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ASO Author Reflections: Incorporating Lymphovascular Invasion to Improve the Prognostic Reliability of the T-Staging System for Adrenocortical Carcinoma-A Multicenter Study
Caroline E. Poorman, MD, Cecilia G. Ethun, MD, MS, and Shishir K. Maithel, MD, FACS
Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
PAST
The 7th edition of the American Joint Committee on Cancer (AJCC) staging system for adrenocortical carci- noma (ACC) does not reliably predict survival outcomes for individual patients.1-3 This led to the proposal of a new staging system by the European Network for the Study of Adrenal Tumors (ENSAT), which was adapted into the 8th edition staging system.2,4 This new staging system does not modify how T-stage is defined, but rather minimizes its influence and redistributes patients based on their nodal status and the presence of metastatic disease. Relying on nodal status, however, can be problematic, as there is typically a low lymph node yield during surgical resection of ACC.5 Lymphovascular invasion (LVI) is a pathologic variable that is routinely reported for all resected adrenal tumors, and has been demonstrated to be an independent prognostic indicator for many other cancers. Our study sought to investigate whether incorporating LVI into the current T-staging system for ACC could better discriminate patient outcomes for disease-specific survival (DSS).6
This ASO Author Reflections is a brief invited commentary on the article “A Novel T-Stage Classification System for Adrenocortical Carcinoma: Proposal from the US Adrenocortical Carcinoma Study Group,” Ann Surg Oncol. 2018; 25:520-527.
@ Society of Surgical Oncology 2018
First Received: 27 September 2018
S. K. Maithel, MD, FACS e-mail: smaithe@emory.edu
PRESENT
Utilizing one of the largest ACC databases in the USA, our study supported that the current T-staging system is not predictive of survival for patients with T2 and T3 disease.6 LVI was associated with worse survival compared with no LVI, and stratified patients with T2 and T3 disease into two distinct groups. By incorporating LVI to redefine T2 and T3 disease, a new T-staging system was devised, which better discriminated between patients with T2 and T3 dis- ease compared with the 7th/8th edition definition of T-stage. The proposed T-staging system offers an appeal- ing alternative to the current definition because it incorporates LVI, which is a readily available histopatho- logic finding, and more accurately risk-stratifies patients with ACC for survival. The improved prognostic value of the proposed T-staging system may improve the reliability of the overall staging system for ACC, without relying heavily on lymph node status, which often is not known.
FUTURE
Before incorporation into future AJCC staging systems, the proposed T-stage should be externally validated using a large database that includes survival data on ACC. Further research would also have to consider the applicability of the T-staging system in the overall tumor-node-metastasis (TNM) staging system. Once externally validated, our novel T-stage system may serve as a selection criterion for clinical trials and adjuvant therapy.
DISCLOSURES The authors have no conflicts of interest to disclose.
REFERENCES
1. Lughezzani G, et al. The European Network for the Study of Adrenal Tumors staging system is prognostically superior to the
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2. Fassnacht M, et al. Limited prognostic value of the 2004 International Union Against Cancer staging classification for adrenocortical carcinoma: proposal for a revised TNM classifica- tion. Cancer. 115, 243-250, https://doi.org/10.1002/cncr.24030 (2009).
3. Asare EA, et al. A novel staging system for adrenocortical carcinoma better predicts survival in patients with stage I/II disease. Surgery. 156, 1378-1385; discussion 1385-1376, https://d oi.org/10.1016/j.surg.2014.08.018 (2014).
4. Amin MB, et al. The Eighth Edition AJCC Cancer Staging Manual: Continuing to build a bridge from a population-based to a more “personalized” approach to cancer staging. CA Cancer J Clin. 67, 93-99, https://doi.org/10.3322/caac.21388 (2017).
5. Nilubol N, Patel D, and Kebebew E. Does lymphadenectomy improve survival in patients with adrenocortical carcinoma? A population-based study. World J Surg. 40, 697-705, https://doi. org/10.1007/s00268-015-3283-2 (2016).
6. Poorman CE, Ethun CG, Postlewait LM, et al. A novel T-stage classification system for adrenocortical carcinoma: Proposal from the US Adrenocortical Carcinoma Study Group. Ann Surg Oncol. 25, 520-527 (2018).