Paula Marincola Smith1, Colleen M Kiernan1, Thuy B Tran2, Lauren M Postlewait3, Shishir K Maithel3, Jason Prescott4, Timothy Pawlik4, Tracy S Wang5, Jason Glenn5, Ioannis Hatzaras6, Rivka Shenoy6, John Phay7, Lawrence A Shirley7, Ryan C Fields8, Linda Jin8, Sharon Weber9, Ahmed Salem9, Jason Sicklick10, Shady Gad10, Adam Yopp11, John Mansour11, Quan-Yang Duh12, Natalie Seiser12, Konstantinos Votanopoulos13, Edward A Levine13, George Poultsides2, Carmen C Solórzano14. 1. Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, 597 Preston Research Building 2220 Pierce Ave, Nashville, TN, 37232, USA. 2. Stanford University School of Medicine, Stanford, CA, USA. 3. Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA. 4. The Johns Hopkins University School of Medicine, Baltimore, MD, USA. 5. Medical College of Wisconsin, Milwaukee, WI, USA. 6. New York University School of Medicine, New York, NY, USA. 7. Department of Surgery, The Ohio State University, Columbus, OH, USA. 8. Barnes-Jewish Hospital and the Alvin J. Siteman Comprehensive Cancer Center, Washington University School of Medicine, St Louis, MO, USA. 9. Department of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA. 10. Department of Surgery, University of California San Diego, San Diego, CA, USA. 11. Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA. 12. Department of Surgery, University of California San Francisco, San Francisco, CA, USA. 13. Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA. 14. Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, 597 Preston Research Building 2220 Pierce Ave, Nashville, TN, 37232, USA. carmen.solorzano@vanderbilt.edu.
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 non-metastatic 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.
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 non-metastatic 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.
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