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de Ponthaud C, Bekada S, Buffet C, Roy M, Bachelot A, Ayed A, Menegaux F, Gaujoux S. Which lymphadenectomy for adrenocortical carcinoma? Surgery 2024:S0039-6060(24)00716-5. [PMID: 39370320 DOI: 10.1016/j.surg.2024.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Revised: 08/29/2024] [Accepted: 09/04/2024] [Indexed: 10/08/2024]
Abstract
BACKGROUND Lymph node dissection improves adrenocortical carcinoma staging, but remains anatomically poorly defined. This ambiguity stems from limited knowledge of the adrenals lymphatic network. This work aims to define lymph node dissection for adrenocortical carcinoma through a systematic review and anatomical study. METHOD First, an anatomical study was conducted on fresh cadavers by injecting blue dye into each adrenal gland before dissection. Concurrently, a systematic review of anatomical and clinical studies was performed, focusing on adrenals lymphatic network, lymph node dissection, and location of invaded lymph nodes in surgical series. RESULTS Twelve adrenals from 6 cadavers were resected en bloc with a median of 3 lymph nodes (1.5-6) removed. Screening of 6,506 studies revealed (1) 18 anatomical studies on cadavers detailing a 3-stage compartmentalized adrenals lymphatic network with distinct right/left lymph nodes relays; (2) 4 clinical studies highlighting discrepancies in lymph node involvement in adrenocortical carcinoma patients compared with anatomical description of adrenals lymphatic network, notably: lower implication of celiac lymph node, preponderance of ipsilateral renal hilum lymph nodes, potential contralateral involvement; (3) 21 series of adrenocortical carcinoma surgery demonstrating the heterogeneity of lymph node dissection practice (22% ± 4% lymph node dissection rate), with an average of 2.7 ± 0.6 lymph nodes removed, already fewer than in our cadaveric study. CONCLUSION Synthesis of anatomical and clinical studies suggest the following lymph node dissection protocol during adrenocortical carcinoma resection: capsular, renal hilum, para-cava, and inter-aortic-cava lymph nodes (right adrenocortical carcinoma); and capsular, renal hilum, para-aortic, and inter-aortic-cava lymph nodes (left adrenocortical carcinoma).
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Affiliation(s)
- Charles de Ponthaud
- Sorbonne University, Paris, France; Department of General, Visceral, and Endocrine Surgery, AP-HP, Pitié-Salpêtrière Hospital, Paris, France; Department of Hepato-biliary and Pancreatic Surgery and Liver Transplantation, AP-HP, Pitié-Salpêtrière Hospital, Paris, France
| | - Soumaya Bekada
- Department of General, Visceral, and Endocrine Surgery, AP-HP, Pitié-Salpêtrière Hospital, Paris, France; Department of Hepato-biliary and Pancreatic Surgery and Liver Transplantation, AP-HP, Pitié-Salpêtrière Hospital, Paris, France
| | - Camille Buffet
- Sorbonne University, Paris, France; Department of Endocrinology, AP-HP, Hospital Pitié Salpétrière, Paris, France
| | - Malanie Roy
- Sorbonne University, Paris, France; Department of Endocrinology, AP-HP, Hospital Pitié Salpétrière, Paris, France
| | - Anne Bachelot
- Sorbonne University, Paris, France; Department of Endocrinology and Reproductive Medicine and Centre de Référence des Maladies Endocriniennes Rares de la Croissance et du Développement, Centre de Référence des Pathologies Gynécologiques Rares, AP-HP, IE3M, Hôpital Pitié-Salpêtrière, Paris, France
| | - Amine Ayed
- Radiology Department, Hôpital Pitié-Salpêtriere, APHP, Paris, France
| | - Fabrice Menegaux
- Sorbonne University, Paris, France; Department of General, Visceral, and Endocrine Surgery, AP-HP, Pitié-Salpêtrière Hospital, Paris, France
| | - Sébastien Gaujoux
- Sorbonne University, Paris, France; Department of General, Visceral, and Endocrine Surgery, AP-HP, Pitié-Salpêtrière Hospital, Paris, France; Department of Hepato-biliary and Pancreatic Surgery and Liver Transplantation, AP-HP, Pitié-Salpêtrière Hospital, Paris, France.
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2
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Mihai R, De Crea C, Guerin C, Torresan F, Agcaoglu O, Simescu R, Walz MK. Surgery for advanced adrenal malignant disease: recommendations based on European Society of Endocrine Surgeons consensus meeting. Br J Surg 2024; 111:znad266. [PMID: 38265812 PMCID: PMC10805373 DOI: 10.1093/bjs/znad266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 08/02/2023] [Indexed: 01/25/2024]
Affiliation(s)
- Radu Mihai
- Churchill Cancer Centre, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Carmela De Crea
- Centro di Ricerca in Chirurgia delle Ghiandole Endocrine e dell’Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
- Endocrine Surgery Unit, Hospital Fatebenefratelli Isola Tiberina—Gemelli Isola, Rome, Italy
| | - Carole Guerin
- Department of Endocrine and Metabolic Surgery, Aix-Marseille University, Hôpital de La Conception, Marseille, France
| | - Francesca Torresan
- Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Orhan Agcaoglu
- Department of General Surgery, Koc University School of Medicine, Istanbul, Turkey
| | - Razvan Simescu
- Department of General and Endocrine Surgery, Medlife-Humanitas Hospital, Cluj-Napoca, Romania
| | - Martin K Walz
- Department of Surgery and Minimally Invasive Surgery, Kliniken Essen-Mitte, Essen, Germany
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3
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Pairon C, Dili A, Bertrand C, D'Hondt L, Fervaille C, Donckier JE. Effective multimodal management of a giant adrenocortical carcinoma. Acta Chir Belg 2023; 123:444-447. [PMID: 35137673 DOI: 10.1080/00015458.2022.2040109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 02/05/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Adrenocortical carcinoma is a rare and aggressive tumour. The only curative treatment is surgery with negative margins. In most series, the average lesion size ranges from 5.5 to 15 cm. METHODS We report the case of a 27-year-old female with hyperandrogenism and Cushing syndrome due to a right adrenocortical carcinoma of 19.7 cm. RESULTS The tumour abutting on liver and vena cava and the presence two nodules in liver required extensive surgery including a right posterior sectionectomy and an en bloc resection of the adrenal mass together with the right kidney and the gallbladder. The vena cava was also resected with a reconstruction using a pericardial patch since it was invaded on its border. Pathological examination confirmed an adrenocortical carcinoma, with tumour invasion of vessels, tumour capsule, vena cava and two metastases in the liver (pT4N0M1). All margins were negative. Three months after surgery, two lung nodules, cardio-phrenic and internal mammary adenomegalies were noticed on a PET/CT scan, justifying the initiation of chemotherapy, alongside with mitotane. After a 10-month follow-up, CT scan was stable excepted for a lung nodule growing from 4 to 7 mm. Targeted stereotaxic radiotherapy was then administered. Twenty-two months after surgery, the patient has improved considerably and all signs of hyperandrogenism and Cushing syndrome have resolved. CONCLUSION This case of adrenocortical carcinoma illustrates one of the largest tumours among those reported. It demonstrates the feasibility and effectiveness of a multimodal approach in its treatment even if it is giant and at high risk.
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Affiliation(s)
- Camille Pairon
- Department of Endocrinology, Université Catholique de Louvain, CHU UCL Namur (Site Godinne), Yvoir, Belgium
| | - Alexandra Dili
- Unit of Digestive, Endocrine and General Surgery, Department of Surgery, Université Catholique de Louvain, CHU UCL Namur (Site Godinne), Yvoir, Belgium
| | - Claude Bertrand
- Unit of Digestive, Endocrine and General Surgery, Department of Surgery, Université Catholique de Louvain, CHU UCL Namur (Site Godinne), Yvoir, Belgium
| | - Lionel D'Hondt
- Department of Oncology, Université Catholique de Louvain, CHU UCL Namur (Site Godinne), Yvoir, Belgium
| | - Caroline Fervaille
- Department of Pathology, Université Catholique de Louvain, CHU UCL Namur (Site Godinne), Yvoir, Belgium
| | - Julian E Donckier
- Department of Endocrinology, Université Catholique de Louvain, CHU UCL Namur (Site Godinne), Yvoir, Belgium
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4
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Nakanishi H, Miangul S, Wang R, El Haddad J, El Ghazal N, Abdulsalam FA, Matar RH, Than CA, Johnson BE, Chen H. Open Versus Laparoscopic Surgery in the Management of Adrenocortical Carcinoma: A Systematic Review and Meta-analysis. Ann Surg Oncol 2023; 30:994-1005. [PMID: 36344710 DOI: 10.1245/s10434-022-12711-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 10/11/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Laparoscopic surgery is considered a standard treatment for benign adrenal tumors; however, no consensus has been reached on the optimal resection technique for adrenocortical carcinomas. This study aims to evaluate the safety and efficacy of laparoscopic surgery and open surgery in the management of adrenocortical carcinoma. METHODS The Cochrane, Embase, PubMed, Scopus, and Web of Science databases were searched for articles from inception to May 2022, by two independent reviewers using the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. The review was registered prospectively on the PROSPERO database (CRD42022316050). RESULTS From 183 studies screened, 11 studies met the eligibility criteria, with a total of 1617 patients with adrenocortical carcinoma undergoing either laparoscopic surgery (n = 472) or open surgery (n = 1145). Open surgery demonstrated a lower rate of positive resection margin compared with laparoscopic surgery (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.10-2.10; I2 = 0%). Additionally, open surgery had more favorable overall survival (OR 0.56, 95% CI 0.44-0.72; I2 = 0%) and recurrence-free rates (OR 0.60, 95% CI 0.42-0.85; I2 = 38%) than laparoscopic surgery at 3 years. Hospital stay was shorter for laparoscopic surgery than open surgery (mean difference - 2.49 days, 95% CI - 2.95 to - 2.04; I2 = 45%). CONCLUSIONS Open surgery should still be considered the standard operative approach; however, laparoscopic surgery could be regarded as an effective and safe operation for selected adrenocortical carcinoma cases with appropriate laparoscopic expertise. Further randomized controlled studies with tumor stage- and resection margin-dependent survival analysis are necessary to ascertain the safety and efficacy of the treatment.
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Affiliation(s)
- Hayato Nakanishi
- St George's University of London, London, UK.,University of Nicosia Medical School, University of Nicosia, Nicosia, Cyprus
| | - Shahid Miangul
- St George's University of London, London, UK.,University of Nicosia Medical School, University of Nicosia, Nicosia, Cyprus
| | - Rongzhi Wang
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Joe El Haddad
- St George's University of London, London, UK.,University of Nicosia Medical School, University of Nicosia, Nicosia, Cyprus
| | - Nour El Ghazal
- St George's University of London, London, UK.,University of Nicosia Medical School, University of Nicosia, Nicosia, Cyprus
| | - Fatma A Abdulsalam
- St George's University of London, London, UK.,University of Nicosia Medical School, University of Nicosia, Nicosia, Cyprus
| | - Reem H Matar
- St George's University of London, London, UK.,University of Nicosia Medical School, University of Nicosia, Nicosia, Cyprus.,Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Christian A Than
- St George's University of London, London, UK.,University of Nicosia Medical School, University of Nicosia, Nicosia, Cyprus.,School of Biomedical Sciences, The University of Queensland, St Lucia, QLD, Australia
| | - Benjamin E Johnson
- Division of Surgery, NorthShore University Health System, Chicago, IL, USA
| | - Herbert Chen
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
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5
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Ginsburg KB, Castro Bigalli AA, Schober JP, Perlman D, Handorf EA, Chen DYT, Greenberg RE, Viterbo R, Uzzo RG, Kutikov A, Smaldone MC, Correa AF. Association of tumor size and surgical approach with oncological outcomes and overall survival in patients with adrenocortical carcinoma. Urol Oncol 2022; 40:455.e19-455.e25. [PMID: 35725937 PMCID: PMC9569182 DOI: 10.1016/j.urolonc.2022.05.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 05/08/2022] [Accepted: 05/22/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To investigate the association of surgical approach with outcomes in patients with adrenocortical carcinomas smaller and larger than 6 cm in size. METHODS We reviewed the national cancer database for patients undergoing minimally invasive adrenalectomy (MIA) and open adrenalectomy (OA) from 2010 to 2017. To adjust for differences between patients undergoing MIA and OA, we performed propensity score matching within each size strata of ≤6 cm, 6.1 to 10 cm, and 10.1 to 20 cm. We fit generalized estmiating equations with a logit link function to assess for the association of surgical approach with positive surgical margins and a Cox proportional hazards model to assess for the association of surgical approach with overall survival. RESULTS We identified 364 patients that underwent MIA (182) and OA (182) in the matched cohort. We noted 21% and 18% of patients undergoing MIA and OA had a positive surgical margin, respectively. We did not identify a significant association between surgical approach and positive surgical margins in the cohort as a whole or within each of strata. Furthermore, we did not appreciate a significant association between surgical approach and overall survival in the cohort as a whole or within each size strata. CONCLUSION In the National Cancer Database, patients undergoing MIA had similar positive surgical margins and overall survival compared with OA for masses ≤6 cm, 6.1 to 10cm, and >10 cm in size. Patients undergoing MIA should be carefully selected with surgical oncologic integrity being the primary determinants of surgical approach.
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Affiliation(s)
- Kevin B Ginsburg
- Department of Surgical Oncology, Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, PA; Wayne State University Department of Urology, Detroit, MI.
| | - Alberto A Castro Bigalli
- Department of Surgical Oncology, Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Jared P Schober
- Department of Surgical Oncology, Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - David Perlman
- Wayne State University Department of Urology, Detroit, MI
| | - Elizabeth A Handorf
- Biostatistics and Bioinformatics Facility, Fox Chase Cancer Center, Philadelphia, PA
| | - David Y T Chen
- Department of Surgical Oncology, Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Richard E Greenberg
- Department of Surgical Oncology, Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Rosalia Viterbo
- Department of Surgical Oncology, Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Robert G Uzzo
- Department of Surgical Oncology, Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Alexander Kutikov
- Department of Surgical Oncology, Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Marc C Smaldone
- Department of Surgical Oncology, Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Andres F Correa
- Department of Surgical Oncology, Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, PA
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6
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Terzolo M, Fassnacht M. ENDOCRINE TUMOURS: Our experience with the management of patients with non-metastatic adrenocortical carcinoma. Eur J Endocrinol 2022; 187:R27-R40. [PMID: 35695575 DOI: 10.1530/eje-22-0260] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 06/13/2022] [Indexed: 11/08/2022]
Abstract
Adrenocortical carcinoma (ACC) accounts for a minority of all malignant tumors in adults. Surgery remains the most important therapeutic option for non-metastatic ACC. Whether a subset of patients with small ACC may benefit from minimally invasive surgery remains a debated issue, but we believe that surgeon's expertise is more important than surgical technique to determine outcome. However, even a state-of-the-art surgery cannot prevent disease recurrence that is determined mainly by specific tumor characteristics. We consider that the concomitant presence of the following features characterizes a cohort of patients at low risk of recurrence, (i) R0 resection (microscopically free margin), (ii) localized disease (stage I-II ACC), and (iii) low-grade tumor (ki-67 <10%). After the ADIUVO study, we do not recommend adjuvant mitotane as a routine measure for such patients, who can be managed with active surveillance thus sparing a toxic treatment. Patients at average risk of recurrence should be treated with adjuvant mitotane. For patients at very high risk of recurrence, defined as the presence of at least one of the following: Ki67 >30%, large venous tumor thrombus, R1 resection or stage IV ACC, we increasingly recommend to combine mitotane with four cycles of platinum-based chemotherapy. However, patients at moderate-to-high risk of recurrence should be ideally enrolled in the ongoing ADIUVO2 trial. We do not use adjuvant radiotherapy of the tumor bed frequently at our institutions, and we select patients with incomplete resection, either microscopically or macroscopically, for this treatment. In the long-term, prospective multicenter trials are required to improve patient care.
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Affiliation(s)
- Massimo Terzolo
- Internal Medicine, Department of Clinical and Biological Sciences, S. Luigi Hospital, Orbassano, University of Turin, Turin, Italy
| | - Martin Fassnacht
- Division of Endocrinology and Diabetes, Department of Internal Medicine, University Hospital, University of Würzburg, Würzburg, Germany
- Comprehensive Cancer Center Mainfranken, University of Würzburg, Würzburg, Germany
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7
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Radiotherapy for Pediatric Adrenocortical Carcinoma – Review of the Literature. Clin Transl Radiat Oncol 2022; 35:56-63. [PMID: 35601796 PMCID: PMC9121070 DOI: 10.1016/j.ctro.2022.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/12/2022] [Accepted: 05/12/2022] [Indexed: 12/18/2022] Open
Abstract
Radiotherapy (RT) is mostly performed for curative intent, only few cases in palliative setting are reported. The site of RT was predominantly tumor bed, abdominal cavity, and/or metastases. Adjuvant RT has to be discussed—even in the context of TPSs—especially for patients with high risk factors. Evidence regarding RT in in pediatric adrenocortical carcinoma is too limited to give any general recommendation. However, we suggest to consider adjuvant radiotherapy in individual patients with high risk of recurrence. A systematic international study with a common data platform is needed to establish evidence. on the role of RT in the treatment of children with adrenocortical carcinoma and to improve the outcome in this rare disease.
Background and purpose Pediatric adrenocortical carcinoma (pACC) is a rare disease with poor prognosis. Publications on radiotherapy (RT) are scarce. This review summarizes the current data on RT for pACC and possibly provides first evidence to justify its use in this setting. Materials and methods We searched the PubMed and Embase database for manuscripts regarding RT for pACC. Results We included 17 manuscripts reporting on 76 patients treated with RT, after screening 2961 references and 269 full articles. In addition, we added data of 4 unreported pACC patients treated by co-authors. All reports based on retrospective data. Median age at first diagnosis was 11.1 years (70% female); 78% of patients presented with hormonal activity. RT was mostly performed for curative intent (78%). 88% of RT were administered during primary therapy. The site of RT was predominantly the local tumor bed (76%). Doses of RT ranged from 15 to 62 Gy (median 50 Gy). Information on target volumes or fractionation were lacking. Median follow-up was 6,9 years and 64% of the patients died of disease, with 33% alive without disease. In 16 of 48 patients with available follow-up data after adjuvant RT (33%) no recurrence was reported and in 3 of 9 patients palliative RT seemed to induce some benefit for the patient. Conclusions Our first systematic review on RT for pACC provides too few data for any general recommendation, but adjuvant RT in patients with high risk might be considered. International collaborative studies are urgently needed to establish better evidence on the role of RT in this rare malignancy.
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Daher M, Varghese J, Gruschkus SK, Jimenez C, Waguespack SG, Bedrose S, Altameemi L, Bazerbashi H, Naing A, Subaiah V, Campbell MT, Shah AY, Zhang M, Sheth RA, Karam JA, Wood CG, Perrier ND, Graham PH, Lee JE, Habra MA. Temporal Trends in Outcomes in Patients With Adrenocortical Carcinoma: A Multidisciplinary Referral-center Experience. J Clin Endocrinol Metab 2022; 107:1239-1246. [PMID: 35092681 PMCID: PMC9016449 DOI: 10.1210/clinem/dgac046] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Indexed: 01/31/2023]
Abstract
CONTEXT Reporting temporal trends in adrenocortical carcinoma (ACC) helps guide management strategies. OBJECTIVE This work aimed to report the trends in disease burden and clinical outcomes over time that cannot be adequately captured from individual clinical trials. METHODS A retrospective study was held of ACC patients seen at a referral cancer center between February 1998 and August 2019. Clinical outcomes were compared between an early cohort (February 1998-June 2007) and a late cohort (July 2007-August 2019). RESULTS A total of 621 patients included with a median age at diagnosis of 49.3 years (range, 0.5-86.6 years). There were 285 (45.9%) patients with hormonal overproduction. More patients in the late cohort had stage IV disease compared to the early cohort (36.8% vs 23.1%; P < .0001). Resection of the primary tumor was performed in 502 patients (80.8%). Complete resection (R0) was more common in the late cohort (165 [60.2%]) than in the early cohort (100 [44.6%]; P = .0005). Of 475 patients with metastatic disease (stage IV or recurrent metastatic disease), 352 (74.1%) received mitotane, 320 (67.4%) received chemotherapy, and 53 (11.2%) received immunotherapy. In the early cohort, 70 (33%) received 2 or more lines of therapy, whereas in the late cohort, 127 (48%) received 2 or more lines of therapy. The 5-year overall survival (OS) rates were 65%, 58%, 45%, and 10% for stage I, II, III, and IV disease, respectively, whereas the 2-year OS rates in patients with stage IV disease was 24% in the early cohort and 46% in the late cohort (P = .01). CONCLUSION ACC clinical outcomes improved over the past 2 decades as more patients had complete resection or received more lines of systemic therapy.
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Affiliation(s)
- Marilyne Daher
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
| | - Jeena Varghese
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
| | - Stephen K Gruschkus
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
| | - Camilo Jimenez
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
| | - Steven G Waguespack
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
| | - Sara Bedrose
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
- Division of Diabetes, Endocrinology, and Metabolism, Baylor College of Medicine, Houston, Texas 77030, USA
| | - Lina Altameemi
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
| | - Hadil Bazerbashi
- Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
| | - Aung Naing
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
| | - Vivek Subaiah
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
| | - Matthew T Campbell
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
| | - Amishi Y Shah
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
| | - Miao Zhang
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
| | - Rahul A Sheth
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
| | - Jose A Karam
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030USA
| | - Christopher G Wood
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
| | - Nancy D Perrier
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
| | - Paul H Graham
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
| | - Jeffery E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
| | - Mouhammed Amir Habra
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
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9
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Al-Ward R, Zsembery C, Habra MA. Adjuvant therapy in adrenocortical carcinoma: prognostic factors and treatment options. ENDOCRINE ONCOLOGY (BRISTOL, ENGLAND) 2022; 2:R90-R101. [PMID: 37435451 PMCID: PMC10259337 DOI: 10.1530/eo-22-0050] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 07/26/2022] [Indexed: 07/13/2023]
Abstract
Adrenocortical carcinoma (ACC) is a rare cancer with high recurrence rates and heterogeneous clinical behavior. The role of adjuvant therapy remains unclear because of the challenges in collecting high-quality data for a rare cancer. The current treatment recommendations and guidelines for adjuvant therapy are mostly derived retrospectively from national databases and the treatment outcomes of patients seen in referral centers. To better select patients for adjuvant therapy, multiple factors need to be considered including staging, markers of cellular proliferation (such as Ki67%), resection margins, hormonal function, and possibly genetic alterations of the tumor as well as patient-related factors such as age and performance status. Adjuvant mitotane remains the most commonly used adjuvant therapy in ACC based on clinical practice guidelines, though emerging data from ADIUVO trial (mitotane vs observation in low-risk ACC) suggest that mitotane use in low-risk patients may not be needed. An ongoing clinical trial (ADIUVO-2) is evaluating the role of mitotane vs mitotane combined with chemotherapy in high-risk ACC. The use of adjuvant therapy has been controversial but can be justified in select patients with positive resection margins or after the resection of localized recurrence. A prospective study is needed to study the role of adjuvant radiation in ACC as radiation is expected to help only with local control without impact on distant microscopic metastases. There are no recommendations or published data about using adjuvant immunotherapy in ACC, but this may be a future study after establishing the efficacy and safety profile of immunotherapy in metastatic ACC.
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Affiliation(s)
- Ruaa Al-Ward
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Endocrinology, Diabetes and Metabolism, Baylor College of Medicine, Houston, Texas, USA
| | - Celeste Zsembery
- Departments of Medicine and Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Mouhammed Amir Habra
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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10
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Riedmeier M, Decarolis B, Haubitz I, Müller S, Uttinger K, Börner K, Reibetanz J, Wiegering A, Härtel C, Schlegel PG, Fassnacht M, Wiegering V. Adrenocortical Carcinoma in Childhood: A Systematic Review. Cancers (Basel) 2021; 13:5266. [PMID: 34771430 PMCID: PMC8582500 DOI: 10.3390/cancers13215266] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 10/13/2021] [Accepted: 10/14/2021] [Indexed: 01/01/2023] Open
Abstract
Adrenocortical tumors are rare in children. This systematic review summarizes the published evidence on pediatric adrenocortical carcinoma (ACC) to provide a basis for a better understanding of the disease, investigate new molecular biomarkers and therapeutic targets, and define which patients may benefit from a more aggressive therapeutic approach. We included 137 studies with 3680 ACC patients (~65% female) in our analysis. We found no randomized controlled trials, so this review mainly reflects retrospective data. Due to a specific mutation in the TP53 gene in ~80% of Brazilian patients, that cohort was analyzed separately from series from other countries. Hormone analysis was described in 2569 of the 2874 patients (89%). Most patients were diagnosed with localized disease, whereas 23% had metastasis at primary diagnosis. Only 72% of the patients achieved complete resection. In 334 children (23%), recurrent disease was reported: 81%-local recurrence, 19% (n = 65)-distant metastases at relapse. Patients < 4 years old had a different distribution of tumor stages and hormone activity and better overall survival (p < 0.001). Although therapeutic approaches are typically multimodal, no consensus is available on effective standard treatments for advanced ACC. Thus, knowledge regarding pediatric ACC is still scarce and international prospective studies are needed to implement standardized clinical stratifications and risk-adapted therapeutic strategies.
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Affiliation(s)
- Maria Riedmeier
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, University Children’s Hospital, University of Wuerzburg, Josef-Schneiderstr. 2, 97080 Wuerzburg, Germany; (M.R.); (I.H.); (C.H.); (P.-G.S.)
| | - Boris Decarolis
- Department of Pediatric Oncology and Hematology, Medical Faculty, University Children’s Hospital of Cologne, 50937 Cologne, Germany;
| | - Imme Haubitz
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, University Children’s Hospital, University of Wuerzburg, Josef-Schneiderstr. 2, 97080 Wuerzburg, Germany; (M.R.); (I.H.); (C.H.); (P.-G.S.)
| | - Sophie Müller
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital, University of Wuerzburg, Oberduerrbacherstr. 6, 97080 Wuerzburg, Germany; (S.M.); (K.U.); (K.B.); (J.R.); (A.W.)
| | - Konstantin Uttinger
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital, University of Wuerzburg, Oberduerrbacherstr. 6, 97080 Wuerzburg, Germany; (S.M.); (K.U.); (K.B.); (J.R.); (A.W.)
| | - Kevin Börner
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital, University of Wuerzburg, Oberduerrbacherstr. 6, 97080 Wuerzburg, Germany; (S.M.); (K.U.); (K.B.); (J.R.); (A.W.)
| | - Joachim Reibetanz
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital, University of Wuerzburg, Oberduerrbacherstr. 6, 97080 Wuerzburg, Germany; (S.M.); (K.U.); (K.B.); (J.R.); (A.W.)
| | - Armin Wiegering
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital, University of Wuerzburg, Oberduerrbacherstr. 6, 97080 Wuerzburg, Germany; (S.M.); (K.U.); (K.B.); (J.R.); (A.W.)
- Department of Biochemistry and Molecular Biology, University of Wuerzburg, Am Hubland, 97074 Wuerzburg, Germany
- Comprehensive Cancer Centre Mainfranken, University of Wuerzburg Medical Centre, Josef-Schneiderstr. 2, 97080 Wuerzburg, Germany;
| | - Christoph Härtel
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, University Children’s Hospital, University of Wuerzburg, Josef-Schneiderstr. 2, 97080 Wuerzburg, Germany; (M.R.); (I.H.); (C.H.); (P.-G.S.)
- Comprehensive Cancer Centre Mainfranken, University of Wuerzburg Medical Centre, Josef-Schneiderstr. 2, 97080 Wuerzburg, Germany;
| | - Paul-Gerhardt Schlegel
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, University Children’s Hospital, University of Wuerzburg, Josef-Schneiderstr. 2, 97080 Wuerzburg, Germany; (M.R.); (I.H.); (C.H.); (P.-G.S.)
- Comprehensive Cancer Centre Mainfranken, University of Wuerzburg Medical Centre, Josef-Schneiderstr. 2, 97080 Wuerzburg, Germany;
| | - Martin Fassnacht
- Comprehensive Cancer Centre Mainfranken, University of Wuerzburg Medical Centre, Josef-Schneiderstr. 2, 97080 Wuerzburg, Germany;
- Department of Medicine, Division of Endocrinology and Diabetes, University Hospital, University of Wuerzburg, Oberduerrbacherstr. 6, 97080 Wuerzburg, Germany
| | - Verena Wiegering
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, University Children’s Hospital, University of Wuerzburg, Josef-Schneiderstr. 2, 97080 Wuerzburg, Germany; (M.R.); (I.H.); (C.H.); (P.-G.S.)
- Comprehensive Cancer Centre Mainfranken, University of Wuerzburg Medical Centre, Josef-Schneiderstr. 2, 97080 Wuerzburg, Germany;
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11
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Beltsevich DG, Troshina EA, Melnichenko GA, Platonova NM, Ladygina DO, Chevais A. Draft of the clinical practice guidelines “Adrenal incidentaloma”. ENDOCRINE SURGERY 2021. [DOI: 10.14341/serg12712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The wider application and technical improvement of abdominal imaging procedures in recent years has led to an increasingly frequent detection of adrenal gland masses — adrenal incidentaloma, which have become a common clinical problem and need to be investigated for evidence of hormonal hypersecretion and/or malignancy. Clinical guidelines are the main working tool of a practicing physician. Laconic, structured information about a specific nosology, methods of its diagnosis and treatment, based on the principles of evidence-based medicine, make it possible to give answers to questions in a short time, to achieve maximum efficiency and personalization of treatment. These clinical guidelines include data on the prevalence, etiology, radiological features and assessment of hormonal status of adrenal incidentalomas. In addition, this clinical practice guideline provides information on indications for surgery, postoperative rehabilitation and follow-up.
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12
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Ardicli B, User IR, Ciftci AO, Akyuz C, Kutluk MT, Yalcin B, Gonc N, Ozon ZA, Alikasifoglu A, Oguz B, Haliloglu M, Orhan D, Tanyel FC, Karnak I, Ekinci S. Adrenocortical tumours in children: a review of surgical management at a tertiary care centre. ANZ J Surg 2021; 91:992-999. [PMID: 33438328 DOI: 10.1111/ans.16542] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 11/23/2020] [Accepted: 12/07/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Adrenocortical tumours (ACT) are rare tumours of childhood usually presenting with endocrine dysfunction. This retrospective study is designed to review our institutional experience in surgical management. METHODS Records of children treated for ACT between 1999 and 2019 were reviewed retrospectively. RESULTS The median age of 24 children was 78 months. Fourteen patients had adrenocortical carcinoma, nine had adrenocortical adenoma and one had neuroendocrine differentiation of ACT. Endocrine dysfunction was noted in 79% of the patients. Five patients had preoperative chemotherapy but none had a decrease in tumour size. Transabdominal approach was used in all but two patients who had thoracoabdominal incision for excision of giant tumours and ipsilateral lung metastases. Two patients had visceral excision to achieve R0 resection. Five patients, four of whom had spillage and one with partial resection died of widespread disease. Two patients with stage 4 adrenocortical carcinoma are still on chemotherapy. All patients with stage I-III disease who had total excision without spillage (n = 17) are disease-free for 2-170 months. CONCLUSIONS Our results show the importance of excision in ACT without spillage for survival. However, multicentre prospective studies should enhance the knowledge of children about ACT and develop alternative therapies for stage III and IV cases.
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Affiliation(s)
- Burak Ardicli
- Department of Medical and Surgical Research, Hacettepe University, Institute of Health Sciences, Ankara, Turkey.,Department of Paediatric Surgery, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Idil R User
- Department of Medical and Surgical Research, Hacettepe University, Institute of Health Sciences, Ankara, Turkey.,Department of Paediatric Surgery, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Arbay O Ciftci
- Department of Paediatric Surgery, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Canan Akyuz
- Department of Paediatric, Paediatric Oncology Unit, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Mustafa T Kutluk
- Department of Paediatric, Paediatric Oncology Unit, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Bilgehan Yalcin
- Department of Paediatric, Paediatric Oncology Unit, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Nazli Gonc
- Department of Paediatric, Paediatric Endocrinology Unit, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Zeynep A Ozon
- Department of Paediatric, Paediatric Endocrinology Unit, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Ayfer Alikasifoglu
- Department of Paediatric, Paediatric Endocrinology Unit, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Berna Oguz
- Department of Radiology, Paediatric Radiology Unit, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Mithat Haliloglu
- Department of Radiology, Paediatric Radiology Unit, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Diclehan Orhan
- Department of Paediatrics, Paediatric Pathology Unit, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Feridun C Tanyel
- Department of Paediatric Surgery, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Ibrahim Karnak
- Department of Paediatric Surgery, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Saniye Ekinci
- Department of Medical and Surgical Research, Hacettepe University, Institute of Health Sciences, Ankara, Turkey.,Department of Paediatric Surgery, Hacettepe University, Faculty of Medicine, Ankara, Turkey
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13
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Abstract
Incidentally discovered adrenal alterations should be separated into those without any clinical importance and adrenal diseases that have to be surgically or conservatively treated. Before operative treatment, in addition to the possible different functional activity of tumors, a differentiation must be made between sporadically arising singular or multiple adrenal tumors or nodular adrenal hyperplasia, adrenal tumors as part of a familial syndrome and metastases of other primary malignant tumors into the adrenal glands. Benign hormonally active adrenal tumors as well as questionable malignant tumors of the adrenal cortex are resected by minimally invasive techniques. For large malignant tumors infiltrating into surrounding tissues and tumors with proven lymph node metastases, the primarily open approach is indicated. Patients with adrenal diseases should always undergo an interdisciplinary assessment and in cases with clear indications for surgery, sometimes transferred to a center with experience in surgery and postoperative management of these patients.
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Affiliation(s)
- S Schimmack
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universität Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland.
| | - P Knoell
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universität Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - L Kihm
- Klinik für Endokrinologie, Stoffwechsel und Klinische Chemie, Universität Heidelberg, Heidelberg, Deutschland
| | - O Strobel
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universität Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
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14
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Delozier OM, Stiles ZE, Deschner BW, Drake JA, Deneve JL, Glazer ES, Tsao MW, Yakoub D, Dickson PV. Implications of Conversion during Attempted Minimally Invasive Adrenalectomy for Adrenocortical Carcinoma. Ann Surg Oncol 2020; 28:492-501. [PMID: 32656720 DOI: 10.1245/s10434-020-08824-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 06/21/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Although advocated by some, minimally invasive adrenalectomy (MIA) for adrenocortical carcinoma (ACC) is controversial. Moreover, the oncologic implications for patients requiring conversion to an open procedure during attempted MIA for ACC are not extensively reported. PATIENTS AND METHODS The National Cancer Database was queried for patients undergoing resection for ACC. Overall survival (OS) for patients undergoing successful MIA was compared with those requiring conversion, and additionally evaluated with a multivariable Cox regression analysis including other factors associated with OS. After propensity matching, those experiencing conversion were further compared with patients who underwent planned open resection. RESULTS Among 196 patients undergoing attempted MIA for ACC, 38 (19.4%) required conversion. Independent of 90-day postoperative mortality, conversion was associated with significantly reduced OS compared with successful MIA (median 27.9 months versus not reached, p = 0.002). Even for tumors confined to the adrenal, conversion was associated with worse median OS compared with successful MIA (median 34.2 months versus not reached, p = 0.003). After propensity matching for clinicopathologic covariates to establish well-balanced cohorts (N = 38 per group), patients requiring conversion during MIA had significantly worse OS than those having planned open resection (27.9 months versus 50.5 months, p = 0.020). On multivariable analysis for predictors of OS, conversion during MIA (HR 2.32, p = 0.003) was independently associated with mortality. CONCLUSIONS ACC is a rare tumor for which adequate oncologic resection is the only chance for cure. Given the relatively high rate of conversion and its associated inferior survival, open resection should be considered standard of care for known or suspected ACC.
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Affiliation(s)
- Olivia M Delozier
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Zachary E Stiles
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Benjamin W Deschner
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Justin A Drake
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jeremiah L Deneve
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Evan S Glazer
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Miriam W Tsao
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Danny Yakoub
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Paxton V Dickson
- Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, Memphis, TN, USA.
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15
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Sinclair TJ, Gillis A, Alobuia WM, Wild H, Kebebew E. Surgery for adrenocortical carcinoma: When and how? Best Pract Res Clin Endocrinol Metab 2020; 34:101408. [PMID: 32265101 DOI: 10.1016/j.beem.2020.101408] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Adrenocortical carcinoma (ACC) is a rare malignancy that is frequently asymptomatic at presentation, yet has a high rate of metastatic disease at the time of diagnosis. Prognosis is overall poor, particularly with cortisol-producing tumors. While the treatment of ACC is guided by stage of disease, complete surgical resection is the most important step in the management of patients with primary, recurrent, or metastatic ACC. Triphasic chest, abdomen, and pelvis computer tomography (CT) scans and 18F flourodeoxyglucose positron emission tomography CT scanning are essential for accurate staging; moreover, MRI may be helpful to identify liver metastasis and evaluate the involvement of adjacent organs for operative planning. Surgical resection with negative margins is the single most important prognostic factor for survival in patients with ACC. To achieve the highest rate of R0 resection, open adrenalectomy is the gold standard surgical approach for confirmed or highly suspected ACC. It is extremely important that the tumor capsule is not ruptured, regardless of the surgical approach used. The best post-operative outcomes (complications and oncologic) are achieved by high-volume surgeons practicing at high-volume centers.
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Affiliation(s)
- Tiffany J Sinclair
- Division of General Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Andrea Gillis
- Division of General Surgery, Department of Surgery, Albany Medical College, Albany, NY, USA
| | - Wilson M Alobuia
- Division of General Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Hannah Wild
- Division of General Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Electron Kebebew
- Division of General Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA.
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16
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Hu X, Yang WX, Shao YX, Dou WC, Xiong SC, Li X. Minimally Invasive Versus Open Adrenalectomy in Patients with Adrenocortical Carcinoma: A Meta-analysis. Ann Surg Oncol 2020; 27:3858-3869. [PMID: 32277316 DOI: 10.1245/s10434-020-08454-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Open surgery remains the preferred surgical treatment of adrenocortical carcinoma (ACC), while the role of minimally invasive adrenalectomy surgery (MIS) in ACC is still controversial. The present study was conducted to compare MIS with open adrenalectomy (OA) in ACC. METHODS The Embase, PubMed, and Cochrane Library databases were comprehensively searched. The weighted mean difference (WMD), relative risk (RR), and hazard ratio (HR) were pooled. RESULTS A total of 15 studies incorporating 2207 patients were included in the present study. MIS approaches were likely to have a comparable operation time (WMD - 17.77; p = 0.150) and postoperative complications (RR 0.74; p = 0.091) compared with OA, and were significantly associated with less blood loss (WMD - 1761.96; p = 0.016) and shorter length of stay (WMD - 2.96; p < 0.001). MIS approaches were also more likely to have an earlier recurrence (WMD - 8.42; p = 0.048) and more positive surgical margin (RR 1.56; p = 0.018) and peritoneal recurrence (RR 2.63; p < 0.001), while the overall recurrence (RR 1.07; p = 0.559) and local recurrence (RR 1.33; p = 0.160) were comparable between the two groups. Furthermore, surgical approaches did not differ in overall survival (HR 0.97; p = 0.801), cancer-specific survival (HR 1.04; p = 0.869), and recurrence/disease-free survival (HR 0.96; p = 0.791). CONCLUSIONS In the present study, MIS approaches were likely to have a better recovery. Although MIS approaches were associated with earlier recurrence and more positive surgical margin and peritoneal recurrence, no significant differences in survival outcomes were found. OA should still be considered as the standard treatment, but MIS approaches could be offered for selected ACC cases, and performed by surgeons with appropriate laparoscopic expertise, ensuring an improved survival for patients.
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Affiliation(s)
- Xu Hu
- West China School of Medicine/West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Wei-Xiao Yang
- West China School of Medicine/West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Yan-Xiang Shao
- West China School of Medicine/West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Wei-Chao Dou
- West China School of Medicine/West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - San-Chao Xiong
- West China School of Medicine/West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Xiang Li
- Department of Urology, West China Hospital, West China Medical School, Sichuan University, Chengdu, People's Republic of China.
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17
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Kazaure HS, Sosa JA. Volume-outcome relationship in adrenal surgery: A review of existing literature. Best Pract Res Clin Endocrinol Metab 2019; 33:101296. [PMID: 31331729 DOI: 10.1016/j.beem.2019.101296] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The relationship between operative volume and perioperative outcomes after several oncologic operations is well documented. Recent studies on adrenalectomy reveal a robust association between higher surgeon volume and improved patient outcomes. Statistical analyses have demonstrated that outcomes are improved when surgeons perform at least six adrenalectomies annually; based on this threshold definition of a 'high-volume' surgeon, more than 80% of adrenalectomies in the United States are performed by 'low-volume' surgeons. When compared to low-volume surgeons, high-volume surgeons on average achieve lower rates of postoperative complications and mortality, as well as a shorter length of hospital stay, and lower cost of hospitalization. There does not appear to be a similar association between hospital adrenalectomy volume and improved patient outcomes; however, there is evidence of benefit for the subset of patients with adrenocortical carcinoma. Despite limitations of existing literature, evidence is sufficient to recommend the referral of patients with adrenal tumors to high-volume surgeons.
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Affiliation(s)
- Hadiza S Kazaure
- Department of Surgery, Section of Endocrine Surgery, Duke University Medical Center, Durham, NC, USA
| | - Julie A Sosa
- Department of Surgery, University of California at San Francisco (UCSF), San Francisco, CA, USA.
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18
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Abstract
Adrenocortical carcinomas (ACC) are rare and aggressive neoplasms. Due to their high rate of local recurrence and distant metastases (up to 85%) they are associated with a poor survival. The 5‑year survival in ACC patients with lymph node metastasis or local infiltration is 50% and with distant metastasis less than 15%. An R0 resection with locoregional and para-aortic/paracaval lymphadenectomy is the only curative option and reasonable treatment possibility. The treatment of these patients should therefore be planned and carried out in centers. Local recurrences and distant metastases should also be treated with R0 resection when feasible, combined with neoadjuvant/adjuvant chemotherapy and/or radiation. In the case of an asymptomatic non-resectable ACC, debulking operations cannot be recommended. The primary operation can also be done in a minimally invasive procedure if principles of oncological surgery are followed (radical resection, no damage of the tumor capsule, lymphadenectomy), since survival after open and minimally invasive laparoscopic resection was comparable. Palliative resections are only indicated in symptomatic patients.
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Affiliation(s)
- S Schimmack
- Klinik für Allgemein‑, Viszeral und Transplantationschirurgie, Universität Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland.
| | - O Strobel
- Klinik für Allgemein‑, Viszeral und Transplantationschirurgie, Universität Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
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19
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Reibetanz J, Rinn B, Kunz AS, Flemming S, Ronchi CL, Kroiss M, Deutschbein T, Pulzer A, Hahner S, Kocot A, Germer CT, Fassnacht M, Jurowich C. Patterns of Lymph Node Recurrence in Adrenocortical Carcinoma: Possible Implications for Primary Surgical Treatment. Ann Surg Oncol 2018; 26:531-538. [DOI: 10.1245/s10434-018-6999-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Indexed: 12/20/2022]
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20
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Dickson PV, Kim L, Yen TWF, Yang A, Grubbs EG, Patel D, Solórzano CC. Evaluation, Staging, and Surgical Management for Adrenocortical Carcinoma: An Update from the SSO Endocrine and Head and Neck Disease Site Working Group. Ann Surg Oncol 2018; 25:3460-3468. [DOI: 10.1245/s10434-018-6749-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Indexed: 08/30/2023]
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21
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Fassnacht M, Dekkers O, Else T, Baudin E, Berruti A, de Krijger R, Haak H, Mihai R, Assie G, Terzolo M. European Society of Endocrinology Clinical Practice Guidelines on the management of adrenocortical carcinoma in adults, in collaboration with the European Network for the Study of Adrenal Tumors. Eur J Endocrinol 2018; 179:G1-G46. [PMID: 30299884 DOI: 10.1530/eje-18-0608] [Citation(s) in RCA: 494] [Impact Index Per Article: 82.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Adrenocortical carcinoma (ACC) is a rare and in most cases steroid hormone-producing tumor with variable prognosis. The purpose of these guidelines is to provide clinicians with best possible evidence-based recommendations for clinical management of patients with ACC based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. We predefined four main clinical questions, which we judged as particularly important for the management of ACC patients and performed systematic literature searches: (A) What is needed to diagnose an ACC by histopathology? (B) Which are the best prognostic markers in ACC? (C) Is adjuvant therapy able to prevent recurrent disease or reduce mortality after radical resection? (D) What is the best treatment option for macroscopically incompletely resected, recurrent or metastatic disease? Other relevant questions were discussed within the group. Selected Recommendations: (i) We recommend that all patients with suspected and proven ACC are discussed in a multidisciplinary expert team meeting. (ii) We recommend that every patient with (suspected) ACC should undergo careful clinical assessment, detailed endocrine work-up to identify autonomous hormone excess and adrenal-focused imaging. (iii) We recommend that adrenal surgery for (suspected) ACC should be performed only by surgeons experienced in adrenal and oncological surgery aiming at a complete en bloc resection (including resection of oligo-metastatic disease). (iv) We suggest that all suspected ACC should be reviewed by an expert adrenal pathologist using the Weiss score and providing Ki67 index. (v) We suggest adjuvant mitotane treatment in patients after radical surgery that have a perceived high risk of recurrence (ENSAT stage III, or R1 resection, or Ki67 >10%). (vi) For advanced ACC not amenable to complete surgical resection, local therapeutic measures (e.g. radiation therapy, radiofrequency ablation, chemoembolization) are of particular value. However, we suggest against the routine use of adrenal surgery in case of widespread metastatic disease. In these patients, we recommend either mitotane monotherapy or mitotane, etoposide, doxorubicin and cisplatin depending on prognostic parameters. In selected patients with a good response, surgery may be subsequently considered. (vii) In patients with recurrent disease and a disease-free interval of at least 12 months, in whom a complete resection/ablation seems feasible, we recommend surgery or alternatively other local therapies. Furthermore, we offer detailed recommendations about the management of mitotane treatment and other supportive therapies. Finally, we suggest directions for future research.
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Affiliation(s)
- Martin Fassnacht
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital
- Comprehensive Cancer Center Mainfranken, University of Würzburg, Würzburg, Germany
| | - Olaf Dekkers
- Department of Clinical Epidemiology
- Department of Clinical Endocrinology and Metabolism, Leiden University Medical Centre, Leiden, the Netherlands
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Tobias Else
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Eric Baudin
- Endocrine Oncology and Nuclear Medicine, Institut Gustave Roussy, Villejuif, France
- INSERM UMR 1185, Faculté de Médecine, Le Kremlin-Bicêtre, Université Paris Sud, Paris, France
| | - Alfredo Berruti
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Medical Oncology, University of Brescia at ASST Spedali Civili, Brescia, Italy
| | - Ronald de Krijger
- Department of Pathology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Pathology, Reinier de Graaf Hospital, Delft, the Netherlands
- Princess Maxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Harm Haak
- Department of Internal Medicine, Máxima Medical Centre, Eindhoven/Veldhoven, the Netherlands
- Maastricht University, CAPHRI School for Public Health and Primary Care, Ageing and Long-Term Care, Maastricht, the Netherlands
- Division of General Internal Medicine, Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Radu Mihai
- Department of Endocrine Surgery, Churchill Cancer Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Guillaume Assie
- Department of Endocrinology, Reference Center for Rare Adrenal Diseases, Reference Center dor Rare Adrenal Cancers, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
- Institut Cochin, Institut National de la Santé et de la Recherche Médicale U1016, Centre National de la Recherche Scientifique UMR8104, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Massimo Terzolo
- Department of Clinical and Biological Sciences, Internal Medicine, San Luigi Hospital, University of Turin, Orbassano, Italy
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22
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Li H, Zheng J, Cai JY, Li SH, Zhang JB, Wang XM, Chen GH, Yang Y, Wang GS. Laparoscopic VS open hepatectomy for hepatolithiasis: An updated systematic review and meta-analysis. World J Gastroenterol 2017; 23:7791-7806. [PMID: 29209120 PMCID: PMC5703939 DOI: 10.3748/wjg.v23.i43.7791] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 07/31/2017] [Accepted: 08/15/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To perform a meta-analysis on laparoscopic hepatectomy VS conventional liver resection for treating hepatolithiasis.
METHODS We conducted a systematic literature search on PubMed, Embase, Web of Science and Cochrane Library, and undertook a meta-analysis to compare the efficacy and safety of laparoscopic hepatectomy VS conventional open liver resection for local hepatolithiasis in the left or right lobe. Intraoperative and postoperative outcomes (time, estimated blood loss, blood transfusion rate, postoperative intestinal function recovery time, length of hospital stay, postoperative complication rate, initial residual stone, final residual stone and stone recurrence) were analyzed systematically.
RESULTS A comprehensive literature search retrieved 16 publications with a total of 1329 cases. Meta-analysis of these studies showed that the laparoscopic approach for hepatolithiasis was associated with significantly less intraoperative estimated blood loss [weighted mean difference (WMD): 61.56, 95% confidence interval (CI): 14.91-108.20, P = 0.01], lower blood transfusion rate [odds ratio (OR): 0.41, 95%CI: 0.22-0.79, P = 0.008], shorter intestinal function recovery time (WMD: 0.98, 95%CI: 0.47-1.48, P = 0.01), lower total postoperative complication rate (OR: 0.52, 95%CI: 0.39-0.70, P < 0.0001) and shorter stay in hospital (WMD: 3.32, 95%CI: 2.32-4.32, P < 0.00001). In addition, our results showed no significant differences between the two groups in operative time (WMD: 21.49, 95%CI: 0.27-43.24, P = 0.05), residual stones (OR: 0.79, 95%CI: 0.50-1.25, P = 0.31) and stone recurrence (OR: 0.34, 95%CI: 0.11-1.08, P = 0.07). Furthermore, with subgroups analysis, our results proved that the laparoscopic approach for hepatolithiasis in the left lateral lobe and left side could achieve satisfactory therapeutic effects.
CONCLUSION The laparoscopic approach is safe and effective, with less intraoperative estimated blood loss, fewer postoperative complications, reduced length of hospital stay and shorter intestinal function recovery time than with conventional approaches.
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Affiliation(s)
- Hui Li
- Department of Hepatic Surgery and Liver Transplantation Center of the Third Affiliated Hospital, Organ Transplantation Institute, Sun Yat-sen University, Organ Transplantation Research Center of Guangdong Province, Guangzhou 510630, Guangdong Province, China
- Guangdong Key Laboratory of Liver Disease Research, Key Laboratory of Liver Disease Biotherapy and Translational Medicine of Guangdong Higher Education Institutes, the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, Guangdong Province, China
| | - Jun Zheng
- Department of Hepatic Surgery and Liver Transplantation Center of the Third Affiliated Hospital, Organ Transplantation Institute, Sun Yat-sen University, Organ Transplantation Research Center of Guangdong Province, Guangzhou 510630, Guangdong Province, China
- Guangdong Key Laboratory of Liver Disease Research, Key Laboratory of Liver Disease Biotherapy and Translational Medicine of Guangdong Higher Education Institutes, the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, Guangdong Province, China
| | - Jian-Ye Cai
- Department of Hepatic Surgery and Liver Transplantation Center of the Third Affiliated Hospital, Organ Transplantation Institute, Sun Yat-sen University, Organ Transplantation Research Center of Guangdong Province, Guangzhou 510630, Guangdong Province, China
- Guangdong Key Laboratory of Liver Disease Research, Key Laboratory of Liver Disease Biotherapy and Translational Medicine of Guangdong Higher Education Institutes, the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, Guangdong Province, China
| | - Shi-Hui Li
- Department of Hepatic Surgery and Liver Transplantation Center of the Third Affiliated Hospital, Organ Transplantation Institute, Sun Yat-sen University, Organ Transplantation Research Center of Guangdong Province, Guangzhou 510630, Guangdong Province, China
- Guangdong Key Laboratory of Liver Disease Research, Key Laboratory of Liver Disease Biotherapy and Translational Medicine of Guangdong Higher Education Institutes, the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, Guangdong Province, China
| | - Jun-Bin Zhang
- Department of Hepatic Surgery and Liver Transplantation Center of the Third Affiliated Hospital, Organ Transplantation Institute, Sun Yat-sen University, Organ Transplantation Research Center of Guangdong Province, Guangzhou 510630, Guangdong Province, China
- Guangdong Key Laboratory of Liver Disease Research, Key Laboratory of Liver Disease Biotherapy and Translational Medicine of Guangdong Higher Education Institutes, the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, Guangdong Province, China
| | - Xiao-Ming Wang
- Department of Hepatobiliary Surgery, Yijishan Hospital affiliated to Wannan Medical College, Wuhu 241001, Anhui Province, China
| | - Gui-Hua Chen
- Department of Hepatic Surgery and Liver Transplantation Center of the Third Affiliated Hospital, Organ Transplantation Institute, Sun Yat-sen University, Organ Transplantation Research Center of Guangdong Province, Guangzhou 510630, Guangdong Province, China
- Guangdong Key Laboratory of Liver Disease Research, Key Laboratory of Liver Disease Biotherapy and Translational Medicine of Guangdong Higher Education Institutes, the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, Guangdong Province, China
| | - Yang Yang
- Department of Hepatic Surgery and Liver Transplantation Center of the Third Affiliated Hospital, Organ Transplantation Institute, Sun Yat-sen University, Organ Transplantation Research Center of Guangdong Province, Guangzhou 510630, Guangdong Province, China
- Guangdong Key Laboratory of Liver Disease Research, Key Laboratory of Liver Disease Biotherapy and Translational Medicine of Guangdong Higher Education Institutes, the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, Guangdong Province, China
| | - Gen-Shu Wang
- Department of Hepatic Surgery and Liver Transplantation Center of the Third Affiliated Hospital, Organ Transplantation Institute, Sun Yat-sen University, Organ Transplantation Research Center of Guangdong Province, Guangzhou 510630, Guangdong Province, China
- Guangdong Key Laboratory of Liver Disease Research, Key Laboratory of Liver Disease Biotherapy and Translational Medicine of Guangdong Higher Education Institutes, the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, Guangdong Province, China
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