J. Passman1, W. Amjad1, J. M. Soegaard Ballester1, S. P. Ginzberg1, H. Wachtel1,2 1Hospital Of The University Of Pennsylvania, Department Of Surgery, Philadelphia, PA, USA 2University Of Pennsylvania, Philadelphia, PA, USA
Introduction: Adrenocortical carcinoma (ACC) is an aggressive cancer with a dismal prognosis. As chemotherapy and radiation are ineffective, surgery remains the mainstay of treatment. En-bloc resection of adjacent organs and use of regional lymphadenectomy have been advocated to improve outcomes, however there is conflicting evidence for these surgical strategies. In this study, we assess the association between extent of surgical resection and survival in ACC.
Methods: We performed a retrospective cohort study of all subjects who underwent surgical intervention for non-metastatic ACC between 2004–2019 utilizing the National Cancer Database. Subjects who underwent partial or total adrenalectomy were compared to those who underwent en-bloc multi-organ resection using Chi-squared tests, Student’s t-tests, and Wilcoxon rank-sum tests as appropriate. Cox proportional-hazards regression was used to create univariate and multivariate models assessing association between subject and tumor characteristics, resection approach and extent, and overall survival.
Results: We identified 2,668 subjects who underwent surgical resection for non-metastatic ACC. The mean age was 54±15 years. The majority were female (60.9%) and White (86.3%). Subjects were primarily Stage 2 (47.0%) and Stage 3 (42.2%) at presentation. Stratified by extent of resection, subjects undergoing radical resection were more commonly male (46.3% vs. 37.7%, p=0.001) and presented more frequently with Stage 3 ACC (p<0.0001). Median survival for subjects undergoing radical resection was significantly shorter at 48.2 vs. 77.0 months for subjects undergoing adrenalectomy alone (Fig. 1). Univariate Cox proportional-hazard modeling identified age > 70 years (HR: 1.97, 95% CI: 1.524- 2.542, p<0.001), multiple comorbidities (HR: 1.67, 95% CI: 1.21-2.31, p=0.002), Stage 3 at presentation (HR: 2.38, 95% CI: 1.76-3.23, p<0.001), lymphadenectomy (HR: 1.26, 95% CI: 1.03-1.54, p=0.025), radical resection (HR: 1.35, 95% CI: 1.17-1.55, p<0.001), and incomplete resection (HR: 1.98, 95% CI: 1.73-2.27, p<0.001) as associated with higher risk of mortality. However, when creating a multivariate model, only age > 70 years (HR: 3.09, 95% CI: 1.66-5.74, p<0.001), Stage 3 disease (HR: 3.25, 95% CI: 1.62-6.55, p<0.001), poorly-differentiated tumors (HR: 3.24, 95% CI: 1.31-8.00, p=0.011) and R1 resection (HR: 1.90, 95% CI: 1.32-2.73, p<0.001) were associated with worse survival.
Conclusion: Accounting for tumor biology, we identified no difference in overall survival for subjects with non-metastatic ACC by operative approach, utilization of lymphadenectomy, or extent of resection. Tumor biology and achieving negative surgical margins appear to be the primary determinants of survival in ACC.
