Surgical management of metastatic adrenocortical carcinoma: Is there a role for multivisceral resection?

Abstract

Recent data suggest that cytoreductive surgery in metastatic adrenocortical carcinoma) may improve survival. However, successful removal of locally invasive primary tumors in such patients may require complex en bloc and/or multivisceral resection, for which the survival benefits remain unclear. We retrospectively analyzed 153 patients with metastatic adrenocortical carcinoma treated at our institution from 1998 to 2024. Patients were categorized into 3 groups based on treatment approach: multivisceral resection, adrenalectomy alone, and nonoperative management. Kaplan-Meier analysis and Cox proportional hazards models were used to evaluate overall survival across these groups. Among 153 patients (52% female; median age 49 years, interquartile range: 36-59 years), 24% underwent multivisceral resection, 18% had adrenalectomy alone, and 58% were managed nonoperatively. Overall, 68% of tumors were functional. The most frequent metastatic sites were the lung (71%) and liver (66%). The most frequent en bloc procedures included radical nephrectomy (64%) and partial hepatectomy (47%). The median overall survival was 33 months after multivisceral resection, 22 months after adrenalectomy alone, and 7 months with nonoperative management (P < .0001). On multivariable analysis, multivisceral resection (hazards ratio = 0.31, 95% confidence interval: 0.18-0.50, P < .0001) and adrenalectomy alone (hazards ratio = 0.50, 95% confidence interval: 0.28-0.88, P = .017) were independently associated with longer overall survival compared with nonoperative management. Cytoreductive surgery, including multivisceral resection, may be associated with improved survival in metastatic adrenocortical carcinoma compared with nonoperative management. However, given the potential risks of these complex operations, they should be judiciously performed in select patients by experienced multidisciplinary teams.