Adrenocortical Carcinoma: Impact of Surgical Margin Status on Long-Term Outcomes.
BACKGROUND
The influence of surgical margin status on long-term outcomes of patients undergoing adrenal resection for ACC remains not well defined. We studied the impact of surgical tumor margin status on recurrence-free survival (RFS) and overall survival (OS) of patients undergoing resection for ACC.


METHODS
A total of 165 patients who underwent adrenal resection for ACC and met inclusion criteria were identified form a multi-institutional database. Clinicopathological data, pathologic margin status, and long-term outcomes were assessed. Patients were stratified into two groups based on margin status: R0 (margin >1 mm) versus R1.


RESULTS
R0 resection was achieved in 126 patients (76.4 %), whereas 39 patients (23.6 %) had an R1 resection. Median and 5-year OS for patients undergoing R0 resection were 96.3 months and 64.8 % versus 25.1 months and 33.8 % for patients undergoing an R1 resection (both p < 0.001). On multivariable analysis, surgical margin status was an independent predictor of worse OS (hazard ratio [HR] 2.22, 95 % confidence interval [CI] 1.03-4.77; p = 0.04). The incidence of recurrence also differed between the two groups; 5-year RFS was 30.3 % among patients with an R0 resection versus 13.8 % among patients who had an R1 resection (p = 0.03). Lymph node metastasis (N1) was an independent predictor of RFS (HR 2.70, 95 % CI 1.04-6.99; p = 0.04).


CONCLUSIONS
A positive margin after ACC resection was associated with worse long-term survival. Patient selection and an emphasis on surgical technique to achieve R0 margins are pivotal to optimizing the best chance for long-term outcome among patients with ACC.
Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Georgios Antonios
GA
Margonis
Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Yuhree
Y
Kim
Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Jason D
JD
Prescott
Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA.
Thuy B
TB
Tran
Department of Surgery, Emory University, Atlanta, GA, USA.
Lauren M
LM
Postlewait
Department of Surgery, Emory University, Atlanta, GA, USA.
Shishir K
SK
Maithel
Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.
Tracy S
TS
Wang
Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.
Douglas B
DB
Evans
Department of Surgery, New York University School of Medicine, New York, NY, USA.
Ioannis
I
Hatzaras
Department of Surgery, New York University School of Medicine, New York, NY, USA.
Rivfka
R
Shenoy
Department of Surgery, The Ohio State University, Columbus, OH, USA.
John E
JE
Phay
Department of Surgery, The Ohio State University, Columbus, OH, USA.
Kara
K
Keplinger
Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA.
Ryan C
RC
Fields
Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA.
Linda X
LX
Jin
Department of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
Sharon M
SM
Weber
Department of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
Ahmed
A
Salem
Department of Surgery, University of California San Diego, San Diego, CA, USA.
Jason K
JK
Sicklick
Department of Surgery, University of California San Diego, San Diego, CA, USA.
Shady
S
Gad
Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA.
Adam C
AC
Yopp
Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA.
John C
JC
Mansour
Department of Surgery, University of California San Francisco, San Francisco, CA, USA.
Quan-Yang
QY
Duh
Department of Surgery, University of California San Francisco, San Francisco, CA, USA.
Natalie
N
Seiser
Department of Surgery, Vanderbilt University, Nashville, TN, USA.
Carmen C
CC
Solorzano
Department of Surgery, Vanderbilt University, Nashville, TN, USA.
Colleen M
CM
Kiernan
Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA.
Konstantinos I
KI
Votanopoulos
Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA.
Edward A
EA
Levine
Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA.
George A
GA
Poultsides
Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA. tpawlik1@jhmi.edu.
Timothy M
TM
Pawlik
D000306:Adrenal Cortex Neoplasms / Q000473:pathology* / Q000601:surgery*; D018268:Adrenocortical Carcinoma / Q000473:pathology* / Q000601:surgery*; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000473:pathology* / Q000601:surgery*; D009367:Neoplasm Staging; D011183:Postoperative Complications; D011379:Prognosis; D015996:Survival Rate