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Discussion
Treatment differences at high volume centers and low volume centers IN NON -metastatic and metastatic adrenocortical carcinoma
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DR. CHRISTOPHER R. McHENRY (Cleveland, Ohio): I will make some comments about the presentation, also some things from your manuscript. The fact that your study population includes only about a little over 2900 patients with ACC over a 14-year period really speaks to the rarity of the disease, and the fact that they were treated at 829 different centers speaks to the difficulty in any one center really devel- oping a large experience. As a result, I think multi-institutional clinical trials are really going to be the best way to improve our knowledge and care of patients with adrenocortical cancer. I have four questions for you.
Number one, can you tell us your rationale for how and why you choose to define a high volume center as one that treated 15 or more adrenocortical cancers and a low volume center as one that treated seven or less adrenocortical cancers during a 14-year period? It seems somewhat arbitrary to me to call a center that sees one adrenocortical cancer a year a high volume center and then a center that sees one every other year a low volume center.
Secondly, because adrenocortical carcinoma is such a rare disease, the evidence for almost all therapeutic strategies is low. One thing that we do know, however, is that surgical resection of adrenocortical car- cinoma with negative margins really is the only chance for cure. In your manuscript I found it interesting that there was no difference in positive tumor margin rates between low and high volume centers. This leads me to believe that there are high volume adrenal surgeons at centers that you’ve chosen to maybe classify as low volume. Can you comment on this?
In most cases, adrenocortical carcinoma is a hormone producing tumor and cortisol-secreting tumors generally have a worst prognosis. Was there any difference in hormone evaluation in perioperative hy- drocortisone administration between high and low volume centers?
Was there any difference in the surgical approach at high and low volume centers, specifically open, laparoscopic or robotic adrenalectomy?
And then, finally, just a comment. I think most people would agree that adrenocortical carcinoma is best managed by a multi-disciplinary team, which includes a high volume adrenal surgeon, as well as exper- tise in oncology, endocrinology, pathologic assessment, as you’ve alluded to in your presentation and integration of palliative care and genetic counseling. I think adrenocortical carcinoma is a disease where patients and providers would benefit from having telemedicine access to really a regional referral center.
DR. MacKINNEY: So I’ll address them from the first question here. How did we decide high volume versus low volume centers? We had a lot of discussion on this and it is kind of arbitrary, but our high volume centers did show at least double the experience or number of patients
than low volume centers, and we wanted to have enough high volume centers to be able to compare with, you know, statistical significance low volume centers. So that’s why we chose those numbers.
Why was there no difference in the margin positivity rate between high volume and low volume centers? We did consider this. It would have been ideal if we could have gotten the experience for all adrenal- ectomies and considered that in our factors, but in the NCDB, there’s only data on cancer, so there was no way to look for the experience of adrenalectomies that didn’t involve cancer. But, yes, that would be ideal.
And adrenocortical carcinomas that produce cortisol do fare worse. Unfortunately, again, the NCDB does not have data to help us with that. There’s no data on functionality. There were some differences in the surgery type between high volume and low volume centers. And, interestingly, high volume centers actually performed open operations with more frequency than low volume centers. And our paper in the future will explore why that may be the case.
Telemedicine, I think, would be a great option for low volume cen- ters that don’t have tumor boards or that kind of thing.
DR. MICHAEL NUSSBAUM (Roanoke, Virginia): Quick question. What’s intriguing is, the low volume centers had a higher incidence of chemotherapy and a lower incidence of surgery, and I don’t know if you can dissect this out of the data, but what I’m wondering is how many of the patients that were operated on at a high volume center were referred from a low volume center. They had their chemotherapy at one place and then were referred to the high volume center for the operation. I think the open operations in a high volume center just shows the experience. I think with adrenocortical carcinoma it’s one of the few indications for oftentimes particularly large tumors for an open operation.
DR. SARGENT: So we did try to exclude patients that were seen at more than one facility, so if they got chemo and surgery at two different sites, the high volume and low volume, they would have been excluded.
DR. L. MICHAEL BRUNT (St. Louis, Missouri): Congratulations on a paper on a condition that’s very difficult to study. My question is about the chemotherapy and the differences. Presumably most of the patients got Mitotane. Were there other differences in chemotherapy that you saw in your analysis?
DR. SARGENT: We did not look at the different types of chemo- therapy administered. We combined all chemotherapies together, but that would be another interesting paper off of this paper to look at different types of chemotherapy and chemotherapy regimens adminis- tered between high volume and low volume.
DR. STEPHANIE VALENTE (Cleveland, Ohio): I do have one more question, and it’s just me being a breast surgeon and not knowing, so you
https://doi.org/10.1016/j.amjsurg.2022.02.017
said that for stage IV of the metastatic, overall survival is about six months. You said it was improved at the high volume centers. Do you have how many days that improved or months? Because you looked at 90-day.
DR. SARGENT: From our manuscript, I don’t remember that off the top of my head.
DR. VALENTE: Okay. Just curious.