Critical analysis of lymph node examination in patients undergoing curative‐intent resection for adrenocortical carcinoma

Abstract

Background: Adrenocortical carcinoma (ACC) is a rare tumor and the role of lymph node dissection remains ill-defined. This study evaluates the effect of no dal examination on prognosis and survival in patients undergoing curative-intent resection of ACC. Methods: The National Cancer Database (2004-2015) was queried for patients undergoing margin-negative resection for ACC. Patients with distant metastases, neoadjuvant therapy, multivisceral resection and T4 tumors were excluded. Results: Among 897 patients, 147 (16.4%) had lymph nodes examined. Factors associated with lymph node examination included increasing tumor size (P < .001), extra-adrenal extension (P < .001), open operation (P < .001), and resection at an academic facility (P = .003). Lymph node metastasis was significantly associated with extra-adrenal tumor extension (P = .04). Lymph node harvest, regardless of the number of nodes examined, was not associated with a survival benefit. Median overall survival was incrementally worse with increasing number of positive lymph nodes (88.2 months for N0, 34.9 months for 1-3 positive nodes, and 15.6 months for ≥4 positive nodes, P < .001). Conclusions: Lymph node harvest and lymph node metastasis were associated with more advanced tumors. Although nodal harvest did not offer a survival advantage, stratifying the nodal staging classification may provide important prognostic information.

Surgical Management of Adrenocortical Carcinoma: Current Highlights

“…Lymph node metastasis is associated with advanced tumors ( p = 0.4). Median overall survival was incrementally worse with increasing number of positive lymph nodes (88.2 months for N0, 34.9 months for 1–3 positive nodes, and 15.6 months for ≥4 positive nodes, p < 0.001) [ 67 ]. The optimal extent of lymphadenectomy in ACC is still not known.…”

Adrenocortical carcinoma: current state of the art, ongoing controversies, and future directions in diagnosis and treatment

“… 107 The authors found that lymphadenectomy was associated with a significantly higher 5-year OS rate of 76% compared to 59% in the group that had no lymph nodes excised. 107 However, multiple studies using the SEER registry and National Cancer Database (NCDB) have shown contradictory results, with either no effect, 108 worse survival, 109 – 112 or a marginal improvement in survival, 113 in patients who underwent lymphadenectomy. Reasons for these discrepancies include the fact that the inclusion criteria in these studies differ widely by stage, presence of metastases, multivisceral resection, and margin status.…”

Impact of Lymphadenectomy on the Oncologic Outcome of Patients with Adrenocortical Carcinoma—A Systematic Review and Meta-Analysis

“…Of these, 14 studies were excluded due to missing data pertaining to our predefined endpoints. Eleven studies were included in the qualitative analysis [ 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 ]. These studies reported patients from five different cancer databases, and study characteristics are summarized in Table A2 .…”

“…Three studies reported the postoperative mortality for the LND and NoLND group [ 17 , 19 , 20 ]. These studies used different time points as the cut-off for mortality, which makes a direct comparison difficult.…”

“…In recent years, the concept of lymphadenectomy (LND) in ACC has gained greater interest and in cases of suspected or proven ACC, LND during primary surgery now appears to be a guideline-compliant procedure [ 7 , 8 , 16 ]. However, published results regarding LND in ACC are conflicting [ 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 ], so its prognostic and therapeutic significance remains to be established. Further, published series usually include a limited number of patients and the reported lymphadenectomy rate within such series is low [ 4 , 18 , 21 , 23 ].…”