Annals of Surgical Oncology

, Volume 25, Issue 5, pp 1425–1431 | Cite as

Impact of Micro- and Macroscopically Positive Surgical Margins on Survival after Resection of Adrenocortical Carcinoma

  • Kevin L. AndersonJr.
  • Mohamed A. Adam
  • Samantha M. Thomas
  • Linda Youngwirth
  • Michael T. Stang
  • Randall P. Scheri
  • Sanziana A. Roman
  • Julie A. Sosa
Endocrine Tumors
  • 76 Downloads

Abstract

Purpose

Adrenocortical carcinoma (ACC) is a rare, aggressive cancer; complete surgical resection offers the best chance for long-term survival. The impact of surgical margin status on survival is poorly understood. Our objective was to determine the association of margin status with survival.

Methods

Patients with ACC were identified from the National Cancer Data Base, 1998–2012, and stratified based on surgical margin status (negative vs. microscopically positive [+] vs. macroscopically [+]). Univariate/multivariate regression/survival analyses were utilized to determine factors associated with margin status and overall survival (OS).

Results

A total of 1553 patients underwent surgery at 589 institutions: 86% had negative, 12% microscopically (+), and 2% macroscopically (+) margins. Those with microscopically (+) and macroscopically (+) margins more often received adjuvant chemotherapy (39.4% macroscopically (+) vs. 38.5% microscopically (+) vs. 25.2% negative margins, p < 0.001). For unadjusted analysis, there was a significant difference in OS between the groups (log-rank p < 0.001), with median survival times of 58 months (95% confidence interval [CI] 49–66) for those with negative margins, 22 months (95% CI 18–34) microscopically (+), and 14 months (95% CI 6–27) macroscopically (+) margins. After adjustment, both microscopically (+) (HR 1.76, p < 0.001) and macroscopically (+) (HR 2.10, p = 0.0019) margin status were associated with compromised survival.

Conclusions

Having micro- or macroscopically (+) margin status after ACC resection is associated with dose-dependent compromised survival. These results underscore the importance of achieving negative surgical margins for optimizing long-term patient outcomes.

Notes

Acknowledgment

This research was supported by a NIH TL-1 clinical and translational science award (CTSA), Grant number 1UL1-TR001117-01 (NCATS). J. A. S. is a member of the data monitoring committee of the Medullary Thyroid Cancer Consortium Registry supported by NovoNordisk, GlaxoSmithKline, Astra Zeneca, and Eli Lilly. The other authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.

References

  1. 1.
    Livhits M, Li N, Yeh MW, Harari A. Surgery is associated with improved survival for adrenocortical cancer, even in metastatic disease. Surgery. 2014;156:1531–40; discussion 1540-1.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Fassnacht M, Johanssen S, Quinkler M, et al. Limited prognostic value of the 2004 International Union Against Cancer staging classification for adrenocortical carcinoma: proposal for a Revised TNM Classification. Cancer. 2009;115:243–50.CrossRefPubMedGoogle Scholar
  3. 3.
    Gratian L, Pura J, Dinan M, et al. Treatment patterns and outcomes for patients with adrenocortical carcinoma associated with hospital case volume in the United States. Ann Surg Oncol. 2014;21:3509–14.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Grubbs EG, Callender GG, Xing Y, et al. Recurrence of adrenal cortical carcinoma following resection: surgery alone can achieve results equal to surgery plus mitotane. Ann Surg Oncol. 2010;17:263–70.CrossRefPubMedGoogle Scholar
  5. 5.
    Dackiw AP, Lee JE, Gagel RF, Evans DB. Adrenal cortical carcinoma. World J Surg. 2001;25:914-26.CrossRefPubMedGoogle Scholar
  6. 6.
    Lee JE, Berger DH, el-Naggar AK, et al. Surgical management, DNA content, and patient survival in adrenal cortical carcinoma. Surgery. 1995;118:1090–8.CrossRefPubMedGoogle Scholar
  7. 7.
    Mihai R: diagnosis, treatment and outcome of adrenocortical cancer. Br J Surg. 2015;102:291–306.CrossRefPubMedGoogle Scholar
  8. 8.
    Ayala-Ramirez M, Jasim S, Feng L, et al. Adrenocortical carcinoma: clinical outcomes and prognosis of 330 patients at a tertiary care center. Eur J Endocrinol. 2013;169:891–9.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Ronchi CL, Kroiss M, Sbiera S, et al. EJE prize 2014: current and evolving treatment options in adrenocortical carcinoma: where do we stand and where do we want to go? Eur J Endocrinol. 2014;171:R1–11.CrossRefPubMedGoogle Scholar
  10. 10.
    Bilimoria KY, Shen WT, Elaraj D, et al. Adrenocortical carcinoma in the United States: treatment utilization and prognostic factors. Cancer. 2008;113:3130–6.CrossRefPubMedGoogle Scholar
  11. 11.
    Kendrick ML, Lloyd R, Erickson L, et al. Adrenocortical carcinoma: surgical progress or status quo? Arch Surg. 2001;136:543–9.Google Scholar
  12. 12.
    Abdel-Wahab M, El-Husseiny TS, El Hanafy E, et al. Prognostic factors affecting survival and recurrence after hepatic resection for hepatocellular carcinoma in cirrhotic liver. Langenbeck’s Arch Surg. 2010;395:625–32.CrossRefGoogle Scholar
  13. 13.
    de Haas RJ, Wicherts DA, Flores E, et al. R1 resection by necessity for colorectal liver metastases: is it still a contraindication to surgery? Ann Surg. 2008;248:626–37.PubMedGoogle Scholar
  14. 14.
    Margonis GA, Spolverato G, Kim Y, et al. Intraoperative surgical margin re-resection for colorectal liver metastasis: is it worth the effort? J Gastrointest Surg. 2015;19:699–707.CrossRefPubMedGoogle Scholar
  15. 15.
    Else T, Williams AR, Sabolch A, et al. Adjuvant therapies and patient and tumor characteristics associated with survival of adult patients with adrenocortical carcinoma. J Clin Endocrinol Metab. 2014;99:455–61.CrossRefPubMedGoogle Scholar
  16. 16.
    Loncar Z, Djukic V, Zivaljevic V, et al. Survival and prognostic factors for adrenocortical carcinoma: a single institution experience. BMC Urol. 2015;15:43.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Wanis KN, Kanthan R: Diagnostic and prognostic features in adrenocortical carcinoma: a single institution case series and review of the literature. World J Surg Oncol. 2015;13:117.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Margonis GA, Kim Y, Prescott JD, et al. Adrenocortical carcinoma: impact of surgical margin status on long-term outcomes. Ann Surg Oncol. 2016;23:134–41.CrossRefPubMedGoogle Scholar
  19. 19.
    Raval MV, Bilimoria KY, Stewart AK, et al. Using the NCDB for cancer care improvement: an introduction to available quality assessment tools. Journal of surgical oncology 2009;99:488–90.CrossRefPubMedGoogle Scholar
  20. 20.
    Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol. 1992;45:613–9.CrossRefPubMedGoogle Scholar
  21. 21.
    Miller BS, Doherty GM. Surgical management of adrenocortical tumours. Nat Rev Endocrinol. 2014;10:282–92.CrossRefPubMedGoogle Scholar
  22. 22.
    Ip JC, Pang TC, Glover AR, et al. Improving outcomes in adrenocortical cancer: an Australian perspective. Ann Surg Oncol. 2015;22:2309–16.CrossRefPubMedGoogle Scholar
  23. 23.
    Amini N, Margonis GA, Kim Y, et al. Curative resection of adrenocortical carcinoma: rates and patterns of postoperative recurrence. Ann Surg Oncol. 2016;23:126–33.CrossRefPubMedGoogle Scholar

Copyright information

© Society of Surgical Oncology 2018

Authors and Affiliations

  • Kevin L. AndersonJr.
    • 1
  • Mohamed A. Adam
    • 2
  • Samantha M. Thomas
    • 3
    • 4
  • Linda Youngwirth
    • 2
  • Michael T. Stang
    • 1
    • 2
    • 4
  • Randall P. Scheri
    • 1
    • 2
    • 4
  • Sanziana A. Roman
    • 1
    • 2
    • 4
  • Julie A. Sosa
    • 1
    • 2
    • 4
    • 5
  1. 1.Duke University School of MedicineDurhamUSA
  2. 2.Department of SurgeryDuke University School of MedicineDurhamUSA
  3. 3.Department of Biostatistics and BioinformaticsDuke University School of MedicineDurhamUSA
  4. 4.Duke Cancer InstituteDurhamUSA
  5. 5.Duke Clinical Research InstituteDurhamUSA

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