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Invited Commentary
A Calculating Device to Predict Individualized Outcomes in Adrenocortical Carcinoma
Nancy D. Perrier, MD
A nomogram is a 2-dimensional calculating device or align- ment chart designed to allow the approximate computation of a function. The use of such a mathematical model for treatment of aggressive and rare diseases is objective and in-
dividualized. Like a slide rule, € its accuracy is limited to the Related article page 365 precision with which “mark- ings” can be drawn and aligned. Kim and colleagues1 have precisely described a coor- dinate system that can be easily reproduced to predict disease-free and overall survival after intended curative re- section of adrenocortical carcinoma. The constants chosen were independent prognostic variables specific to the patient and the tumor.
This work is modeled after the concept introduced by Zini et al in 2009.2 At that time, Zini et al attempted to pre- dict prognosis for adrenocortical carcinoma based on surgical vs nonsurgical management. Zini et al used 3 predictors of survival: grade, stage, and resection status. For validation of the model, Surveillance, Epidemiology, and End Results data were incorporated, and the endpoints had accuracy of 80%,
75%, 73%, and 71% at 1, 2, 3, and 5 years, respectively. Be- cause those patients who underwent resection were ex- pected to have a better prognosis, the work was limited.
The work led by Kim et al1 differed in that the validation cohort was a large multi-institutional group of patients treated in the United States with an intention of complete resection. The nomogram model allocated points deemed significant by regression coefficients and applied them to survival. The “markings” of the nomogram calculations centered on tumor size, lymph node metastases, and complete resection (R1). The model proved to have accurate discrimination capacity. The independent risk stratification would be useful for decision making pertaining to adjuvant treatment such as mitotane or cytotoxic chemotherapy.
The oncology world has a paucity of durable solutions for cure of this rare tumor. This is a step forward toward select- ing and guiding treatment plans. Further discernment of mul- tihormone production, which oncologic pathways and driv- ers are potentially targetable, and whether neoadjuvant therapy affects outcome will be important points for further dialogue.
| ARTICLE INFORMATION | Published Online: December 16, 2015. | carcinoma [published online December 16, 2015]. |
| Author Affiliation: Department of Surgical | doi:10.1001/jamasurg.2015.4655. | JAMA Surg. doi:10.1001/jamasurg.2015.4516. |
| Oncology, MD Anderson Cancer Center, Houston, Texas. | Conflict of Interest Disclosures: None reported. | 2. Zini L, Capitanio U, Jeldres C, et al. External validation of a nomogram predicting mortality in |
| Corresponding Author: Nancy D. Perrier, MD, | REFERENCES | patients with adrenocortical carcinoma. BJU Int. |
| Department of Surgical Oncology, MD Anderson | 1. Kim Y, Margonis GA, Prescott JD, et al. | 2009;104(11):1661-1667. |
| Cancer Center, 1400 Pressler St, Unit 1484, | Nomograms to predict recurrence-free and overall survival after curative resection of adrenocortical | |
| Houston, TX 77030 (nperrier@mdanderson.org). |