CrossMark
ASO Author Reflections: Additional Organ Resection in Adrenocortical Carcinoma
Paula Marincola Smith, MD, Colleen M. Kiernan, MD, MPH, and Carmen C. Solórzano, MD
Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
PAST
Adrenocortical carcinoma (ACC) is a rare but aggres- sive malignancy with a poor prognosis.1 Extra-adrenal organs often are removed en bloc during index adrenalec- tomy for ACC.2 In the past, some have advocated compulsory ipsilateral nephrectomy due to the close asso- ciation of the adrenal gland and the kidney and their lack of separation by a complete fascial layer, suggesting concur- rent nephrectomy may improve outcomes.3,4 However, no data exist to support this approach. The anatomic and intraoperative factors that lead to resection of the extra- adrenal organs, the most common organs removed, and the benefits and risks of these additional organ resections have yet to be described in detail. The current study attempted to examine the anatomic and intraoperative factors associated with en bloc resection and to determine whether such resections are associated with differences in outcome.5
PRESENT
This large, multi-institutional, retrospective analysis demonstrated that the operating surgeons believed en bloc resection of extra-adrenal organs was necessary for more than 40% of ACC patients without evidence of metastatic disease at the time of index adrenalectomy. The patients
who underwent en bloc resection of extra-adrenal organs were more likely to have preoperative imaging concerning for large vein invasion or thrombus than the patients who underwent adrenalectomy alone, and they also had larger and higher-grade tumors. The most commonly resected extra-adrenal organs in our analysis were kidney and liver. Despite their more advanced tumors, en bloc resection led to equivalent rates of margin-negative resections and sim- ilar disease-free and overall survival rates. Among those who had additional organs resected, more than 75% did not have extra-adrenal direct organ involvement by tumor on final pathology. When a margin-negative resection could otherwise be achieved, removal of extra-adrenal organs en bloc during index adrenalectomy for ACC was not asso- ciated with additional survival advantage.
FUTURE
Our findings validate current practice in that en bloc resection of extra-adrenal organs should occur when a T4 lesion is suspected on preoperative imaging or intraopera- tively, or when additional organs must be removed to obtain negative margins and avoid tumor rupture. Addi- tionally, when a margin-negative resection can otherwise be achieved, removal of extra-adrenal organs en bloc does not appear to provide additional survival benefit. However, it is important to note that we identified a large gap between preoperative concern for extra-adrenal organ involvement and true involvement on final pathology. Further investigation into methods that can more accurately determine histologic involvement of extra-adrenal organs pre- or intraoperatively could help to identify more reliably patients who will benefit from these extended resections.
DISCLOSURE The authors have no conflicts of interest to disclose.
ASO Author Reflections is a brief invited commentary on the article, “Role of Additional Organ Resection in Adrenocortical Carcinoma: Analysis of 167 Patients from the U.S. Adrenocortical Carcinoma Database.” Ann Surg Oncol. 2018;25:2308-15.
@ Society of Surgical Oncology 2018
First Received: 4 October 2018
REFERENCES
1. Bilimoria KY, Shen WT, Elaraj D, et al. Adrenocortical carcinoma in the United States. Cancer. 2008;113(11):3130-6. https://doi.or g/10.1002/cncr.23886.
2. Livhits M, Li N, Yeh MW, Harari A. Surgery is associated with improved survival for adrenocortical cancer, even in metastatic disease. Surgery. 2014;156(6):1531-41. https://doi.org/10.1016/j. surg.2014.08.047.
3. Gaujoux S, Brennan MF. Clinical review recommendation for standardized surgical management of primary adrenocortical
carcinoma. Surgery. 2012;152(1):123-32. https://doi.org/10.1016/ j.surg.2011.09.030.
4. Icard P, Louvel A, Chapuis Y. Survival rates and prognostic factors in adrenocortical carcinoma. World J Surg. 2018;16:753-8.
5. Marincola Smith P, Kiernan CM, Tran TB, et al. Role of additional organ resection in adrenocortical carcinoma: analysis of 167 patients from the U.S. Adrenocortical Carcinoma Database. Ann Surg Oncol. 2018;25(8):2308-15. https://doi.org/10.1245/s10434- 018-6546-y.