Impact of Regional Lymph Node Dissection on Disease Specific Survival in Adrenal Cortical Carcinoma

Abstract

Adrenocortical carcinoma (ACC) is a rare malignancy with a poor prognosis. The purpose of this study is to evaluate the impact of a more extensive regional lymph node dissection (LND) has on survival in ACC patients in the United States. Patients ≥ 15 years of age without distant metastases who underwent surgical intervention for primary ACC were identified from the SEER18 registry from 1988-2009. Patients were divided into 2 groups: having a regional LND (≥ 5 LNs removed) vs. no-LND (0-4 LNs removed). Overall survival (OS) and disease specific survival (DSS) were compared between groups. Of 259 patients with complete data on nodal resection, 243 (93.8%) underwent no-LND and 16 (6.2%) LND. There was no difference in age, sex, metastases, or ENSAT stage between groups. However, LND patients had larger tumors (p=0.004), and more frequently underwent en-bloc surgery (p=0.002). One- and 3-year OS and DSS did not differ between groups. In a cox regression model, performance of a regional LND did not significantly influence DSS. However, female gender (HR: 1.67, CI: 1.04-2.69, p=0.033) and later stage (stage III-HR: 4.78, CI: 1.14-20.00, p=0.032) or positive LNs (HR: 5.92, CI: 2.05-17.08, p=0.001) were risk factors for worse DSS. Regional LND may not improve DSS or OS in nonmetastatic ACC patients undergoing adrenalectomy. It remains controversial as an essential part of the surgical management for ACC and deserves further investigation in a larger, prospective study. However, regional LND should still be considered for staging and prognostic purposes and to standardize surgical care.

Impact of Laparoscopic Adrenalectomy on Overall Survival in Patients with Nonmetastatic Adrenocortical Carcinoma

“…39 However, despite improvements in staging, there is conflicting evidence with regard to improved disease-free survival or recurrence. 39,40 In this analysis, stage III patients appeared to benefit from adjuvant chemotherapy despite historically disappointing treatment results in general. 2 This may reflect advances in single and multiagent chemotherapy that have so far not been reported in such a large group due to the rarity of the malignancy.…”

Lymphadenectomy for Adrenocortical Carcinoma: Is There a Therapeutic Benefit?

“…Three previous studies have utilized the Surveillance, Epidemiology, and End Results (SEER) database to examine the impact of LAD on survival after ACC resection and have provided contradictory results mainly due to their differing inclusion criteria and LAD definition. 7,10,11 No difference in survival was noted when LAD was defined as 4+ nodes removed and all stages were included, or when stage 4 patients were excluded and LAD was defined as 5+ nodes examined. 10,11 However, on a subset analysis of T4M0 tumors, a survival benefit was noted if any lymphadenectomy was performed.…”

Adrenocortical Carcinoma: Impact of Surgical Margin Status on Long-Term Outcomes

“…40,41 The finding that lymph node metastasis had an impact on staging and prognosis is clinically relevant in that lymph node dissection remains a topic of debate among surgeons, because it is not a routine component of radical adrenalectomy. 13,42 For example, only 30 % of patients in our large nationwide collaborative had lymph node sampling performed. In contrast to lymph node metastasis, we did not find an association of patient age, tumor size, or tumor grade with prognosis.…”