Role of Additional Organ Resection in Adrenocortical Carcinoma: Analysis of 167 Patients from the U.S. Adrenocortical Carcinoma Database

Abstract

Background. Adrenocortical carcinoma (ACC) is a rare and aggressive cancer. This report describes factors and outcomes associated with resection of extra-adrenal organs en bloc during index adrenalectomy. Methods. Patients who underwent ACC resection for nonmetastatic disease from 1993 to 2014 at 13 participating institutions of the US-ACC Group were included in the study. Factors associated with en bloc resection were assessed by uni- and multivariate analysis. The primary end point was overall survival. Results. In this study, 167 patients were included and categorized as adrenalectomy with en bloc resection (AdEBR) if they had extra-adrenal organs removed or adrenalectomy (Ad) if they did not. The demographics were similar between the AdEBR (n = 68, 40.7%) and Ad groups, including age, gender, race, American Society of Anesthesiology (ASA) class, and body mass index (BMI). The AdEBR group had larger tumors (13 vs. 10 cm), more open operations (97.1 vs. 63.6%), and more lymph node dissections (LNDs) (36.8 vs. 12.1%). The most common organs removed were kidney (55.9%), liver (27.9%), and spleen (23.5%). Multiple organs were removed in 38.2% (n = 26) of the patients. Margin-negative resections were similar between the two groups. In the multivariate Cox regression adjusted for T and N stages, LND, margin, size, and hormone hypersecretion, en bloc resection was not associated with improved survival (hazard ratio [HR], 1.42; p = 0.323). Conclusion. The study findings validated current practice by showing that en bloc resection should occur at index adrenalectomy for ACC when a T4 lesion is suspected pre- or intraoperatively, or when it is necessary to avoid tumor rupture. However, in this study, when a negative margin resection was otherwise achieved, removal of extra-adrenal organs en bloc was not associated with additional survival benefit.

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

“…Indeed, of the 212 patients with MVR excluded, lymph nodes were identified in 46.4%, compared with only 17.5% in non‐MVR ( P < .001). This is similar to what Marincola Smith et al found in a 13‐institution retrospective database (47.1% vs 16.2%; P < .001), again highlighting the possibility of non‐regional lymph node harvest in these cases 24 . A well‐established consensus definition for anatomic regional lymphadenectomy during resection for ACC is lacking, likely contributing to the low rates observed in both this and previous studies.…”

Management of adrenocortical carcinoma in Western Australia: a perspective over 14 years

“…An open en bloc approach with a low threshold for multivisceral resection is critical in avoiding inadvertent capsular rupture, tumour seeding and positive margins 5 . Multivisceral resection including nephrectomy, however, can be performed selectively where possible, with no evidence for improved survival with potential increased morbidity or compromising adjuvant chemotherapy 13,14 . In our series, an 85% R0 resection margin rate was obtained in an open en bloc approach with local recurrence rates of 11%.…”

Large adrenal tumours mimicking hepatic malignancy: the role of concurrent adrenalectomy and anterior approach hepatectomy

“…Although liver resection has been well‐described for adrenal malignancy with adjacent liver infiltration or non‐contiguous liver metastasis, 5,6 there are only a few case reports or series published highlighting adrenal tumours mimicking hepatic SOLs 3,18,20,22 . Yu et al .…”

“…These atypically behaving tumours may require liver resection of the involved segments or sections. One multi‐institutional retrospective study on adrenocortical carcinoma described 68 patients requiring multi‐visceral resection 5 . Among these, approximately 28% ( n = 19) patients required liver resection.…”