Patterns of Lymph Node Recurrence in Adrenocortical Carcinoma: Possible Implications for Primary Surgical Treatment

Abstract

Background

In the surgical treatment of adrenocortical carcinoma (ACC), lymphadenectomy may improve oncologic outcome. However, patterns of metastatic lymphatic spread in ACC are unknown.

Methods

Clinical data of patients included in the European Network for the Study of Adrenal Tumors (ENSAT) registry were retrospectively reviewed. Inclusion criteria were: nonmetastatic ACC, complete resection of the primary tumor, a disease-free time of > 3 months, and lymph node metastases as the first disease relapse. The retroperitoneal lymphatic drainage area was evaluated by using follow-up imaging.

Results

Of 971 patients from the ENSAT registry, 56 patients were included. In left-sided ACC (n = 36), lymphatic recurrence was detected in the left renal hilum (50%), in the perirenal fat tissue cranial to the renal hilum (ventral, 47%; dorsal, 55%), para-aortic (47%), interaorto-caval (22%), and/or in the perirenal fat tissue caudal to the renal hilum (ventral, 20%; dorsal, 17%). In right-sided ACC (n = 20), lymph node metastases were detected in the perirenal fat tissue cranial to the renal hilum (dorsal, 55%; ventral, 45%), interaorto-caval (35%), in the area of the right renal artery (10%), and/or paracaval (15%). Patients with right-sided ACC showed left-paraaortic lymph node recurrences in 10% of cases.

Conclusion

Metastatic lymphatic spread appears to be more extensive than previously thought. The distribution pattern of lymph node metastases described in our study could be used as a guide for a more extended lymph node dissection.

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References

  1. 1.

    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.

    Article  PubMed  Google Scholar 

  2. 2.

    Fassnacht M, Kroiss M, Allolio B. Update in adrenocortical carcinoma. J Clin Endocrinol Metab. 2013;98:4551–64.

    Article  CAS  PubMed  Google Scholar 

  3. 3.

    Else T, Kim AC, Sabolch A, et al. Adrenocortical carcinoma. Endocr Rev. 2014;35:282–326.

    Article  CAS  PubMed  Google Scholar 

  4. 4.

    Berruti A, Fassnacht M, Haak H, et al. Prognostic role of overt hypercortisolism in completely operated patients with adrenocortical cancer. Eur Urol. 2014;65:832–38.

    Article  CAS  PubMed  Google Scholar 

  5. 5.

    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.

    Article  PubMed  Google 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.

    Article  CAS  PubMed  Google Scholar 

  7. 7.

    Schulick RD, Brennan MF. Long-term survival after complete resection and repeat resection in patients with adrenocortical carcinoma. Ann Surg Oncol. 1999;6:719–26.

    Article  CAS  PubMed  Google Scholar 

  8. 8.

    Berruti A, Baudin E, Gelderblom H, et al. Adrenal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2012;23 Suppl 7:vii131–138.

  9. 9.

    Zini L, Porpiglia F, Fassnacht M. Contemporary management of adrenocortical carcinoma. Eur Urol. 2011;60:1055–65.

    Article  PubMed  Google Scholar 

  10. 10.

    Porpiglia F, Fiori C, Daffara FC, et al. Does nephrectomy during radical adrenalectomy for stage II adrenocortical cancer affect patient outcome? J Endocrinol Invest. 2016;39:465–71.

    Article  CAS  PubMed  Google Scholar 

  11. 11.

    Vanbrugghe C, Lowery AJ, Golffier C, Taieb D, Sebag F. Adrenocortical carcinoma surgery-surgical extent and approach. Langenbecks Arch Surg. 2016;401:991–7.

    Article  CAS  PubMed  Google Scholar 

  12. 12.

    Dy BM, Strajina V, Cayo AK, et al. Surgical resection of synchronously metastatic adrenocortical cancer. Ann Surg Oncol. 2015;22:146–51.

    Article  PubMed  Google Scholar 

  13. 13.

    Reibetanz J, Jurowich C, Erdogan I, et al. Impact of lymphadenectomy on the oncologic outcome of patients with adrenocortical carcinoma. Ann Surg. 2012;255:363–9.

    Article  PubMed  Google Scholar 

  14. 14.

    Fassnacht M, Dekkers OM, Else T, et al. 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.

    Article  CAS  PubMed  Google Scholar 

  15. 15.

    Gaujoux S, Brennan MF. Recommendation for standardized surgical management of primary adrenocortical carcinoma. Surgery. 2012;152:123–32.

    Article  PubMed  Google Scholar 

  16. 16.

    Koschker AC, Fassnacht M, Hahner S, Weismann D, Allolio B. Adrenocortical carcinoma: improving patient care by establishing new structures. Exp Clin Endocrinol Diabetes. 2006;114:45–51.

    Article  CAS  PubMed  Google Scholar 

  17. 17.

    Beuschlein F, Weigel J, Saeger W, et al. Major prognostic role of Ki67 in localized adrenocortical carcinoma after complete resection. J Clin Endocrinol Metab. 2015;100:841–49.

    Article  CAS  PubMed  Google Scholar 

  18. 18.

    Fassnacht M, Hahner S, Polat B, et al. Efficacy of adjuvant radiotherapy of the tumor bed on local recurrence of adrenocortical carcinoma. J Clin Endocrinol Metab. 2006;91:4501–04.

    Article  CAS  PubMed  Google Scholar 

  19. 19.

    Sabolch A, Feng M, Griffith K, Hammer G, Doherty G, Ben-Josef E. Adjuvant and definitive radiotherapy for adrenocortical carcinoma. Int J Radiat Oncol Biol Phys. 2011;80:1477–84.

    Article  PubMed  Google Scholar 

  20. 20.

    Bellantone R, Ferrante A, Boscherini M, et al. Role of reoperation in recurrence of adrenal cortical carcinoma: results from 188 cases collected in the Italian National Registry for Adrenal Cortical Carcinoma. Surgery. 1997;122:1212–8.

    Article  CAS  PubMed  Google Scholar 

  21. 21.

    Kendrick ML, Lloyd R, Erickson L, et al. Adrenocortical carcinoma: surgical progress or status quo? Arch Surg. 2001;136:543–9.

    Article  CAS  PubMed  Google Scholar 

  22. 22.

    Panjwani S, Moore MD, Gray KD, et al. The Impact of Nodal Dissection on Staging in Adrenocortical Carcinoma. Ann Surg Oncol. 2017;24:3617–23.

    Article  PubMed  Google Scholar 

  23. 23.

    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;104:358–76.

    Article  CAS  PubMed  Google Scholar 

  24. 24.

    Polat B, Fassnacht M, Pfreundner L, et al. Radiotherapy in adrenocortical carcinoma. Cancer. 2009;115:2816–23.

    Article  PubMed  Google Scholar 

  25. 25.

    Brix D, Allolio B, Fenske W, et al. Laparoscopic versus open adrenalectomy for adrenocortical carcinoma: surgical and oncologic outcome in 152 patients. Eur Urol. 2010;58:609–15.

    Article  PubMed  Google Scholar 

  26. 26.

    Porpiglia F, Fiori C, Daffara F, et al. Retrospective evaluation of the outcome of open versus laparoscopic adrenalectomy for stage I and II adrenocortical cancer. Eur Urol. 2010;57:873–8.

    Article  PubMed  Google Scholar 

  27. 27.

    Jurowich C, Fassnacht M, Kroiss M, Deutschbein T, Germer CT, Reibetanz J. Is there a role for laparoscopic adrenalectomy in patients with suspected adrenocortical carcinoma? A critical appraisal of the literature. Horm Metab Res. 2013;45:130–6.

    Article  CAS  PubMed  Google Scholar 

  28. 28.

    Langenhuijsen J, Birtle A, Klatte T, Porpiglia F, Timsit MO. Surgical management of adrenocortical carcinoma: impact of laparoscopic approach, lymphadenectomy, and surgical volume on outcomes-a systematic review and meta-analysis of the current literature. Eur Urol Focus. 2016;1:241–50.

    Article  PubMed  Google Scholar 

  29. 29.

    Gerry JM, Tran TB, Postlewait LM, et al. Lymphadenectomy for adrenocortical carcinoma: is there a therapeutic benefit? Ann Surg Oncol. 2016;23:708–13.

    Article  PubMed  PubMed Central  Google Scholar 

  30. 30.

    Saade N, Sadler C, Goldfarb M. Impact of regional lymph node dissection on disease specific survival in adrenal cortical carcinoma. Horm Metab Res. 2015;47:820–5.

    Article  CAS  PubMed  Google Scholar 

  31. 31.

    Nilubol N, Patel D, Kebebew E. Does lymphadenectomy improve survival in patients with adrenocortical carcinoma? A population-based study. World J Surg. 2016;40:697–705.

    Article  PubMed  Google Scholar 

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Acknowledgment

We are very grateful to Michaela Haaf for data management of the local ENSAT ACC Registry. The study was supported by the German Research Foundation (DFG) via an individual Grant to MF (FA 466/4-1/2) and within the CRC/Transregio 205/1 “The Adrenal: Central Relay in Health and Disease” to MK, SH, and MF.

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Correspondence to Joachim Reibetanz MD.

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Reibetanz, J., Rinn, B., Kunz, A.S. et al. Patterns of Lymph Node Recurrence in Adrenocortical Carcinoma: Possible Implications for Primary Surgical Treatment. Ann Surg Oncol 26, 531–538 (2019). https://doi.org/10.1245/s10434-018-6999-z

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Keywords

  • Lymphatic Recurrence
  • Adrenocortical Carcinoma (ACC)
  • European Network For The Study Of Adrenal Tumors (ENSAT)
  • Renal Hilum
  • Lymphatic Metastatic Spread