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A Novel T-Stage Classification System for Adrenocortical Carcinoma: Proposal from the US Adrenocortical Carcinoma Study Group

  • Endocrine Tumors
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

The 7th AJCC T-stage system for adrenocortical carcinoma (ACC), based on size and extra-adrenal invasion, does not adequately stratify patients by survival. Lymphovascular invasion (LVI) is a known poor prognostic factor. We propose a novel T-stage system that incorporates LVI to better risk-stratify patients undergoing resection for ACC.

Method

Patients undergoing curative-intent resections for ACC from 1993 to 2014 at 13 institutions comprising the US ACC Group were included. Primary outcome was disease-specific survival (DSS).

Results

Of the 265 patients with ACC, 149 were included for analysis. The current T-stage system failed to differentiate patients with T2 versus T3 disease (p = 0.10). Presence of LVI was associated with worse DSS versus no LVI (36 mo vs. 168 mo; p = 0.001). After accounting for the individual components of the current T-stage system (size, extra-adrenal invasion), LVI remained a poor prognostic factor on multivariable analysis (hazard ratio 2.14, 95% confidence interval 1.05–4.38, p = 0.04). LVI positivity further stratified patients with T2 and T3 disease (T2: 37 mo vs. median not reached; T3: 36 mo vs. 96 mo; p = 0.03) but did not influence survival in patients with T1 or T4 disease. By incorporating LVI, a new T-stage classification system was created: [T1: ≤ 5 cm, (−)local invasion, (+/−)LVI; T2: > 5 cm, (−)local invasion, (−)LVI OR any size, (+)local invasion, (−)LVI; T3: > 5 cm, (−)local invasion, (+)LVI OR any size, (+)local invasion, (+)LVI; T4: any size, (+)adjacent organ invasion, (+/−)LVI]. Each progressive new T-stage group was associated with worse median DSS (T1: 167 mo; T2: 96 mo; T3: 37 mo; T4: 15 mo; p < 0.001).

Conclusions

Compared with the current T-stage system, the proposed T-stage system, which incorporates LVI, better differentiates T2 and T3 disease and accurately stratifies patients by disease-specific survival. If externally validated, this T-stage classification should be considered for future AJCC staging systems.

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Authors and Affiliations

  1. Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA

    Caroline E. Poorman BA, Cecilia G. Ethun MD, Lauren M. Postlewait MD, Charles A. Staley MD, FACS & Shishir K. Maithel MD, FACS

  2. Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA

    Thuy B. Tran MD & George A. Poultsides MD, FACS

  3. Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Jason D. Prescott MD, PhD & Timothy M. Pawlik MD, MPH, PhD, FACS

  4. Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA

    Tracy S. Wang MD, MPH, FACS & Jason Glenn MD

  5. Department of Surgery, New York University School of Medicine, New York, NY, USA

    Ioannis Hatzaras MD, MPH, FACS & Rivfka Shenoy MD

  6. Department of Surgery, The Ohio State University, Columbus, OH, USA

    John E. Phay MD, FACS & Kara Keplinger MD

  7. Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA

    Ryan C. Fields MD, FACS & Linda X. Jin MD

  8. Department of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA

    Sharon M. Weber MD, FACS & Ahmed Salem MD

  9. Department of Surgery, University of California San Diego, San Diego, CA, USA

    Jason K. Sicklick MD, FACS & Shady Gad MD

  10. Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA

    Adam C. Yopp MD, FACS & John C. Mansour MD, FACS

  11. Department of Surgery, University of California San Francisco, San Francisco, CA, USA

    Quan-Yang Duh MD, FACS & Natalie Seiser MD, PhD

  12. Department of Surgery, Vanderbilt University, Nashville, TE, USA

    Carmen C. Solórzano MD, FACS & Colleen M. Kiernan MD

  13. Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA

    Konstantinos I. Votanopoulos MD, FACS & Edward A. Levine MD, FACS

  14. Division of Surgical Oncology, Winship Cancer Institute, 1365C Clifton Road NE, 2nd Floor, Atlanta, GA, 30322, USA

    Shishir K. Maithel MD, FACS

Authors
  1. Caroline E. Poorman BA
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  2. Cecilia G. Ethun MD
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  3. Lauren M. Postlewait MD
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  4. Thuy B. Tran MD
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  5. Jason D. Prescott MD, PhD
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  6. Timothy M. Pawlik MD, MPH, PhD, FACS
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  7. Tracy S. Wang MD, MPH, FACS
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  8. Jason Glenn MD
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  9. Ioannis Hatzaras MD, MPH, FACS
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  10. Rivfka Shenoy MD
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  11. John E. Phay MD, FACS
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  12. Kara Keplinger MD
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  13. Ryan C. Fields MD, FACS
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  14. Linda X. Jin MD
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  15. Sharon M. Weber MD, FACS
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  16. Ahmed Salem MD
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  17. Jason K. Sicklick MD, FACS
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  18. Shady Gad MD
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  19. Adam C. Yopp MD, FACS
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  20. John C. Mansour MD, FACS
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  21. Quan-Yang Duh MD, FACS
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  22. Natalie Seiser MD, PhD
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  23. Carmen C. Solórzano MD, FACS
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  24. Colleen M. Kiernan MD
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  25. Konstantinos I. Votanopoulos MD, FACS
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  26. Edward A. Levine MD, FACS
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  27. Charles A. Staley MD, FACS
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  28. George A. Poultsides MD, FACS
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  29. Shishir K. Maithel MD, FACS
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Corresponding author

Correspondence to Shishir K. Maithel MD, FACS.

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Poorman, C.E., Ethun, C.G., Postlewait, L.M. et al. A Novel T-Stage Classification System for Adrenocortical Carcinoma: Proposal from the US Adrenocortical Carcinoma Study Group. Ann Surg Oncol 25, 520–527 (2018). https://doi.org/10.1245/s10434-017-6236-1

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