A meaningful use of the phrase “appropriately selected patients”
Philip W. Smith, MD, FACS and John B. Hanks, MD, FACS, Charlottesville, VA
From the Department of Surgery, University of Virginia, Charlottesville, VA
MANY AGGRESSIVE OR NOVEL TREATMENT PARADIGMS contain a directive to apply the described approach in “appropriately selected patients.” In this issue of Surgery the article by Livhits et al,1 is in part a review of the practice of primary tumor resection in adrenocortical carcinoma (ACC) with known distant metastases, an aggressive treat- ment paradigm that is undertaken without expec- tation of cure. In this series, they report an association with prolonged survival in those pa- tients undergoing resection of the primary lesion (with or without adjuvant therapy). They end their manuscript with the advice that this approach ” … be considered for appropriately selected pa- tients.” In many manuscripts, this phrase is used largely out of deference to limitations of the anal- ysis. We believe, however, that if consideration is to be given to operative management of metastatic ACC, reserving that approach to “appropriately selected patients” truly is the crux of the issue.
ACC has a dismal prognosis. The rarity of the disease makes it hard to examine the impact of treatment options out of relatively small single institution series, and the authors have reasonably turned to a larger dataset. As invariably is the case in registry data, there are limitations in breadth, specificity, precision, and accuracy. The authors have described these limitations, and they have nicely reported the information that reasonably can be extracted. Within these bounds, it does appear that resection of the primary tumor is statistically associated with prolonged survival in ACC with distant metastases. However, it would be inappropriate to take away the message that primary tumor resection is the standard approach to patients presenting with metastatic ACC.
Accepted for publication August 19, 2014.
Reprint requests: Philip W. Smith, MD, FACS, Department of Surgery, University of Virginia, Box 800709, Charlottesville, VA 22908. E-mail: philip@virginia.edu.
Surgery 2014;156:1529-30.
0039-6060/$ - see front matter
http://dx.doi.org/10.1016/j.surg.2014.08.048
A patient recently was presented to us with a large left suprarenal mass. A biopsy had been performed before our involvement that was consis- tent with ACC. He also had multiple pulmonary and hepatic lesions consistent with metastases, renal vein thrombus, and kidney and diaphragm invasion. Our personal imaging review was further highly concerning for aortic and superior mesen- teric artery origin abutment or invasion, not commented on by the original radiologist. Given his significant acute Cushing’s syndrome, we were asked to consider resection. We certainly agree that palliation of severe Cushing’s is an important reason to consider resection, and therefore gave this request careful consideration. However, given the high likelihood of unresectability as the result of vascular involvement, the predicted morbidity of the approach, and the dismal prognosis, we declined to offer resection. The patient sought a second opinion and underwent an attempted resection, which was abandoned because of vascular involvement. He transitioned to comfort care 8 weeks after that attempted resection. This result may well have decreased his total survival and resulted in an unknown expense to the patient and his family.
In contrast, we believe a patient with a clearly resectable primary tumor, limited metastatic dis- ease, and a previously good functional status who is suffering from medically uncontrollable endo- crinopathy very reasonably could be offered a resection. However, if resection is to be offered to a patient with distant metastases from ACC, we believe several considerations are mandatory and must be agreed on by the treatment team and the patient. The patient must be evaluated prospec- tively by a multidisciplinary treatment team. The objective of the resection must be understood to be palliative or for short-interval life prolongation without giving the expectation of long-term sur- vival. The imaging must be recent because these tumors may progress rapidly. Additionally, the imaging must be adequate to asses extent of vascular and organ involvement to appropriately counsel the patient about the extent of the
procedure and the anticipated recovery. Repeat imaging should be used liberally. The imaging must be reviewed in detail in conjunction with a trusted radiologist. The patient must be able to participate in a completely frank discussion of expectations of the quality of remaining life with the existing disease versus the quality of life while he or she is recovering from the proposed procedure.
In these “appropriately selected patients,” it may be true that resection with or without adjuvant therapy leads to prolonged survival. However, it also may be that the findings demonstrated in the Livhits et al analysis reflect that surgeons already are appropriately selecting patients for aggressive
therapy and not operating on those who stand no chance of deriving benefit. Livhits et al1 address this possibility, but such a selection bias cannot be controlled for in the available data. With this in mind, we encourage thoughtful application of hero- ic measures in these challenging disease processes, but caution against misinterpreting reports such as these to imply that we should operate nonselectively. That would lead to a preponderance of induced morbidity and expense over meaningful benefit.
REFERENCE
1. Livhits M, Li N, Yeh MW, Harari A. Surgery is associated with improved survival for adrenocortical cancer, even in metasta- tic disease. Surgery 2014;156:1531-41.