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Carr SR, Villa Hernandez F, Varghese DG, Choo-Wosoba H, Steinberg SM, Teke ME, Del Rivero J, Schrump DS, Hoang CD. Pulmonary Metastasectomy for Adrenocortical Carcinoma-Not If, but When. Cancers (Basel) 2024; 16:702. [PMID: 38398093 PMCID: PMC10886862 DOI: 10.3390/cancers16040702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 02/03/2024] [Accepted: 02/05/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Adrenocortical carcinoma (ACC) commonly metastasizes to the lungs, and pulmonary metastasectomy (PM) is utilized due to limited systemic options. METHODS All ACC patients with initially only lung metastases (LM) from a single institution constituted this observational case series. Kaplan-Meier and Cox proportional hazard analyses evaluated the association with potential prognostic factors and outcomes. Overall survival (OS) was calculated from the date of the PM or, in those patients who did not undergo surgery, from the development of LM. RESULTS A total of 75 ACC patients over a 45-year period met the criteria; 52 underwent PM, and 23 did not. The patients undergoing PM had a median OS of 3.1 years (95% CI: 2.4, 4.7 years) with the 5- and 10-year OS being 35.5% and 32.8%, respectively. The total resected LM did not impact the OS nor the DFS. The patients who developed LM after 11 months from the initial ACC resection had an improved OS (4.2 years; 95% CI: 3.2, NR; p = 0.0096) compared to those developing metastases earlier (2.4 years; 95% CI: 1.6, 2.8). Patients who underwent PM within 11 months of adrenalectomy demonstrated a reduced OS (2.2 years; 95% CI: 1.0, 2.7) compared to those after 11 months (3.6 years, 95% CI: 2.6, NR; p = 0.0045). PM may provide benefit to those patients with LM at presentation (HR: 0.5; p = 0.2827), with the time to first PM as a time-varying covariate. CONCLUSIONS PM appears to have a role in ACC patients. The number of nodules should not be an exclusion factor. Patients developing LM within a year of primary tumor resection may benefit from waiting before further surgeries, which may provide additional insight into who may benefit from PM.
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Affiliation(s)
- Shamus R. Carr
- Thoracic Surgery Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA;
| | - Frank Villa Hernandez
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA; (F.V.H.); (M.E.T.)
| | - Diana Grace Varghese
- Developmental Therapeutics Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA; (D.G.V.)
| | - Hyoyoung Choo-Wosoba
- Biostatistics and Data Management Section, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Seth M. Steinberg
- Biostatistics and Data Management Section, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Martha E. Teke
- Surgical Oncology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA; (F.V.H.); (M.E.T.)
| | - Jaydira Del Rivero
- Developmental Therapeutics Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA; (D.G.V.)
| | - David S. Schrump
- Thoracic Surgery Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA;
| | - Chuong D. Hoang
- Thoracic Surgery Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA;
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Debets P, Dreijerink KMA, Engelsman A, Dahele M, Haak HR, Steenaard RV, Kapiteijn E, Corssmit E, Menke-van der Houven van Oordt CW. Impact of EDP-M on survival of patients with metastatic adrenocortical carcinoma: A population-based study. Eur J Cancer 2024; 196:113424. [PMID: 37977106 DOI: 10.1016/j.ejca.2023.113424] [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: 05/16/2023] [Revised: 09/27/2023] [Accepted: 10/25/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION Historically, stage IV adrenocortical carcinoma (mACC) has a poor prognosis with a median overall survival (OS) of only 5 months. Based on the FIRM-ACT trial published in 2012, guidelines now advise first line systemic treatment with etoposide, cisplatin, doxorubicin and mitotane (EDP-M). The effect of EDP-M on patient survival in clinical practice in the Netherlands is unknown. METHODS The data of all patients with mACC (2005-2020) were obtained from the Netherlands comprehensive cancer organization (IKNL). The effect of EDP-M on patient survival was assessed using Kaplan-Meier analysis and multivariate Cox regression analysis including clinical, therapy and tumor characteristics. RESULTS In total 167 patients with mACC were included. For patients diagnosed from 2014 onwards, EDP-M (in 22 patients (22%)) lead to a numerically but not statistically significant improved OS compared to those not receiving EDP-M (11.8 vs 5.6 months, p = 0.525). For systemic treatments, patients treated with mitotane only had the best 5-year OS (11.4%, p = 0.006) regardless of year of diagnosis. In multivariate Cox regression analysis EPD-M was not associated with OS; palliative adrenalectomy (HR: 0.26, p = <.001) and local treatment of metastases (HR: 0.35, p = 0.001) were associated with a better OS and a primary tumor Ki-67 index > 20% (HR: 2.67, p = 0.003) with a worse OS from 2014 onwards. Patients diagnosed before 2014 had a significantly poorer OS compared to from 2014 onwards (5-yr: 4.5 vs 8.4%, OS: 6.8 vs 8.3 months, p = 0.032). CONCLUSION OS for mACC in the Netherlands has improved in the last decade. Receiving EDP-M did not significantly improve OS for patients with mACC. The use of multimodality treatment including palliative adrenalectomy, mitotane and local treatment of (oligo-)metastases in appropriately selected patients has improved the OS for mACC patients since 2014.
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Affiliation(s)
- Pien Debets
- Amsterdam UMC location VU Medical Center, department of Medical Oncology, Amsterdam, the Netherlands
| | - Koen M A Dreijerink
- Amsterdam UMC location VU Medical Center, department of Endocrinology and Metabolism, Amsterdam, the Netherlands; Cancer Center Amsterdam, the Netherlands
| | - Anton Engelsman
- Amsterdam UMC location VU Medical Center, department of Surgery, Amsterdam, the Netherlands
| | - Max Dahele
- Amsterdam UMC location VU Medical Center, Department of Radiation Oncology and Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Harm R Haak
- Maxima Medical Center, department of Internal Medicine, Eindhoven, the Netherlands; Maastricht University, CAPHRI School for Public Health and Primary Care, Ageing and Long-Term Care, Maastricht, the Netherlands; Department of Internal Medicine, Division of General Internal Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Rebecca V Steenaard
- Maxima Medical Center, department of Internal Medicine, Eindhoven, the Netherlands; Maastricht University, CAPHRI School for Public Health and Primary Care, Ageing and Long-Term Care, Maastricht, the Netherlands; Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands
| | - Ellen Kapiteijn
- Leiden University Medical Center, Department of Medical Oncology, Leiden, the Netherlands
| | - Eleonora Corssmit
- Leiden University Medical Center, Center of Endocrine Tumours, Division of Endocrinology, Department of Internal Medicine, Leiden, the Netherlands
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Zhang F, Liu Z, Feng D, Tang Y, Liu S, Wu K, Zhang F, Zhu Y, Lu Y. Reoperation for Recurrent Adrenocortical Carcinoma: A Systematic Review and Pooled Analysis of Population-Based Studies. Front Surg 2022; 9:781406. [PMID: 35252325 PMCID: PMC8892209 DOI: 10.3389/fsurg.2022.781406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 01/17/2022] [Indexed: 11/13/2022] Open
Abstract
Background Adrenocortical carcinoma (ACC) is a rare neoplasm with a high recurrence rate. This study aimed to assess the role of surgery in the clinical management of recurrent ACC. Methods The PubMed, Embase, Web of Science, and Cochrane Library databases were searched, and the hazard ratios were pooled. Results Patients who underwent resection for recurrence had significantly better OS or OS after recurrence than those who received only nonsurgical treatments (HR 0.34, p < 0.001). Prognostic factors were associated with decreased OS after recurrence, including multiple recurrence (HR 3.23, p = 0.001), shorter disease-free interval (HR 2.94, p < 0.001), stage III-IV of the original tumor (HR 6.17, p = 0.001), sex of male (HR 1.35, p = 0.04), and initial non-R0 resection (HR 2.13, p = 0.001). Prolonged OS after recurrence was observed in those who experienced incomplete resection (HR 0.43, 95% CI 0.31–0.52, I2 = 53%) compared with patients who only received nonsurgical treatments. In the reoperated group, patients who underwent complete resection of recurrence had a prolonged OS after recurrence compared with those who underwent incomplete resection (HR 0.23, p = 0.004). Conclusions We confirmed the role of reoperation in the clinical management of recurrent ACC. Select patients might benefit from debulking surgery. The preoperative evaluation of the complete resection of the recurrence is the key means to decide whether patients should undergo surgery. Other prognostic factors associated with prolonged OS include single recurrence site, relatively longer disease-free interval, stage I-II of the original tumor, and female sex.
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Shariq OA, McKenzie TJ. Adrenocortical carcinoma: current state of the art, ongoing controversies, and future directions in diagnosis and treatment. Ther Adv Chronic Dis 2021; 12:20406223211033103. [PMID: 34349894 PMCID: PMC8295938 DOI: 10.1177/20406223211033103] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 06/23/2021] [Indexed: 12/22/2022] Open
Abstract
Adrenocortical carcinoma (ACC) is a rare, aggressive malignancy with an annual incidence of ~1 case per million population. Differentiating between ACC and benign adrenocortical tumors can be challenging in patients who present with an incidentally discovered adrenal mass, due to the limited specificity of standard diagnostic imaging. Recently, urine steroid metabolite profiling has been prospectively validated as a novel diagnostic tool for the detection of malignancy with improved accuracy over current modalities. Surgery represents the only curative treatment for ACC, although local recurrence and metastases are common, even after a margin-negative resection is performed. Unlike other intra-abdominal cancers, the role of minimally invasive surgery and lymphadenectomy in ACC is controversial. Adjuvant therapy with the adrenolytic drug mitotane is used to reduce the risk of recurrence after surgery, although evidence supporting its efficacy is limited; it is also currently unclear whether all patients or a subset with the highest risk of recurrence should receive this treatment. Large-scale pan-genomic studies have yielded insights into the pathogenesis of ACC and have defined distinct molecular signatures associated with clinical outcomes that may be used to improve prognostication. For patients with advanced ACC, palliative combination chemotherapy with mitotane is the current standard of care; however, this is associated with poor response rates (RR). Knowledge from molecular profiling studies has been used to guide the development of novel targeted therapies; however, these have shown limited efficacy in early phase trials. As a result, there is an urgent unmet need for more effective therapies for patients with this devastating disease.
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Affiliation(s)
| | - Travis J McKenzie
- Department of Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905, USA
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Adrenal Surgery for Synchronously Metastatic Adrenocortical Carcinoma: A Population-Based Analysis. World J Surg 2021; 45:1457-1465. [PMID: 33481081 DOI: 10.1007/s00268-021-05957-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Metastatic adrenocortical carcinoma (ACC) is an aggressive cancer with poor prognosis, with limited treatment options. The survival benefit of adrenal surgery in patients with synchronous metastatic disease has not been well explored. METHODS Patients with ACC with synchronous metastases were identified from the Surveillance, Epidemiology, and End Results database (2010-2016). The effect of adrenal surgery on different patterns of distant metastases was assessed. The overall survival was estimated by the Kaplan-Meier method. Multivariable Cox regression analysis was performed to identify prognostic factors associated with survival outcome. RESULTS A total of 202 patients with synchronous metastatic ACC were identified from the SEER database, 76 (37.6%) patients underwent adrenal surgery. Compared to nonsurgical patients, patients who underwent adrenal surgery had a better survival (median overall survival: 4 vs. 13 months, P < 0.001). In sub-analyses, except for patients with liver metastases (P = 0.670), adrenalectomy could consistently confer a significant survival benefit in patients with lung metastases (P = 0.003), bone metastases (P = 0.020), and multiple metastases (P = 0.002). Cox regression analysis revealed that in addition to adrenalectomy [hazard ratio (HR) = 0.64, 95% confidence interval (CI) 0.45-0.92; P = 0.017], metastasectomy (HR = 0.48, 95% CI 0.26-0.86; P = 0.013), and chemotherapy (HR = 0.59, 95% CI 0.42-0.82; P = 0.002) were also associated with improved survival. CONCLUSIONS Our findings support the view that adrenal surgery may be associated with improved survival in patients with synchronous metastatic ACC (except for patients with liver metastases), and the metastatic sites have significant prognostic implications on survival outcomes with adrenal surgery.
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Wu K, Liu Z, Li X, Lu Y. Clinical Score Predicting Overall Survival After Surgery for Synchronous Metastatic Adrenocortical Carcinoma: A Surveillance, Epidemiology, and End Result-Based Study. Am Surg 2020; 87:805-811. [PMID: 33228399 DOI: 10.1177/0003134820956275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Surgery remains the only potential option for prolonging survival in synchronous metastatic adrenocortical carcinoma (ACC). The purpose of this study is to identify patients who may benefit from adrenalectomy. Using the Surveillance, Epidemiology, and End Results (SEER) database (2010-2015), we identified synchronous metastatic ACC patients who underwent adrenalectomy. Cox regression analysis was performed to identify prognostic factors associated with overall survival. A clinical scoring system was created to predict survival after surgery. Sixty-two patients underwent adrenalectomy for synchronous metastatic ACC. Median age was 54.5 years. Median overall survival was 12 months. In univariable analysis revealed that age 65≥years, tumor stage: T3/4, multiple metastases, liver metastases, and no chemotherapy were associated with poor survival. In the multivariable Cox analysis, liver metastases (P = .017) and no chemotherapy (P = .039) remained independent predictors of worse prognosis. A clinical scoring system including of 1-point each for the 2 predictors demonstrated good discrimination in predicting survival after adrenalectomy (3-year survival: 45.9% for 0 points and 0% for 1 or 2 points; P < .001, area under the curve = .78). Prolonged survival after adrenalectomy combined with chemotherapy can be potentially achieved in synchronous metastatic ACC patients without liver metastases. Patients with liver metastases should be carefully evaluated for surgery.
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Affiliation(s)
- Kan Wu
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, China
| | - Zhihong Liu
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, China
| | - Xiang Li
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, China
| | - Yiping Lu
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, China
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Sada A, Glasgow AE, Lyden ML, Thompson GB, Dy BM, McKenzie TJ, Habermann EB. Positive Lymph Nodes in Adrenocortical Carcinoma: What Does It Mean? World J Surg 2020; 45:188-194. [PMID: 33034710 DOI: 10.1007/s00268-020-05801-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND The role of lymphadenectomy in adrenocortical carcinoma resection is controversial. Therefore, we conducted a population-based study to assess the association between positive lymph nodes (LN) and survival. METHODS The Surveillance, Epidemiology, and End Results set of cancer registries were utilized. The associations between positive lymph nodes and tumor size, grade and laterality were assessed. Cancer specific survival (CSS) trends and factors affecting survival were analyzed. RESULTS A total of 2170 adult patients were identified; 60% underwent resection. Among those resected, LN were examined in 23% and were positive in 25% of patients with LN examined. Patients with positive LN tended to have smaller tumors compared to those with negative LN (12 ± 5 vs 15 ± 11 cm, p = 0.02). The rate of positive LN was higher in right ACC, p = 0.03. Median overall CSS was 21 months, with significant differences between resection (42 months) and no resection (4 months), p < 0.01. Median CSS did not change over time when comparing ACC patients who underwent surgery before 2000, 2000-2009, and 2010-2016. On multivariable analysis including resection group, advanced age, grades III and IV, regional and distant stage, in addition to positive LN were associated with worse survival, p < 0.05. CONCLUSION Lymphadenectomy is infrequently performed during ACC resection, and when performed, regional LN involvement tends to be associated with worse survival. Neoplasm size and grade were not associated with LN involvement and therefore, do not inform lymphadenectomy need. Further studies are needed to assess the indications for, and value of lymphadenectomy in ACC.
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Affiliation(s)
- Alaa Sada
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Amy E Glasgow
- Surgical Outcomes Program, Robert D and Patricia E Kern Center for The Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | | | | | - Benzon M Dy
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Elizabeth B Habermann
- Department of Surgery, Mayo Clinic, Rochester, MN, USA. .,Surgical Outcomes Program, Robert D and Patricia E Kern Center for The Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
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Development and Internal Validation of a Multivariable Prediction Model for Adrenocortical-Carcinoma-Specific Mortality. Cancers (Basel) 2020; 12:cancers12092720. [PMID: 32971946 PMCID: PMC7564668 DOI: 10.3390/cancers12092720] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/09/2020] [Accepted: 09/11/2020] [Indexed: 01/23/2023] Open
Abstract
Simple Summary Adrenocortical carcinoma is a rare and aggressive cancer. Great variability in clinical course is observed, ranging from patients with extreme long survival to aggressive tumors with prompt fatal outcome. This heterogeneity in survival makes it complicated to tailor treatment strategies for an individual patient. Therefore we sought to identify prognostic factors associated with ACC specific mortality. We analyzed the data of 160 ACC patients and developed a clinical prediction model including age, modified European Network for the Study of Adrenal Tumors (mENSAT) stage, and radical resection. This easy-to-use prediction model for ACC-specific mortality has the potential to guide clinical decision making if externally validated. Abstract Adrenocortical carcinoma (ACC) has an incidence of about 1.0 per million per year. In general, survival of patients with ACC is limited. Predicting survival outcome at time of diagnosis is a clinical challenge. The aim of this study was to develop and internally validate a clinical prediction model for ACC-specific mortality. Data for this retrospective cohort study were obtained from the nine centers of the Dutch Adrenal Network (DAN). Patients who presented with ACC between 1 January 2004 and 31 October 2013 were included. We used multivariable Cox proportional hazards regression to compute the coefficients for the prediction model. Backward stepwise elimination was performed to derive a more parsimonious model. The performance of the initial prediction model was quantified by measures of model fit, discriminative ability, and calibration. We undertook an internal validation step to counteract the possible overfitting of our model. A total of 160 patients were included in the cohort. The median survival time was 35 months, and interquartile range (IQR) 50.7 months. The multivariable modeling yielded a prediction model that included age, modified European Network for the Study of Adrenal Tumors (mENSAT) stage, and radical resection. The c-statistic was 0.77 (95% Confidence Interval: 0.72, 0.81), indicating good predictive performance. We developed a clinical prediction model for ACC-specific mortality. ACC mortality can be estimated using a relatively simple clinical prediction model with good discriminative ability and calibration.
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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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Puglisi S, Calabrese A, Basile V, Ceccato F, Scaroni C, Altieri B, Della Casa S, Loli P, Pivonello R, De Martino MC, Canu L, Russo M, Badalamenti G, Torlontano M, Stigliano A, Ferraù F, Arnaldi G, Saba L, Quirino A, Perotti P, Berchialla P, Terzolo M. Mitotane Concentrations Influence Outcome in Patients with Advanced Adrenocortical Carcinoma. Cancers (Basel) 2020; 12:E740. [PMID: 32245135 PMCID: PMC7140087 DOI: 10.3390/cancers12030740] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 03/16/2020] [Accepted: 03/18/2020] [Indexed: 12/15/2022] Open
Abstract
Mitotane is the main option of treatment for advanced adrenocortical carcinoma (ACC). However, limited evidence is available regarding the impact of plasma mitotane levels on patient outcome. To address this question, we retrospectively analyzed patients with advanced ACC treated with mitotane for ≥3 months, with ≥3 measurements of plasma mitotane reported in the Lysosafe Online® database (HRA Pharma, France), followed at 12 tertiary centers in Italy from 2005 to 2017. We identified 80 patients, initially treated with mitotane alone (56.2%) or plus chemotherapy (43.8%). The preference toward combination therapy was given to de novo stage IV ACC and younger patients. After the first line of treatment, 25% of valid cases experienced clinical benefit (14.5% objective response, 10.5% stabilization of disease) and 75% progression, without differences between the groups of treatment. Patients with progression had a lower time in the target range (TTR) of plasma mitotane and an unfavorable outcome. Death occurred in 76.2% of cases and multivariate analysis showed that clinical benefit after first treatment and longer TTR were favorable predictors of overall survival (OS). In conclusion, the present findings support the importance of mitotane monitoring and strengthen the concept of a therapeutic window for mitotane.
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Affiliation(s)
- Soraya Puglisi
- Internal Medicine, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, 10043 Turin, Italy; (S.P.); (V.B.); (L.S.); (A.Q.); (P.P.); (M.T.)
| | - Anna Calabrese
- Internal Medicine, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, 10043 Turin, Italy; (S.P.); (V.B.); (L.S.); (A.Q.); (P.P.); (M.T.)
| | - Vittoria Basile
- Internal Medicine, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, 10043 Turin, Italy; (S.P.); (V.B.); (L.S.); (A.Q.); (P.P.); (M.T.)
| | - Filippo Ceccato
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padua, 35128 Padua, Italy; (F.C.); (C.S.)
| | - Carla Scaroni
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padua, 35128 Padua, Italy; (F.C.); (C.S.)
| | - Barbara Altieri
- Division of Endocrinology and Metabolic Diseases, University-Hospital Gemelli, IRCSS, Catholic University of the Sacred Heart, 00168 Rome, Italy; (B.A.); (S.D.C.)
| | - Silvia Della Casa
- Division of Endocrinology and Metabolic Diseases, University-Hospital Gemelli, IRCSS, Catholic University of the Sacred Heart, 00168 Rome, Italy; (B.A.); (S.D.C.)
| | - Paola Loli
- Endocrinology, Hospital Niguarda Ca’ Granda, 20121 Milan, Italy;
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, 80131 Naples, Italy; (R.P.); (M.C.D.M.)
| | - Maria Cristina De Martino
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, 80131 Naples, Italy; (R.P.); (M.C.D.M.)
| | - Letizia Canu
- Endocrinology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, 50134 Florence, Italy;
| | - Marco Russo
- Endocrinology Division, Department of Clinical and Experimental Medicine, ARNAS Garibaldi, University of Catania, 95122 Catania, Italy;
| | - Giuseppe Badalamenti
- Department of Surgical, Oncological, and Oral Sciences, Section of Medical Oncology, University of Palermo, 90127 Palermo, Italy;
| | - Massimo Torlontano
- Unit of Endocrinology, Fondazione IRCCS Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy;
| | - Antonio Stigliano
- Endocrinology, Department of Clinical and Molecular Medicine, Sant’Andrea Hospital, Sapienza University of Rome, 00189 Rome, Italy;
| | - Francesco Ferraù
- Department of Human Pathology of Adulthood and Childhood ‘G. Barresi’, University of Messina, 98125 Messina, Italy;
| | - Giorgio Arnaldi
- Division of Endocrinology, Department of Clinical and Molecular Sciences (DISCLIMO), Polytechnic University of Marche, 60121 Ancona, Italy;
| | - Laura Saba
- Internal Medicine, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, 10043 Turin, Italy; (S.P.); (V.B.); (L.S.); (A.Q.); (P.P.); (M.T.)
| | - Alessandra Quirino
- Internal Medicine, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, 10043 Turin, Italy; (S.P.); (V.B.); (L.S.); (A.Q.); (P.P.); (M.T.)
| | - Paola Perotti
- Internal Medicine, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, 10043 Turin, Italy; (S.P.); (V.B.); (L.S.); (A.Q.); (P.P.); (M.T.)
| | - Paola Berchialla
- Statistical Unit, Department of Clinical and Biological Sciences, Orbassano, University of Turin, 10143 Orbassano, Italy;
| | - Massimo Terzolo
- Internal Medicine, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, 10043 Turin, Italy; (S.P.); (V.B.); (L.S.); (A.Q.); (P.P.); (M.T.)
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Sada A, Asaad M, Bews KA, Thompson GB, Young WF, Bancos I, Farley DR, Dy BM, Lyden ML, Habermann EB, McKenzie TJ. Comparison between functional and non-functional adrenocortical carcinoma. Surgery 2019; 167:216-223. [PMID: 31543320 DOI: 10.1016/j.surg.2019.04.066] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 03/28/2019] [Accepted: 04/27/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND While roughly half of adrenocortical carcinomas are functional, whether functional status impacts outcomes remains controversial. We compared presentation and survival for functional and nonfunctional neoplasms. METHODS Adult patients presented with adrenocortical carcinomas at the Mayo Clinic were included. Tumor characteristics and outcomes were analyzed. RESULTS The 266 identified patients presented with stage I (6%), II (33%), III (26%), and IV disease (32%); stage was unknown in 3%. Fifty-three percent of tumors were functional; patients with functional adrenocortical carcinomas were younger, more likely to be female, and more likely to present with metastatic disease. Surgical resection was undertaken in 84% of patients with 69% having R0 resection. While 30-day morbidity was similar between functional and nonfunctional adrenocortical carcinomas, median overall survival was better for nonfunctional adrenocortical carcinomas (median 66 vs 22 months, P = .01). Functional adrenocortical carcinomas was independently associated with shorter survival after adjusting for age, sex, grade, stage, and resection attempt: hazard ratio = 1.5 (95% confidence interval, 1.04-2.14, P = .03). CONCLUSION In our cohort, long term survival was worse for all patients with functional tumors. However, when analyzing patients with R0 resection, there was no survival difference between functional and nonfunctional adrenocortical carcinomas, signaling need for better understanding of adrenocortical carcinomas behavior to individualize and optimize treatment strategies.
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Affiliation(s)
- Alaa Sada
- Department of Surgery, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Malke Asaad
- Department of Surgery, Mayo Clinic, Rochester, MN
| | - Katherine A Bews
- Department of Health Services Research, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | | | | | - Irina Bancos
- Division of Endocrinology, Mayo Clinic, Rochester, MN
| | | | - Benzon M Dy
- Department of Surgery, Mayo Clinic, Rochester, MN
| | | | - Elizabeth B Habermann
- Department of Health Services Research, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
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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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14
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Prendergast KM, Smith PM, Tran TB, Postlewait LM, Maithel SK, Prescott JD, Pawlik TM, Wang TS, Glenn J, Hatzaras I, Shenoy R, Phay JE, Shirley LA, Fields RC, Jin LX, Weber SM, Salem A, Sicklick JK, Gad S, Yopp AC, Mansour JC, Duh QY, Seiser N, Votanopoulos KI, Levine EA, Poultsides GA, Solórzano CC, Kiernan CM. Features of synchronous versus metachronous metastasectomy in adrenal cortical carcinoma: Analysis from the US adrenocortical carcinoma database. Surgery 2019; 167:352-357. [PMID: 31272813 DOI: 10.1016/j.surg.2019.05.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 04/09/2019] [Accepted: 05/19/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Adrenocortical carcinoma is a rare, aggressive cancer. We compared features of patients who underwent synchronous versus metachronous metastasectomy. METHODS Adult patients who underwent resection for metastatic adrenocortical carcinoma from 1993 to 2014 at 13 institutions of the US adrenocortical carcinoma group were analyzed retrospectively. Patients were categorized as synchronous if they underwent metastasectomy at the index adrenalectomy or metachronous if they underwent resection after recurrence of the disease. Factors associated with overall survival were assessed by univariate analysis. RESULTS In the study, 84 patients with adrenocortical carcinoma underwent metastasectomy; 26 (31%) were synchronous and 58 (69%) were metachronous. Demographics were similar between groups. The synchronous group had more T4 tumors at the index resection (42 vs 3%, P < .001). The metachronous group had prolonged median survival after the index resection (86.3 vs 17.3 months, P < .001) and metastasectomy (36.9 vs 17.3 months, P = .007). Synchronous patients with R0 resections had improved survival compared to patients with R1/2 resections (P = .008). Margin status at metachronous metastasectomy was not associated with survival (P = .452). CONCLUSION Select patients with metastatic adrenocortical carcinoma may benefit from metastasectomy. Patients with metachronous metastasectomy have a more durable survival benefit than those undergoing synchronous metastasectomy. This study highlights need for future studies examining differences in tumor biology that could explain outcome disparities in these distinct patient populations.
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Affiliation(s)
| | | | - Thuy B Tran
- Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Lauren M Postlewait
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Jason D Prescott
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Timothy M Pawlik
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Tracy S Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Jason Glenn
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Ioannis Hatzaras
- Department of Surgery, New York University School of Medicine, New York, NY
| | - Rivfka Shenoy
- Department of Surgery, New York University School of Medicine, New York, NY
| | - John E Phay
- Department of Surgery, The Ohio State University, Columbus, OH
| | | | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Linda X Jin
- Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Sharon M Weber
- Department of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Ahmed Salem
- Department of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Jason K Sicklick
- Department of Surgery, University of California San Diego, San Diego, CA
| | - Shady Gad
- Department of Surgery, University of California San Diego, San Diego, CA
| | - Adam C Yopp
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - John C Mansour
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Quan-Yang Duh
- Department of Surgery, University of California San Francisco, San Francisco, CA
| | - Natalie Seiser
- Department of Surgery, University of California San Francisco, San Francisco, CA
| | | | - Edward A Levine
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC
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15
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A phase II study of the orally administered negative enantiomer of gossypol (AT-101), a BH3 mimetic, in patients with advanced adrenal cortical carcinoma. Invest New Drugs 2019; 37:755-762. [PMID: 31172443 DOI: 10.1007/s10637-019-00797-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 05/22/2019] [Indexed: 02/06/2023]
Abstract
Background Adrenal cortical carcinoma (ACC) is a rare cancer with treatment options of limited efficacy, and poor prognosis if metastatic. AT-101 is a more potent inhibitor of B cell lymphoma 2 family apoptosis-related proteins than its racemic form, gossypol, which showed preliminary clinical activity in ACC. We thus evaluated the efficacy of AT-101 in patients with advanced ACC. Methods Patients with histologically confirmed metastatic, recurrent, or primarily unresectable ACC were treated with AT-101 (20 mg/day orally, 21 days out of 28-day cycles) until disease progression and/or prohibitive toxicity. The primary endpoint was objective response rate, wherein a Response Evaluation Criteria In Solid Tumors (RECIST) partial response rate of 25% would be considered promising and 10% not, with a Type I error of 10% and 90% power. In a 2-stage design, 2 responses were required of the first 21 assessable subjects to warrant complete accrual of 44 patients. Secondary endpoints included safety, progression-free survival and overall survival. Results This study accrued 29 patients between 2009 and 2011; median number of cycles was 2. Seven percent experienced grade 4 toxicity including cardiac troponin elevations and hypokalemia. None of the first 21 patients attained RECIST partial response; accordingly, study therapy was deemed ineffective and the trial was permanently closed. Conclusions AT-101 had no meaningful clinical activity in this study in patients with advanced ACC, but demonstrated feasibility of prospective therapeutic clinical trials in this rare cancer.
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Lo WM, Kariya CM, Hernandez JM. Operative Management of Recurrent and Metastatic Adrenocortical Carcinoma: A Systematic Review. Am Surg 2019. [DOI: 10.1177/000313481908500111] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Metastatic adrenocortical carcinoma (ACC) is associated with a poor 5-year survival rate and high rate of recurrence. Outcomes after resection for patients with limited disease remain poorly described. We conducted a PubMed search for articles published between 1950 and 2017 using the terms “ACC,” “recurrence,” and “surgery.” Patients with metastatic ACC at any anatomic site who had undergone surgical resection were included. Thirteen studies met the criteria. Patients were grouped according to the recurrence site. Pulmonary metastasectomy was reported in 50 patients with moderate complications and without perioperative mortality. Disease recurrence rates range from 25 to 42 per cent, with median overall survival of 40 to 50 months. Hepatic metastasectomy was reported in 108 patients with a single perioperative mortality. Disease recurrence rates range from 65 to 100 per cent, with median disease-free survival (DFS) and OS of five to nine months and 22 to 76 months. Peritoneal cytoreduction and heated intraperitoneal chemotherapy have been reported for 10 patients with minimal morbidity and without perioperative mortality. The disease recurrence rate was 70 per cent, with DFS of 19 months. For selected patients with recurrent ACC in the lungs, liver, or peritoneum, metastasectomy is safe and can be associated with prolonged survival. However, subsequent disease recurrence is common, and patients should be counseled accordingly.
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Affiliation(s)
- Winifred M. Lo
- From the Thoracic and Surgical Oncology Branch, National Cancer Institute, Bethesda, Maryland
| | - Christine M. Kariya
- From the Thoracic and Surgical Oncology Branch, National Cancer Institute, Bethesda, Maryland
| | - Jonathan M. Hernandez
- From the Thoracic and Surgical Oncology Branch, National Cancer Institute, Bethesda, Maryland
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Glenn JA, Else T, Hughes DT, Cohen MS, Jolly S, Giordano TJ, Worden FP, Gauger PG, Hammer GD, Miller BS. Longitudinal patterns of recurrence in patients with adrenocortical carcinoma. Surgery 2019; 165:186-195. [DOI: 10.1016/j.surg.2018.04.068] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 04/14/2018] [Accepted: 04/23/2018] [Indexed: 12/18/2022]
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18
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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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19
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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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20
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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: 474] [Impact Index Per Article: 79.0] [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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Gaujoux S, Weinandt M, Bonnet S, Reslinger V, Bertherat J, Dousset B. Surgical treatment of adrenal carcinoma. J Visc Surg 2017; 154:335-343. [DOI: 10.1016/j.jviscsurg.2017.06.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Outcome after resection of Adrenocortical Carcinoma liver metastases: a retrospective study. BMC Cancer 2017; 17:522. [PMID: 28778197 PMCID: PMC5545028 DOI: 10.1186/s12885-017-3506-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Accepted: 07/27/2017] [Indexed: 12/12/2022] Open
Abstract
Background Metastatic Adrenocortical Carcinoma (ACC) is a rare malignancy with a poor 5-year-survival rate (<15%). A surgical approach is recommended in selected patients if complete resection of distant metastasis can be achieved. To date there are only limited data on the outcome after surgical resection of hepatic metastases of ACC. Methods A retrospective analysis of the German Adrenocortical Carcinoma Registry was conducted. Patients with liver metastases of ACC but without extrahepatic metastases or incomplete tumour resection were included. Results Seventy-seven patients fulfilled these criteria. Forty-three patients underwent resection of liver metastases of ACC. Complete tumour resection (R0) could be achieved in 30 (69.8%). Median overall survival after liver resection was 76.1 months in comparison to 10.1 months in the 34 remaining patients with unresected liver metastases (p < 0.001). However, disease free survival after liver resection was only 9.1 months. Neither resection status (R0/R1) nor extent of liver resection were significant predictive factors for overall survival. Patients with a time interval to the first metastasis/recurrence (TTFR) of greater than 12 months or solitary liver metastases showed significantly prolonged survival. Conclusions Liver resection in the case of ACC liver metastases can achieve long term survival with a median overall survival of more than 5 years, but disease free survival is short despite metastasectomy. Time to recurrence and single versus multiple metastases are predictive factors for the outcome.
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Gaujoux S, Mihai R. European Society of Endocrine Surgeons (ESES) and European Network for the Study of Adrenal Tumours (ENSAT) recommendations for the surgical management of adrenocortical carcinoma. Br J Surg 2017; 104:358-376. [PMID: 28199015 DOI: 10.1002/bjs.10414] [Citation(s) in RCA: 112] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 06/10/2016] [Accepted: 09/28/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Radical surgery provides the best chance of cure for adrenocortical carcinoma (ACC), but perioperative surgical care for these patients is yet to be standardized. METHODS A working group appointed jointly by ENSAT and ESES used Delphi methodology to produce evidence-based recommendations for the perioperative surgical care of patients with ACC. Papers were retrieved from electronic databases. Evidence and recommendations were classified according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system, and were discussed until consensus was reached within the group. RESULTS Twenty-five recommendations for the perioperative surgical care of patients with ACC were formulated. The quality of evidence is low owing to the rarity of the disease and the lack of prospective surgical trials. Multi-institutional prospective cohort studies and prospective RCTs are urgently needed and should be strongly encouraged. CONCLUSION The present evidence-based recommendations provide comprehensive advice on the optimal perioperative care for patients undergoing surgery for ACC.
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Affiliation(s)
- S Gaujoux
- Department of Digestive and Endocrine Surgery, Cochin Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Paris, France
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Paris, France
- Institut National de la Santé et de la Recherche Médicale (INSERM) Unit 1016, Centre National de la Recherche Scientifique Unité Mixte de Recherche 8104, Institut Cochin, Paris, France
| | - R Mihai
- Churchill Cancer Centre, Oxford University Hospitals Foundation Trust, Oxford, UK
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Kerkhofs TMA, Ettaieb MHT, Hermsen IGC, Haak HR. Developing treatment for adrenocortical carcinoma. Endocr Relat Cancer 2015; 22:R325-38. [PMID: 26259571 DOI: 10.1530/erc-15-0318] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/10/2015] [Indexed: 02/02/2023]
Abstract
Cancer of the adrenal cortex (ACC) is a rare endocrine malignancy with limited treatment options. Patients typically present with autonomous hormonal overproduction and/or a large abdominal mass. Hormonal assays and medical imaging can be diagnostic, but urinary steroid profiling might be a more sensitive technique to assess malignancy in adrenal tumours. The stage of the disease at diagnosis is the most important prognostic factor. The current staging system needs refinement, especially to separate aggressive from indolent disease in stage IV patients and to select patients who need adjuvant treatment after complete surgical resection. Regarding the latter, assessing the proliferation index Ki-67 seems the best tool currently available. Genomic profiling is expected to become of clinical relevance in the future. Medical therapy is centred on the adrenolytic drug mitotane, which carries considerable toxicity and is not easy to manage. Its tolerability and long plasma level build-up phase may be improved by therapeutic drug monitoring based on pharmacokinetic modelling and intensive counselling of patients. Current chemotherapy regimens can offer disease stabilization in about 50% of patients, but an objective response should be expected in <25%. Research on targeted therapy and immunotherapy is difficult in this rare disease with often heavily pre-treated patients and has not yet been successful. Quality of care should be ensured by treating patients in centres with established experience in multidisciplinary oncologic care, who adhere to prevailing guidelines and state-of-the-art in diagnostic and treatment concepts. International collaboration in fundamental research and clinical trials is the key to further elucidate the pathogenesis and to improve patient care.
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Affiliation(s)
- T M A Kerkhofs
- Department of Internal MedicineMaxima Medical Center, Ds. Th. Fliednerstraat 1, 5631 BM Eindhoven/Veldhoven, The NetherlandsDivision of General Internal MedicineDepartment of Internal Medicine, Maastricht University Medical Centre+, Maastricht, The NetherlandsDepartment of Health Services Research and CAPHRI School for Public Health and Primary CareMaastricht University Medical Center, The Netherlands
| | - M H T Ettaieb
- Department of Internal MedicineMaxima Medical Center, Ds. Th. Fliednerstraat 1, 5631 BM Eindhoven/Veldhoven, The NetherlandsDivision of General Internal MedicineDepartment of Internal Medicine, Maastricht University Medical Centre+, Maastricht, The NetherlandsDepartment of Health Services Research and CAPHRI School for Public Health and Primary CareMaastricht University Medical Center, The Netherlands
| | - I G C Hermsen
- Department of Internal MedicineMaxima Medical Center, Ds. Th. Fliednerstraat 1, 5631 BM Eindhoven/Veldhoven, The NetherlandsDivision of General Internal MedicineDepartment of Internal Medicine, Maastricht University Medical Centre+, Maastricht, The NetherlandsDepartment of Health Services Research and CAPHRI School for Public Health and Primary CareMaastricht University Medical Center, The Netherlands
| | - H R Haak
- Department of Internal MedicineMaxima Medical Center, Ds. Th. Fliednerstraat 1, 5631 BM Eindhoven/Veldhoven, The NetherlandsDivision of General Internal MedicineDepartment of Internal Medicine, Maastricht University Medical Centre+, Maastricht, The NetherlandsDepartment of Health Services Research and CAPHRI School for Public Health and Primary CareMaastricht University Medical Center, The Netherlands Department of Internal MedicineMaxima Medical Center, Ds. Th. Fliednerstraat 1, 5631 BM Eindhoven/Veldhoven, The NetherlandsDivision of General Internal MedicineDepartment of Internal Medicine, Maastricht University Medical Centre+, Maastricht, The NetherlandsDepartment of Health Services Research and CAPHRI School for Public Health and Primary CareMaastricht University Medical Center, The Netherlands Department of Internal MedicineMaxima Medical Center, Ds. Th. Fliednerstraat 1, 5631 BM Eindhoven/Veldhoven, The NetherlandsDivision of General Internal MedicineDepartment of Internal Medicine, Maastricht University Medical Centre+, Maastricht, The NetherlandsDepartment of Health Services Research and CAPHRI School for Public Health and Primary CareMaastricht University Medical Center, The Netherlands
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Abstract
Adrenocortical carcinoma frequently presents with sequelae of steroid precursor overproduction and has a proclivity for aggressive local growth, early metastasis, and recurrence. En bloc surgical resection with negative margins is the cornerstone of therapy for localized disease, and re-resection has a role in selected recurrent cases. Presence of occult micrometastatic disease at the time of presentation is confirmed by frequent distant failure after apparent negative margin resection. Data for many aspects of therapy are limited or nonexistent. This review critically considers existing evidence with a particular focus on surgical management.
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Loncar Z, Djukic V, Zivaljevic V, Pekmezovic T, Diklic A, Tatic S, Dundjerovic D, Olujic B, Slijepcevic N, Paunovic I. Survival and prognostic factors for adrenocortical carcinoma: a single institution experience. BMC Urol 2015; 15:43. [PMID: 26013141 PMCID: PMC4443614 DOI: 10.1186/s12894-015-0038-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 05/19/2015] [Indexed: 12/24/2022] Open
Abstract
Background Adrenocortical carcinoma (ACC) is aggressive, but rare tumours that have not been sufficiently studied. The aim of our study was to present the demographic and clinical characteristics of patients with ACC, to determine the overall survival rates, analyse the effect of prognostic factors on survival, as well as to identify favorable and unfavourable predictors of survival. Method The study included 72 patients (42 women and 30 men) with ACC. We analysed the prognostic value of the demographic and clinical characteristics of the patients, tumour characteristics, therapy administered and survival rates. Kaplan-Meier survival curves and the log-rank test were used to estimate the overall and specific survival probabilities and the Cox regression model was used to identify independent prognostic factors for survival. Results The patients had mean age of 50 years. The 1-, 5-, and 10-year probabilities of survival in patients with ACC were 52.5 %, 41.1 %, and 16.4 %, respectively. The median survival time was 36 months. The results of multivariate Cox regression analysis showed that the presence of lymphatic metastases (HR = 7.37, 95 % CI = 2.31-23.48, p = 0.001) and therapy with mitotane (HR = 0.11, 95 % CI = 0.04-0.27, p = 0.001) were independent prognostic factors for survival. Conclusion The presence of lymphatic metastasis is an unfavourable prognostic factor, while postoperative therapy with mitotane is a favorable prognostic factor for survival in patients with ACC.
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Affiliation(s)
- Zlatibor Loncar
- Emergency Centre, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Pasterova 2, 11000, Belgrade, Serbia.
| | - Vladimir Djukic
- Emergency Centre, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Pasterova 2, 11000, Belgrade, Serbia.
| | - Vladan Zivaljevic
- Centre for Endocrine Surgery, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Pasterova 2, 11000, Belgrade, Serbia.
| | - Tatjana Pekmezovic
- Institute of Epidemiology, Faculty of Medicine, University of Belgrade, Visegradska 26A, Belgrade, 11000, Serbia.
| | - Aleksandar Diklic
- Centre for Endocrine Surgery, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Pasterova 2, 11000, Belgrade, Serbia.
| | - Svetislav Tatic
- Institute of Pathology, Faculty of Medicine, University of Belgrade, Dr Subotica 1, 11000, Belgrade, Serbia.
| | - Dusko Dundjerovic
- Institute of Pathology, Faculty of Medicine, University of Belgrade, Dr Subotica 1, 11000, Belgrade, Serbia.
| | - Branislav Olujic
- Emergency Centre, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Pasterova 2, 11000, Belgrade, Serbia.
| | - Nikola Slijepcevic
- Centre for Endocrine Surgery, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Pasterova 2, 11000, Belgrade, Serbia.
| | - Ivan Paunovic
- Centre for Endocrine Surgery, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Pasterova 2, 11000, Belgrade, Serbia.
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