The importance of national cooperation and centralized surgery for adrenocortical surgery
To the Editors:
We read with great interest the article by Hermsen et al,1 and would like to congratulate them for bringing this im- portant issue into focus. Overall, their work strongly sug- gests the need of large cooperation and centralized surgery in adrenocortical carcinoma (ACC). This is in ac- cordance with recent literature, highlighting better patient outcome in Italian high-volume centers2 or in German pa- tients receiving early postoperative specialized care.3 It is worth noting that these 2 studies were only rendered possi- ble through intense national collaboration. Overall, it seems now clear that all recent significant advances in ACC management, such as improvement in stratification,4 need for lymphadenectomy,5 or adjuvant treatment6,7 were only been made possible by large, comprehensive, national and international networks.
Regarding complex resections for cancer, such as pancreaticoduodenectomy, centralized surgery in high- volume centers has been associated with both reduced postoperative mortality and increased long-term survival. The standard of care for pancreatic adenocarcinoma are now relatively well-defined because of the >100 prospec- tive, randomized trials published over the last decade. The situation is diametrically opposed for ACC, for which no clear standards of surgical care based on oncologic principles have been defined. Wide variations in ACC surgery have been highlighted in a large French collaborative study,8 which again emphasizes the need for further standardization. In the past, improvement in operative techniques has been shown to have a direct and major effect on cancer outcomes. For example, this has been proven for rectal cancer operations with the large diffusion in the surgical community of the total mesorectal excision concept, associated with a signifi- cant decrease in local recurrence and cancer-related deaths.
The medical community has conducted recently a randomized, controlled trial on combination chemo- therapy in advanced ACC7 (FIRM-ACT; First Interna- tional Randomized trial in locally advanced and Metastatic Adrenocortical Carcinoma Treatment). Such an ambitious project should also be the aim of the surgical community; questions to be answered include the extent of surgery, locoregional lymphadenectomy, significance of the laparoscopic approach, and surgical strategy, if any, for stage IV ACC. National endocrine sur- gical societies and international network such as ENS@T (European Network for the Study of Adrenal Tumors; available at http://www.ensat.org/) already exist and should be ready to organize an international surgical task force on ACC to eventually define the optimal surgi- cal management of ACC surgery and initiate collabora- tive, prospective trials.
Because stronger political integration seems to be among the main solutions to the European crisis, greater European surgical integration seems to be the crucial
solution to improve operative care of rare adrenal malignant disease.
Sébastien Gaujoux, MD, PhD Department of Digestive and Endocrine Surgery Cochin Hospital AP-HP, Paris, France E-mail: sebastien.gaujoux@gmail.com
Christian Jurowich, MD, PhD Department of General, Visceral, Vascular and Pediatric Surgery University Hospital Wuerzburg Wuerzburg, Germany
Fabrice Ménégaux, MD, PhD Department of Digestive and Endocrine Surgery La Pitié Salpêtrière Hospital AP-HP, Paris, France
Thomas Mussack, MD Department of Surgery University of Munich Munich, Germany Francesco Porpiglia, MD, PhD Division of Urology University of Turin “San Luigi Gonzaga” Hospital Orbassano, Turin, Italy
Bertrand Dousset, MD Department of Digestive and Endocrine Surgery Cochin Hospital, AP-HP, Paris, France
References
1. Hermsen IG, Kerkhofs TM, Butter G, et al. Surgery in adreno- cortical carcinoma: Importance of national cooperation and centralized surgery. Surgery 2012;152:50-6.
2. Lombardi CP, Raffaelli M, Boniardi M, et al. Adrenocortical carcinoma: effect of hospital volume on patient outcome. Langenbecks Arch Surg 2012;397:201-7.
3. Fassnacht M, Johanssen S, Fenske W, et al. Improved survival in patients with stage II adrenocortical carcinoma followed up prospectively by specialized centers. J Clin Endocrinol Metab 2010;95:4925-32.
4. Fassnacht M, Johanssen S, Quinkler M, et al. Limited prog- nostic value of the 2004 International Union Against Cancer staging classification for adrenocortical carcinoma: proposal for a Revised TNM Classification. Cancer 2009;115:243-50.
5. Reibetanz J, Jurowich C, Erdogan I, et al. Impact of lymphad- enectomy on the oncologic outcome of patients with adreno- cortical carcinoma. Ann Surg 2012;255:363-9.
6. Terzolo M, Angeli A, Fassnacht M, et al. Adjuvant mitotane treatment for adrenocortical carcinoma. N Engl J Med 2007;356:2372-80.
7. Fassnacht M, Terzolo M, Allolio B, et al. Combination chemo- therapy in advanced adrenocortical carcinoma. N Engl J Med 2012;366:2189-97.
8. Icard P, Goudet P, Charpenay C, et al. Adrenocortical carcino- mas: surgical trends and results of a 253-patient series from the French Association of Endocrine Surgeons study group. World J Surg 2001;25:891-7.