title: Nomograms to Predict Recurrence-Free and Overall Survival After Curative Resection of Adrenocortical Carcinoma.
abstract: OBJECTIVE
  Adrenocortical carcinoma (ACC) is a rare but aggressive endocrine tumor, and the prognostic factors associated with long-term outcomes after surgical resection remain poorly defined.
  
  
  OBJECTIVE
  To define clinicopathological variables associated with recurrence-free survival (RFS) and overall survival (OS) after curative surgical resection of ACC and to propose nomograms for individual risk prediction.
  
  
  METHODS
  Nomograms to predict RFS and OS after surgical resection of ACC were proposed using a multi-institutional cohort of patients who underwent curative-intent surgery for ACC at 13 major institutions in the United States between March 17, 1994, and December 22, 2014. The dates of our study analysis were April 15, 2015, to May 12, 2015.
  
  
  METHODS
  The discriminative ability and calibration of the nomograms to predict RFS and OS were tested using C statistics, calibration plots, and Kaplan-Meier curves.
  
  
  RESULTS
  In total, 148 patients who underwent surgery for ACC were included in the study. The median patient age was 53 years, and 65.5% (97 of 148) of the patients were female. One-third of the patients (35.1% [52 of 148]) had a functional tumor, and the median tumor size was 11.2 cm. Most patients (77.7% [115 of 148]) underwent R0 resection, and 8.8% (13 of 148) of the patients had N1 disease. Using backward stepwise selection of clinically important variables with the Akaike information criterion, the following variables were incorporated in the prediction of RFS: tumor size of at least 12 cm (hazard ratio [HR], 3.00; 95% CI, 1.63-5.70; P < .001), positive nodal status (HR, 4.78; 95% CI, 1.47-15.50; P = .01), stage III/IV (HR, 1.80; 95% CI, 0.95-3.39; P = .07), cortisol-secreting tumor (HR, 2.38; 95% CI, 1.27-4.48; P = .01), and capsular invasion (HR, 1.96; 95% CI, 1.02-3.74; P = .04). Factors selected as predicting OS were tumor size of at least 12 cm (HR, 1.78; 95% CI, 1.00-3.17; P = .05), positive nodal status (HR, 5.89; 95% CI, 2.05-16.87; P = .001), and R1 margin (HR, 2.83; 95% CI, 1.51-5.30; P = .001). The discriminative ability and calibration of the nomograms revealed good predictive ability as indicated by the C statistics (0.74 for RFS and 0.70 for OS).
  
  
  CONCLUSIONS
  Independent predictors of survival and recurrence risk after curative-intent surgery for ACC were selected to create nomograms predicting RFS and OS. The nomograms were able to stratify patients into prognostic groups and performed well on internal validation.
authors.affiliation: Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Yuhree
authors.initials: Y
authors.lastname: Kim
authors.affiliation: Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Georgios A
authors.initials: GA
authors.lastname: Margonis
authors.affiliation: Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Jason D
authors.initials: JD
authors.lastname: Prescott
authors.affiliation: Department of Surgery, Stanford University School of Medicine, Stanford, California.
authors.forename: Thuy B
authors.initials: TB
authors.lastname: Tran
authors.affiliation: Department of Surgery, Emory University, Atlanta, Georgia.
authors.forename: Lauren M
authors.initials: LM
authors.lastname: Postlewait
authors.affiliation: Department of Surgery, Emory University, Atlanta, Georgia.
authors.forename: Shishir K
authors.initials: SK
authors.lastname: Maithel
authors.affiliation: Department of Surgery, Medical College of Wisconsin, Milwaukee.
authors.forename: Tracy S
authors.initials: TS
authors.lastname: Wang
authors.affiliation: Department of Surgery, Medical College of Wisconsin, Milwaukee.
authors.forename: Douglas B
authors.initials: DB
authors.lastname: Evans
authors.affiliation: Department of Surgery, New York University School of Medicine, New York.
authors.forename: Ioannis
authors.initials: I
authors.lastname: Hatzaras
authors.affiliation: Department of Surgery, New York University School of Medicine, New York.
authors.forename: Rivfka
authors.initials: R
authors.lastname: Shenoy
authors.affiliation: Department of Surgery, The Ohio State University, Columbus.
authors.forename: John E
authors.initials: JE
authors.lastname: Phay
authors.affiliation: Department of Surgery, The Ohio State University, Columbus.
authors.forename: Kara
authors.initials: K
authors.lastname: Keplinger
authors.affiliation: Department of Surgery, Washington University School of Medicine in St Louis, Missouri.
authors.forename: Ryan C
authors.initials: RC
authors.lastname: Fields
authors.affiliation: Department of Surgery, Washington University School of Medicine in St Louis, Missouri.
authors.forename: Linda X
authors.initials: LX
authors.lastname: Jin
authors.affiliation: Department of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison.
authors.forename: Sharon M
authors.initials: SM
authors.lastname: Weber
authors.affiliation: Department of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison.
authors.forename: Ahmed I
authors.initials: AI
authors.lastname: Salem
authors.affiliation: Department of Surgery, University of California, San Diego.
authors.forename: Jason K
authors.initials: JK
authors.lastname: Sicklick
authors.affiliation: Department of Surgery, University of California, San Diego.
authors.forename: Shady
authors.initials: S
authors.lastname: Gad
authors.affiliation: Department of Surgery, University of Texas Southwestern Medical Center, Dallas.
authors.forename: Adam C
authors.initials: AC
authors.lastname: Yopp
authors.affiliation: Department of Surgery, University of Texas Southwestern Medical Center, Dallas.
authors.forename: John C
authors.initials: JC
authors.lastname: Mansour
authors.affiliation: Department of Surgery, University of California, San Francisco.
authors.forename: Quan-Yang
authors.initials: QY
authors.lastname: Duh
authors.affiliation: Department of Surgery, University of California, San Francisco.
authors.forename: Natalie
authors.initials: N
authors.lastname: Seiser
authors.affiliation: Department of Surgery, Vanderbilt University, Nashville, Tennessee.
authors.forename: Carmen C
authors.initials: CC
authors.lastname: Solorzano
authors.affiliation: Department of Surgery, Vanderbilt University, Nashville, Tennessee.
authors.forename: Colleen M
authors.initials: CM
authors.lastname: Kiernan
authors.affiliation: Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina.
authors.forename: Konstantinos I
authors.initials: KI
authors.lastname: Votanopoulos
authors.affiliation: Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina.
authors.forename: Edward A
authors.initials: EA
authors.lastname: Levine
authors.affiliation: Department of Surgery, Stanford University School of Medicine, Stanford, California.
authors.forename: George A
authors.initials: GA
authors.lastname: Poultsides
authors.affiliation: Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Timothy M
authors.initials: TM
authors.lastname: Pawlik
mesh_terms: D000306:Adrenal Cortex Neoplasms / Q000175:diagnosis / Q000401:mortality* / Q000601:surgery; D000315:Adrenalectomy; D018268:Adrenocortical Carcinoma / Q000175:diagnosis / Q000401:mortality* / Q000601:surgery; D000328:Adult; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000453:epidemiology*; D049451:Nomograms; D011184:Postoperative Period; D011379:Prognosis; D015996:Survival Rate / Q000639:trends; D014481:United States / Q000453:epidemiology