.00
0
12
24
36
48
60
Time from Diagnosis (Months)
Number at risk
OA 55
43
30
14
MIA 55
36
21
9
OA
MIA
E)
1.00
Kaplan-Meier Survival Estimates
Overall Survival Probability
0.75
HR: 1.06, 95% CI 0.74-1.50, p=0.762
0.50
0.25
0.00
0
20
40
60
Time from Diagnosis (Months)
Number at risk
OA 149
114
80
46
MIA 144
110
67
37
OA
MIA
F)
1.00
Kaplan-Meier Survival Estimates
Overall Survival Probability
0.75
HR: 1.12, 95% CI: 0.64-1.97, p=0.685
0.50
0.25
0.00
0
20
40
60
Time from Diagnosis (Months)
Number at risk
OA 33
18
12
5
MIA 38
19
9
4
OA
MIA
Table 1. Clinical, demographics, and oncological parameters of patients with adrenocortical carcinoma in the unmatched and matched cohort. Cells suppressed per NCDB DUA.
| Unmatched | Matched | |||||
|---|---|---|---|---|---|---|
| Open (n=421) | MIS (n=277) | p | Open (n=182) | MIS (n=182) | p | |
| Size (continuous) | 10. 9 (7.5-14.5) | 7.0 (5-9.5) | <0.001 | 8.5 (6-11) | 8.0 (6-11) | 0.746 |
| Size (categorical) | <0.001 | >0.999 | ||||
| ≤6 cm | 56 (13%) | 112 (40%) | 43 (24%) | 43 (24%) | ||
| 6.1-10 cm | 135 (32%) | 110 (40%) | 84 (46%) | 84 (46%) | ||
| 10.1-20 cm | 230 (55%) | 55 (20%) | 55 (30%) | (30%) | ||
| cT Stage | <0.001 | 0.616 | ||||
| cT1 | 29 (6.9%) | 54 (19%) | 15 (8.2%) | 16 (8.8%) | ||
| cT2 | 200 (48%) | 117 (42%) | 85 (47%) | 90 (49%) | ||
| cT3 | 69 (16%) | 29 (10%) | 22 (12%) | 27 (15%) | ||
| Missing | 123 (29%) | 77 (28%) | 60 (33%) | 49 (27%) | ||
| Age | 56 (44-66) | 57 (46-67) | 0.156 | 58 (47-68) | 56 (44-67) | 0.0961 |
| Race | 0.116 | 0.865 | ||||
| White | 358 (85%) | 247 (89%) | 162 (89%) | 163 (90%) | ||
| Non-white | 63 (15%) | 30 (11%) | 20 (11%) | 19 (10%) | ||
| Sex | 0.659 | 0.276 | ||||
| Male | 162 (38%( | 102 (37%) | 61 (34%) | 71 (39%) | ||
| Female | 259 (62%) | 175 (63%) | 121 (66%) | 111 (61%) | ||
| Comorbidity Score | 0.029 | 0.92 | ||||
| 0 | 324 (77%) | 188 (68%) | 140 (77%) | 137 (75%) | ||
| 1 | 72 (17%) | 66 (24%) | - | - | ||
| ≥2 | 24 (5.7%) | 23 (8.3%) | - | - | ||
| Insurance Type | 0.324 | 0.577 | ||||
| Private | 222 (53%0 | 155 (56%) | 87 (48%) | 97 (53%) | ||
| Government | 166 (39%) | 108 (39%) | - | - | ||
| Unknown/Not Insured | 33 (7.8%) | 14 (5.1%) | - | - | ||
* Cells suppressed per NCDB DUA.
Table 2a. Generalized estimation equations with a logit link function testing an association between surgical approach and positive surgical margins in the propensity score matched cohort. Model 1 includes the entire cohort. Model 2 includes the entire cohort and is adjusted for size. The models 2-4, which are stratified by size, include only surgical approach.
| OR | 95% CI | p | |
|---|---|---|---|
| Model 1: All Patients | 1.20 | 0.71-2.00 | 0.495 |
| Model 2: All Patients (adjusted for size) | 1.20 | 0.71-2.00 | 0.499 |
| Model 3: ≤6 cm | 1.36 | 0.47-3.96 | 0.574 |
| Model 4: 6.1-10 cm | 0.90 | 0.41-1.94 | 0.783 |
| Model 5: 10.1-20 cm | 1.47 | 0.73-2.98 | 0.284 |
Table 2b. Cox proportional hazards models testing an association of surgical approach with overall survival in the propensity score matched cohort. Model 1 includes the entire cohort. Model 2 includes the entire cohort and is adjusted for size. The models 2-4, which are stratified by size, include only surgical approach.
| HR | 95% CI | p | |
|---|---|---|---|
| Model 1: All Patients | 1.11 | 0.82-1.50 | 0.501 |
| Model 2: All Patients (adjusted for size) | 1.13 | 0.83-1.52 | 0.438 |
| Model 3: ≤6 cm | 0.77 | 0.38-1.53 | 0.454 |
| Model 4: 6.1-10cm | 1.27 | 0.84-1.92 | 0.264 |
| Model 5: 10.1-20 cm | 1.19 | 0.72-1.97 | 0.495 |