July 30, 2022
The recent and rapid evolution of multimodal cancer treatment has contributed substantially to improvements in patient outcomes. New advances in systemic therapy and surgical oncology can prolong survival for aggressive malignancies such as pancreatic, esophageal and gastric cancers.
However, the treatment of adrenocortical carcinoma (ACC) continues to pose significant challenges. ACC is associated with poor outcomes, and little improvement in survival has been seen over decades. The role of systemic therapy is limited, which makes surgical resection the only curative and sometimes salvage option. About 30% of ACC patients present with metastatic disease.
However, the role of surgical resection of metastatic ACC is poorly understood. In the setting of limited treatment options, the role of cytoreduction in metastatic ACC requires further investigation. Alaa Sada, M.D., M.S., surgery resident, at Mayo Clinic in Rochester, Minnesota, says, "Mayo Clinic recently collaborated with the American Australian Asian Adrenal Alliance (A5) in a retrospective multi-institutional study that evaluated the role of cytoreduction surgery of the primary tumor in patients with metastatic ACC."
This study — published in the 2022 edition of The Journal of Clinical Endocrinology and Metabolism — included 239 patients with ENSAT stage IV ACC from nine centers. The patients were grouped into cytoreduction (N = 128) and noncytoreduction (N = 111) groups after propensity score matching based on age and number of organs with metastases (two or fewer versus more than two).
Results
- Over a mean follow-up of 67 months, patients who did not undergo cytoreduction had a greater risk of death than patients who underwent cytoreduction, with a hazard ratio (HR) of 3.18 and 95% confidence interval (CI) of 2.34 to 4.32.
- The median overall survival for patients who underwent cytoreduction was 25 months versus 9 months in the group that did not undergo cytoreduction.
Independent predictors of survival on multivariate analysis included:
- Hormone oversecretion (HR = 2.56; 95% CI, 1.66 to 3.92)
- Age (HR = 1.02; 95% CI, 1.00 to 1.03)
- Local metastasis therapy (HR = 0.41; 95% CI, 0.47 to 0.65) and cytoreductive surgery
Travis J. McKenzie, M.D., Surgery, at Mayo Clinic Rochester, Minnesota, states, "In this study, the 30-day mortality rate after cytoreduction of ACC was 2.3%."
Besides examining resection, this paper highlights the importance of combining multimodal treatments for metastatic ACC. A significant proportion of the cytoreduction group underwent different treatment modalities of both primary and metastatic tumor sites. The combination of cytoreduction along with multimodal nonsurgical treatments of metastatic ACC appears to provide better survival outcomes than nonsurgical treatments.
Irina Bancos, M.D., Endocrinology, Diabetes, Metabolism, and Nutrition, at Mayo Clinic in Rochester, Minnesota, concludes: "This study represents one of the largest international collaborative multi-institutional studies of patients with metastatic ACC, and the findings provide new hope for patients with this serious malignancy. Surgical cytoreduction along with multimodal treatment of ACC needs to be individualized on a case-by-case basis. Further studies are critically needed to evaluate the role of neoadjuvant and adjuvant treatments in this group of patients."
For more information
Srougi V, et al. Cytoreductive surgery of the primary tumor in metastatic adrenocortical carcinoma: impact on patients' survival. The Journal of Clinical Endocrinology and Metabolism. 2022;107:964
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