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Repeat Surgery for Recurrent ACC

Management of Recurrent Disease

Repeat surgery for recurrent adrenocortical carcinoma (ACC) refers to resection of locoregional relapse or metachronous metastatic disease after prior adrenalectomy, usually with curative or disease-controlling intent. Within ACC care, it sits under management of recurrent disease and overlaps with metastasis-directed therapy, endocrine oncology, and site-specific surgical oncology for thoracic, hepatobiliary, retroperitoneal, or vascular disease.12 Because recurrence is common even after apparently complete primary resection, repeat surgery remains an important consideration in a subset of patients with anatomically limited recurrent disease.34

The supporting evidence is limited and is derived mainly from retrospective institutional series, registry analyses, systematic reviews of observational data, and case reports rather than randomized or prospective comparative studies.564 Reported survival advantages are therefore difficult to interpret causally, since patients selected for reoperation typically have more favorable tumor biology, lower disease burden, longer recurrence-free intervals, and better performance status than those treated nonoperatively.724

Across these limitations, the literature shows a relatively consistent pattern: outcomes after repeat surgery are most favorable when all visible recurrent disease appears resectable, recurrence occurs after a longer disease-free interval, and disease is confined to one or a few sites.829 By contrast, rapidly progressive, multifocal, or clearly unresectable recurrence is less likely to be controlled by surgery alone and is more often approached with systemic therapy, palliative local treatment, or surveillance depending on symptoms and tempo.105

Repeat surgery in recurrent ACC is therefore best understood as a selective component of multimodality care rather than a routine standard for all relapse. What appears most reliable is the prognostic importance of resectability and recurrence timing; what remains uncertain is the magnitude of any treatment effect relative to systemic therapy, ablation, radiotherapy, or observation. In practice, decisions are usually individualized in specialized multidisciplinary settings after reassessment of disease distribution, endocrine activity, expected morbidity, and competing nonoperative options.26

Diagnostic and clinical context

Recurrent ACC commonly involves the tumor bed, lung, liver, and lymph nodes, so repeat surgery may include either salvage resection of isolated locoregional relapse or metastasectomy for oligometastatic disease.3 Depending on presentation, the goals may include durable clearance of macroscopic disease, postponement of systemic therapy, reduction of hormonally active tumor burden, or palliation of symptoms caused by mass effect or vascular, neurologic, or endocrine complications.1011

Compared with systemic therapy, surgery offers immediate local control but applies to only a minority of patients. Retrospective data and reviews generally support the clearest surgical role in patients with limited recurrent disease for whom complete resection seems realistic, whereas mitotane-based systemic therapy remains central for unresectable or disseminated recurrence.1254 The practical implication is that recurrence alone is not the indication for surgery; the key question is whether resection can plausibly achieve meaningful cytoreduction, and ideally complete gross clearance.

Patterns of recurrence relevant to repeat surgery

Locoregional recurrence

Locoregional recurrence is one of the most frequent reasons for reoperation. Retrospective surgical series suggest that complete resection of isolated or limited local relapse is associated with longer survival than incomplete resection or no surgery, although local failures in the retroperitoneum may be technically difficult because of prior surgery, adhesions, adjacent-organ invasion, and occult multifocal spread.1810

The most reliable conclusion is that isolated local recurrence may still be surgically meaningful when negative-margin or complete macroscopic resection appears feasible.1113 Less reliable is any expectation of durable cure, since further recurrence remains common even after apparently successful salvage resection.3 Clinically, this favors careful restaging and operative planning over reflexive reintervention.

Pulmonary recurrence

The lung is a common site of recurrent ACC and one of the better described settings for metastasectomy. Selected thoracic series report low perioperative mortality and overall survival measured in years after pulmonary metastasectomy, and repeated lung resections have been feasible in some patients.1415 However, thoracic recurrence after surgery is frequent, indicating that pulmonary surgery often controls visible lesions without eliminating systemic metastatic potential.146

A further limitation is that not every suspicious pulmonary nodule proves to be metastatic ACC. Indirect clinicopathologic evidence from pulmonary metastasectomy cohorts shows a small but relevant risk of non-neoplastic findings at resection, which matters when lesions are equivocal or small.16 The practical implication is that lung metastasectomy is most persuasive in otherwise controlled disease with limited fully resectable lesions, while uncertain findings may justify interval imaging or diagnostic confirmation.

Hepatic and other metastatic sites

Liver metastasectomy has been used in selected patients with liver-limited or liver-dominant metachronous recurrence. Retrospective data suggest that hepatectomy may be associated with longer survival than nonsurgical management in highly selected cases, but recurrence-free survival is usually short and most patients recur.1718 Outcomes appear less favorable in synchronous metastatic presentations or when recurrence follows a short interval from primary treatment.1920

Other metastatic sites, including brain, spine, cardiac structures, abdominal wall, skin, and the contralateral adrenal gland, are described mainly in case reports or very small series.21222324 These reports reliably demonstrate technical feasibility and occasional symptom relief, but they do not establish generalizable survival benefit. In practice, surgery at these sites is usually individualized for isolated lesions, tissue diagnosis, neurologic or mechanical compromise, or endocrine palliation rather than as routine disease-control strategy.

Prognostic factors and expected outcomes

Across observational studies, the most reproducible favorable factors are complete resection of recurrent disease and a longer interval between initial adrenalectomy and recurrence, often greater than 6 to 12 months.729 Solitary recurrence, lower initial stage, and locoregional or pulmonary recurrence rather than extrapulmonary disseminated disease have also been associated with better postoperative outcomes in some cohorts.9254 Emerging biomarkers and clinical scores may help refine selection, but they remain retrospective and insufficiently validated for routine decision-making.926

What seems reliable is that these features stratify prognosis among patients already considered for intervention. What is not reliable is whether operating in biologically aggressive patterns changes the natural history of disease. The clinical implication is that early multifocal relapse often shifts management toward systemic therapy or observation of disease tempo before major reoperation, whereas delayed, limited recurrence more often supports a surgical approach.227

Even in favorable groups, repeat surgery rarely represents definitive cure. Multiple series report frequent subsequent relapse after local resection or metastasectomy, sometimes repeatedly within the same organ system, so surgery may function as part of longitudinal disease control rather than a one-time curative event.15173 This makes postoperative surveillance and integration with systemic or other local therapies central to care.

Limitations, pitfalls, and role in management

Repeat surgery for recurrent ACC can require multivisceral, thoracic, hepatic, or vascular procedures, including complex management of inferior vena cava thrombus in rare cases.2829 Experience from specialized centers suggests acceptable perioperative mortality, but morbidity may be substantial and depends strongly on disease site, prior operations, and the extent of resection.156 This supports concentrating such procedures in centers able to combine endocrine, oncologic, and organ-specific surgical expertise.

A recurring boundary in the literature is the limited value of noncurative debulking. Debulking has not shown a consistent survival advantage, although it may still be justified for severe hormone excess or compressive symptoms.104 The practical implication is that complete gross resection remains the main oncologic rationale for repeat surgery, while incomplete operations are usually symptom-directed.

The main interpretive pitfall is selection bias. Longer survival after reoperation may partly reflect indolent biology rather than the effect of surgery itself, and dramatic case reports mainly illustrate what is possible in exceptional patients rather than what is typical.54 For research and practice, repeat surgery is therefore best viewed as a potentially useful option within individualized multimodality care for highly selected recurrent ACC, not as definitive evidence that surgery is superior to alternative strategies in unselected recurrence.

Included Articles

  • PMID 4286799: A case of recurrent virilizing ACC with two pulmonary metastases was managed by en bloc left lower lobectomy and diaphragmatic resection after a five-year disease-free interval, followed by prolonged remission and normalization of androgen excess. The report suggests selected patients with controlled primary disease and limited lung recurrence may benefit from aggressive repeat surgery.30
  • PMID 7563362: This case report describes nonfunctional ACC with a solitary pulmonary metastasis that partially regressed after resection of the primary adrenal tumor, enabling subsequent lung metastasectomy. The patient remained without evidence of disease 38 months after complete resection and no adjuvant mitotane.31
  • PMID 7614407: A case report describes nonfunctioning ACC with multiple local and distant recurrences managed by repeated complete resections, including abdominal, thoracic, hepatic, chest wall, and colonic lesions, with survival exceeding 18 years after initial adrenalectomy. The report argues that selected patients with resectable recurrent or metastatic disease may achieve prolonged survival through aggressive repeat surgery.32
  • PMID 7740813: A review of hepatic resection for noncolorectal, nonneuroendocrine liver metastases reports eight cases of hepatic metastasectomy for adrenocortical carcinoma, including two very long-term survivors, and suggests that liver resection may be appropriate in selected ACC patients with hepatic metastatic disease.33
  • PMID 8337981: This case report describes a nonfunctioning adrenocortical carcinoma with isolated local recurrence 14 years after initial resection, managed by repeat en bloc surgery including splenectomy and partial pancreatectomy. It highlights that ACC recurrence can occur very late and may still be approached with aggressive resection when apparently localized.34
  • PMID 9179672: This case report describes late para-aortic lymph node recurrence of aldosterone-producing adrenocortical carcinoma detected 7 years after adrenalectomy, with prolonged survival after surgical metastasectomy. It supports considering aggressive resection of limited recurrent disease in selected patients with apparently slow-growing ACC.35
  • PMID 9726741: In a retrospective series of endocrine tumors with pulmonary metastases, no patient with adrenocortical carcinoma was considered a candidate for pulmonary metastasectomy. Across the broader cohort, resection was reserved for isolated, fully resectable lung disease with controlled primary tumor, while positive mediastinal nodes and shorter disease-free interval predicted worse survival.36
  • PMID 10622498: In a 113-patient surgical series, complete repeat resection for recurrent or metastatic adrenocortical carcinoma was associated with substantially longer survival than incomplete second resection. Complete re-resection was achieved more often for discrete distant metastases than for bulky local recurrences.1
  • PMID 10752787: This case report describes late ACC recurrence 6 years after initial resection, involving the contralateral adrenal gland and peritoneal cavity, with successful second resection and prolonged survival without further recurrence. It highlights that selected recurrent disease may still be amenable to repeat surgery.37
  • PMID 11848245: This case report describes a solitary abdominal wall scar metastasis appearing 4.5 years after open resection of a nonfunctioning ACC, likely related to intraoperative capsule rupture and tumor spill. The isolated recurrence was treated with radical en bloc resection, with no recurrence during 12 months of follow-up.38
  • PMID 12094420: In a retrospective 22-patient surgical series, complete repeat resection of locoregional ACC recurrence was associated with longer post-recurrence survival in selected patients, while unresected recurrence led to rapid death. Lower stage, lower Weiss score, and lower mitotic index were linked to fewer locoregional recurrences after initial surgery.8
  • PMID 12512139: This case describes rapidly enlarging isolated local recurrence of nonfunctional stage III ACC three months after en bloc resection, without distant metastases. Planned salvage surgery was declined, and subsequent EDP plus mitotane produced radiographic progression, highlighting the narrow window in which reoperation for recurrent ACC may be feasible.12
  • PMID 15586188: This case report describes repeated surgical management of metastatic hormone-producing ACC with liver metastases, including staged adrenalectomy and hepatectomy, followed by radiotherapy for hepatic recurrence. It highlights that re-resection and local treatment may provide symptom relief, hormonal improvement, and prolonged survival in selected technically resectable recurrent disease.39
  • PMID 15663687: A case of metachronous bilateral nonfunctioning ACC showed that resection of a delayed contralateral adrenal tumor, appearing 4 years after initial adrenalectomy without other metastases, was associated with 8 years of disease-free survival after the second surgery. The report argues that resectable recurrent or metachronous lesions should be surgically removed when feasible.40
  • PMID 15739057: This review addresses local recurrence of adrenocortical carcinoma, emphasizing that complete resection of resectable local recurrence, with or without resectable metastases, is associated with substantially better survival than incomplete resection or nonoperative treatment. It also notes that debulking has no clear survival benefit and should be considered mainly for severe hormonal symptom control.10
  • PMID 16409610: A case report describes resection of an isolated local ACC recurrence 2 years after adrenalectomy using a thoracoscopic transdiaphragmatic approach after prior open surgery. The patient had no evident metastases, achieved negative margins without major complications, and remained recurrence-free for 3 years after surgery plus adjuvant chemotherapy.41
  • PMID 18296284: A case report describes locally recurrent ACC extending as a tumour thrombus through the inferior vena cava into the right atrium, causing hepatic congestion, ascites, and leg edema. Staged repeat surgery, including extracorporeal circulation with deep hypothermic circulatory arrest for thrombus removal, achieved symptom relief and one-year disease-free follow-up.28
  • PMID 18307006: This case report describes very late recurrent ACC with pulmonary, brain, and renal metastases occurring 12 years after adrenalectomy, where repeated metastasectomy plus focal radiation and mitotane was associated with 36-month survival from first recurrence. The report emphasizes considering surgical resection for limited recurrent or metastatic disease when lesions are resectable.42
  • PMID 18333256: This review of reported hepatic resections for ACC liver metastases suggests that repeat surgery may be reasonable for selected patients with metachronous liver-only recurrence arising at least 1 year after primary treatment when complete resection is feasible. Outcomes appeared poor for synchronous metastases or short disease-free intervals, and evidence remained very limited.19
  • PMID 19566520: This retrospective surgical series describes recurrent ACC managed with repeat operations, including resection of local recurrence and selected metastatic sites after multidisciplinary review and, in one case, response to mitotane-based systemic therapy. The excerpt emphasizes that surgery remained the main effective treatment for recurrent disease, while incomplete initial resection and capsule rupture were linked to local recurrence.11
  • PMID 21958764: In a retrospective single-institution series, selected patients with pulmonary metastatic ACC who underwent pulmonary metastasectomy had median overall survival of 40 months and 5-year survival of 41%, despite rapid thoracic recurrence. Longer interval to first recurrence after adrenalectomy and lower primary tumor T stage were associated with better survival after lung resection.14
  • PMID 22000277: In a retrospective series of 24 highly selected patients with ACC undergoing 56 pulmonary metastasectomies, lung metastasectomy had no perioperative deaths and was associated with median survival of 50.2 months from first pulmonary surgery. Repeated pulmonary metastasectomy was feasible and associated with longer survival, supporting consideration of re-resection in selected recurrent pulmonary disease.15
  • PMID 22189845: A single-center retrospective series suggests that repeat resection or ablation for recurrent or metastatic ACC can be performed safely and may prolong survival in selected patients. Longer disease-free interval before recurrence, particularly more than 12 months, was associated with better survival after first metastasectomy.7
  • PMID 22421721: This case report describes a solitary hepatic metastasis from previously resected stage II nonfunctioning ACC detected 15 years after primary surgery and successfully managed with liver resection. It highlights that very late recurrence can occur and supports repeat resection for potentially resectable recurrent or metastatic ACC.43
  • PMID 22526905: In selected patients with ACC liver metastases, hepatectomy was associated with median overall survival of 31.5 months and 5-year survival of 39%, but all patients recurred and median disease-free survival was 7 months. Surgical treatment of recurrence, including repeat hepatectomy, was independently associated with better outcome.17
  • PMID 23150691: In a retrospective registry study of first recurrent ACC after prior radical resection, longer time to first recurrence and complete resection of recurrent disease were the strongest predictors of better progression-free and overall survival. Patients with recurrence more than 12 months after initial surgery and disease amenable to R0 resection had the most favorable outcomes, while incomplete resection or no surgery was associated with worse survival.2
  • PMID 25412413: This clinical series describes brain metastases as a rare late recurrence pattern in advanced ACC, usually emerging months to years after initial diagnosis and after multiple prior systemic treatments. Selected patients with limited intracranial disease underwent metastasectomy and/or radiosurgery, with neurological recovery in several cases after multidisciplinary intervention.21
  • PMID 26932330: This case report describes locally recurrent ACC after initial stage II adrenalectomy, with recurrence detected 14 months later in the retroperitoneum. Complete resection of recurrent disease followed by mitotane and EDP chemotherapy was associated with prolonged recurrence-free survival, and the report highlights recurrence interval and feasibility of R0 resection as key factors for repeat surgery.44
  • PMID 26960512: This case report describes metachronous recurrent ACC with an exceptionally rare intradural extramedullary spinal metastasis plus liver metastases presenting years after adrenalectomy. In a symptomatic patient, surgical resection of the spinal lesion provided marked pain relief and tissue confirmation when imaging mimicked benign intradural tumors.22
  • PMID 27275470: This case report describes an isolated liver metastasis appearing 23 years after curative resection of stage II ACC, emphasizing that very late recurrence can occur. It also supports repeat metastasectomy for resectable liver recurrence, with complete resection achieved and short-term disease-free follow-up.45
  • PMID 27618748: In selected patients undergoing curative-intent repeat resection for recurrent ACC, longer survival was associated with solitary recurrence, disease-free interval greater than 12 months, and locoregional or pulmonary rather than extrapulmonary distant recurrence. A 3-factor clinical score stratified 5-year survival after repeat surgery and may help identify candidates for re-intervention.9
  • PMID 27855966: In a multicenter retrospective cohort of recurrent ACC after initial resection, patients selected for reoperation had markedly longer overall survival after recurrence than those managed nonoperatively. Longer disease-free interval over 12 months also correlated with better outcomes, supporting surgery as a consideration in selected recurrent cases.5
  • PMID 27859792: This case report describes aggressive debulking surgery for metastatic ACC with multiple liver metastases and extensive inferior vena cava tumor thrombus reaching the right atrium. It illustrates that intracaval extension was not treated as an absolute contraindication to surgery, with ex vivo liver resection and vena cava reconstruction used in a highly selected patient.46
  • PMID 28778197: In selected adults with isolated ACC liver metastases and no extrahepatic disease, hepatic metastasectomy was associated with markedly longer overall survival than no resection, despite short disease-free survival and frequent recurrence. Longer time to first metastasis or recurrence and solitary liver metastasis were favorable selection factors.18
  • PMID 30343951: In resected stage I-III ACC, recurrence was common and often rapid, with lung and tumor-bed sites predominating initially. Reoperation or metastasectomy was followed by frequent further relapse, often in the same organ, and more than three total operations did not improve overall survival.3
  • PMID 30527003: This discussion highlights recurrent ACC management, noting tumor-bed recurrence as common and suggesting that a recurrence-free interval under 12 months is a negative survival predictor, while patients with longer initial intervals were more likely to undergo repeat surgery. It also emphasizes site-specific resectability and outcomes in selected patients.27
  • PMID 30760340: A systematic review of recurrent and metastatic ACC reports that pulmonary and hepatic metastasectomy, and selected peritoneal cytoreduction with HIPEC, are generally feasible with low perioperative mortality in carefully selected patients, but recurrence after surgery remains common. Longer disease-free interval after primary adrenalectomy, particularly over 6 months, and repeat pulmonary resection were associated with more favorable survival in some retrospective series.6
  • PMID 31272813: A multi-institutional retrospective analysis suggests that selected patients with metastatic ACC may benefit from metastasectomy, with more durable survival after metachronous resection for recurrent disease than after synchronous metastasectomy at initial adrenalectomy. In synchronous cases, R0 resection was associated with improved survival, whereas margin status was not prognostic in metachronous metastasectomy.20
  • PMID 31484583: In a heterogeneous series of laparoscopic liver resections for non-colorectal non-neuroendocrine metastases that included two ACC cases, recurrence after hepatectomy was common, but repeat liver-directed procedures were feasible in selected patients. The paper supports a general ACC-relevant point that re-intervention for limited recurrent metastatic disease may be considered in carefully chosen cases.47
  • PMID 31733070: In patients undergoing resection for recurrent adrenocortical carcinoma, a preoperative lymphocyte-to-monocyte ratio above 4 and time to recurrence over 12 months were associated with longer disease-specific survival. These factors may help select candidates more likely to benefit from aggressive reoperation, though evidence is limited by a small retrospective surgical cohort.26
  • PMID 31808558: In recurrent or metastatic ACC considered for re-resection or metastasectomy, longer disease-free interval and lower stage at diagnosis were independently associated with prolonged postoperative survival, whereas tumor size, hormonal status, margin status, and use of chemotherapy, radiation, or mitotane were not. Long-term survivors often required multiple subsequent procedures.25
  • PMID 32370618: This case report describes recurrent metastatic ACC with rare intracardiac spread causing severe right ventricular outflow tract obstruction. Palliative surgical debulking of right-sided cardiac metastases improved dyspnea, chest pain, and echocardiographic obstruction despite residual disease and later systemic progression.23
  • PMID 32673783: This case report describes a large isolated intrahepatic ACC metastasis discovered more than 10 years after resection of a nonsecreting adrenal tumor, illustrating the potential for very delayed recurrence and the diagnostic difficulty of nonfunctional metastatic disease. It also highlights that surgery for metastatic ACC can be complicated by severe perioperative vasoplegic shock resembling secondary systemic capillary leak syndrome.48
  • PMID 34850915: In a multicenter retrospective cohort of adults presenting with metastatic ACC, cytoreductive resection of the primary adrenal tumor was associated with longer overall survival than no primary-tumor surgery. Hormone excess predicted worse survival, while local therapy directed at metastases was also associated with improved outcomes.49
  • PMID 34898541: In a retrospective CT volumetry study of 12 patients with untreated metastatic ACC, liver metastases had markedly shorter volume doubling time than lung or lymph node lesions, suggesting faster progression in the liver. These findings support especially close monitoring and potentially more aggressive local intervention for liver metastatic disease.50
  • PMID 35252325: A systematic review and pooled analysis found that reoperation for recurrent ACC was associated with longer overall survival than nonsurgical management, with the greatest benefit when complete resection of recurrence was achievable. Favorable factors included single-site recurrence, longer disease-free interval, earlier original stage, female sex, and prior R0 primary resection.4
  • PMID 36069780: This case report describes metastatic ACC with pulmonary and liver metastases achieving durable complete remission after multimodal therapy, including chemotherapy, prolonged mitotane, delayed resection of the primary tumor, and subsequent liver metastasectomy. It supports that selected metastatic disease may become amenable to radical local treatment after systemic response.51
  • PMID 37246079: This case report highlights an isolated scalp cutaneous metastasis detected after prior adrenalectomy for ACC, initially mimicking a benign sebaceous cyst and managed with surgical excision. It underscores that rare, limited recurrences may warrant individualized management rather than automatic escalation, given heterogeneous outcomes.24
  • PMID 39037524: A case report describes repeat surgery for recurrent adrenocortical carcinoma with right liver invasion and retrohepatic inferior vena cava tumor thrombus extending to the hepatic vein confluence, using ante situm right hepatectomy with vena cava reconstruction. The patient was discharged on postoperative day 20 and was alive and disease free at 1 year on mitotane.29
  • PMID 39151391: This case report describes isolated locoregional ACC recurrence one year after resection, involving spleen, diaphragm, and Gerota’s fascia, managed with en bloc repeat surgery achieving negative margins and short-term disease control. It emphasizes that carefully selected recurrent disease may benefit from complete resection in a specialized multidisciplinary setting.13
  • PMID 24369217: A clinicopathologic series of 88 resections for suspected pulmonary metastatic carcinoma found that 8% were non-neoplastic on final histology and included one adrenocortical carcinoma case, highlighting indirect but relevant diagnostic uncertainty when selecting patients for pulmonary metastasectomy.16

References

Footnotes

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  2. The role of surgery in the management of recurrent adrenocortical carcinoma.. J Clin Endocrinol Metab. 2013. PMID: 23150691. Local full text: 23150691.md ↩ ↩2 ↩3 ↩4 ↩5 ↩6 ↩7

  3. Longitudinal patterns of recurrence in patients with adrenocortical carcinoma.. Surgery. 2019. PMID: 30343951. Local full text: 30343951.md ↩ ↩2 ↩3 ↩4 ↩5

  4. Reoperation for Recurrent Adrenocortical Carcinoma: A Systematic Review and Pooled Analysis of Population-Based Studies.. Front Surg. 2022. PMID: 35252325. Local full text: 35252325.md ↩ ↩2 ↩3 ↩4 ↩5 ↩6 ↩7 ↩8

  5. Surgery for recurrent adrenocortical carcinoma: A multicenter retrospective study.. Surgery. 2017. PMID: 27855966. Local full text: 27855966.md ↩ ↩2 ↩3 ↩4 ↩5

  6. Operative Management of Recurrent and Metastatic Adrenocortical Carcinoma: A Systematic Review.. Am Surg. 2019. PMID: 30760340. Local full text: 30760340.md ↩ ↩2 ↩3 ↩4 ↩5

  7. Operative management for recurrent and metastatic adrenocortical carcinoma.. J Surg Oncol. 2012. PMID: 22189845. Local full text: 22189845.md ↩ ↩2 ↩3

  8. [Adrenocortical carcinoma: prognostic factors for local recurrence and indications for reoperation. A report on a series of 22 patients].. Ann Chir. 2002. PMID: 12094420. Local full text: 12094420.md ↩ ↩2 ↩3

  9. Clinical Score Predicting Long-Term Survival after Repeat Resection for Recurrent Adrenocortical Carcinoma.. J Am Coll Surg. 2016. PMID: 27618748. Local full text: 27618748.md ↩ ↩2 ↩3 ↩4 ↩5

  10. [Recurrent operations on the adrenal glands].. Chirurg. 2005. PMID: 15739057. Local full text: 15739057.md ↩ ↩2 ↩3 ↩4 ↩5

  11. Reoperative adrenal surgery: lessons learnt.. ANZ J Surg. 2009. PMID: 19566520. Local full text: 19566520.md ↩ ↩2 ↩3

  12. [A case of adrenal cortical carcinoma].. Hinyokika Kiyo. 2002. PMID: 12512139. Local full text: 12512139.md ↩ ↩2

  13. Loco-regional recurrence of adrenocortical carcinoma: A case report.. Int J Surg Case Rep. 2024. PMID: 39151391. Local full text: 39151391.md ↩ ↩2

  14. Pulmonary resection for metastatic adrenocortical carcinoma: the National Cancer Institute experience.. Ann Thorac Surg. 2011. PMID: 21958764. Local full text: 21958764.md ↩ ↩2 ↩3

  15. Metastatic adrenocortical carcinoma: results of 56 pulmonary metastasectomies in 24 patients.. Ann Thorac Surg. 2011. PMID: 22000277. Local full text: 22000277.md ↩ ↩2 ↩3 ↩4

  16. A clinicopathologic analysis of 88 lung resections of suspected metastatic carcinomas with proven primaries.. Indian J Cancer. 2013. PMID: 24369217. Local full text: 24369217.md ↩ ↩2

  17. Resection of adrenocortical carcinoma liver metastasis: is it justified?. Ann Surg Oncol. 2012. PMID: 22526905. Local full text: 22526905.md ↩ ↩2 ↩3

  18. Outcome after resection of Adrenocortical Carcinoma liver metastases: a retrospective study.. BMC Cancer. 2017. PMID: 28778197. Local full text: 28778197.md ↩ ↩2

  19. Liver resection for hepatic metastases from adrenocortical carcinoma.. HPB (Oxford). 2006. PMID: 18333256. Local full text: 18333256.md ↩ ↩2

  20. Features of synchronous versus metachronous metastasectomy in adrenal cortical carcinoma: Analysis from the US adrenocortical carcinoma database.. Surgery. 2020. PMID: 31272813. Local full text: 31272813.md ↩ ↩2

  21. Brain metastasis in patients with adrenocortical carcinoma: a clinical series.. J Clin Endocrinol Metab. 2015. PMID: 25412413. Local full text: 25412413.md ↩ ↩2

  22. Metachronous intradural and liver metastasis from adrenocortical carcinoma.. Indian J Cancer. 2015. PMID: 26960512. Local full text: 26960512.md ↩ ↩2

  23. Metastatic Adrenocortical Carcinoma Causing Profound Right Ventricular Outflow Tract Obstruction: An Improvement Following Surgical Resection.. Circ Cardiovasc Imaging. 2020. PMID: 32370618. Local full text: 32370618.md ↩ ↩2

  24. Scalp nodule in a patient with adrenocortical cancer.. Asian J Surg. 2023. PMID: 37246079. Local full text: 37246079.md ↩ ↩2

  25. Stage and disease-free interval help select patients for surgical management of locally recurrent and metastatic adrenocortical carcinoma.. J Surg Oncol. 2020. PMID: 31808558. Local full text: 31808558.md ↩ ↩2

  26. Preoperative systemic inflammatory markers are prognostic indicators in recurrent adrenocortical carcinoma.. J Surg Oncol. 2019. PMID: 31733070. Local full text: 31733070.md ↩ ↩2

  27. Discussion.. Surgery. 2019. PMID: 30527003. Local full text: 30527003.md ↩ ↩2

  28. [Successful surgical removal of adrenocortical carcinoma growing into the inferior vena cava and the right atrium].. Magy Seb. 2008. PMID: 18296284. Local full text: 18296284.md ↩ ↩2

  29. Ante Situm Liver Resection for Tumors Invading the Inferior Vena Cava Hepatic Vein Confluence.. Ann Surg Oncol. 2024. PMID: 39037524. Local full text: 39037524.md ↩ ↩2

  30. Survival after pulmonary lobectomy for metastatic adrenocortical carcinoma.. Ann Thorac Surg. 1966. PMID: 4286799. Local full text: 4286799.md ↩

  31. Spontaneous regression of pulmonary metastasis from nonfunctioning adrenocortical carcinoma after removal of the primary lesion: a case report.. J Urol. 1995. PMID: 7563362. Local full text: 7563362.md ↩

  32. Metastatic adrenocortical carcinoma treated by repeated resection: a case report of long-term survival over 18 years.. Int J Urol. 1995. PMID: 7614407. Local full text: 7614407.md ↩

  33. Hepatic resection for noncolorectal nonneuroendocrine metastases.. World J Surg. 1995. PMID: 7740813. Local full text: 7740813.md ↩

  34. [Local recurrence of non-functioning adrenocortical carcinoma 14 years following surgical treatment: a case report].. Hinyokika Kiyo. 1993. PMID: 8337981. Local full text: 8337981.md ↩

  35. Aldosterone-producing adrenocortical carcinoma metastases found seven years after adrenalectomy.. Int J Urol. 1997. PMID: 9179672. Local full text: 9179672.md ↩

  36. Pulmonary metastases of endocrine origin: the role of surgery.. Chest. 1998. PMID: 9726741. Local full text: 9726741.md ↩

  37. Recurrence of giant adrenocortical carcinoma in the contralateral adrenal gland 6 years after surgery: report of a case.. Surg Today. 2000. PMID: 10752787. Local full text: 10752787.md ↩

  38. Abdominal wall metastasis after open resection of an adrenocortical carcinoma.. Eur J Surg. 2001. PMID: 11848245. Local full text: 11848245.md ↩

  39. [Surgical treatment of hormone-producing adrenocortical carcinoma with liver metastases].. Tidsskr Nor Laegeforen. 2004. PMID: 15586188. Local full text: 15586188.md ↩

  40. Long-term survival after bilateral adrenalectomy for metachronous adrenocortical cancer.. Int J Urol. 2004. PMID: 15663687. Local full text: 15663687.md ↩

  41. Thoracoscopic transdiaphragmatic adrenalectomy for isolated locally recurrent adrenal carcinoma.. Int J Urol. 2005. PMID: 16409610. Local full text: 16409610.md ↩

  42. Alpha-fetoprotein (AFP)-producing adrenocortical carcinoma—long survival with various therapeutic strategies including a lung resection: report of a case.. Surg Today. 2008. PMID: 18307006. Local full text: 18307006.md ↩

  43. Hepatic metastasis from adrenocortical carcinoma fifteen years after primary resection.. Saudi J Gastroenterol. 2012. PMID: 22421721. Local full text: 22421721.md ↩

  44. [A Case of Adrenocortical Carcinoma Successfully Treated with Multimodal Therapy].. Hinyokika Kiyo. 2016. PMID: 26932330. Local full text: 26932330.md ↩

  45. An unusual case of adrenocortical carcinoma with liver metastasis that occurred at 23 years after surgery.. Hepatobiliary Surg Nutr. 2016. PMID: 27275470. Local full text: 27275470.md ↩

  46. Ex vivo liver resection with replacement of inferior vena cava without the use of cardiopulmonary bypass in a patient with metastatic adrenocortical carcinoma.. Int J Urol. 2017. PMID: 27859792. Local full text: 27859792.md ↩

  47. Laparoscopic liver resection for non-colorectal non-neuroendocrine metastases: perioperative and oncologic outcomes.. World J Surg Oncol. 2019. PMID: 31484583. Local full text: 31484583.md ↩

  48. Refractory shock during the anesthetic and surgical management of an intrahepatic tumor arising from the adrenal cortex: A case report.. Int J Surg Case Rep. 2020. PMID: 32673783. Local full text: 32673783.md ↩

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  50. Tumor Doubling Time Using CT Volumetric Segmentation in Metastatic Adrenocortical Carcinoma.. Curr Oncol. 2021. PMID: 34898541. Local full text: 34898541.md ↩

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