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ASO Author Reflections: Incorporating Adjuvant Radiation into the Treatment Planning for Select Adrenocortical Carcinomas
Daniel W. Nelson, DO1 and Melanie Goldfarb, MD, MSc, MS, FACS, FACE2,3
1Department of Surgery, William Beaumont Army Medical Center, El Paso, TX; 2Division of Surgical Oncology, John Wayne Cancer Institute at Providence Saint John’s Health Center, Santa Monica, CA; 3Center for Endocrine Tumors and Disorders, John Wayne Cancer Institute at Providence Saint John’s Health Center, Santa Monica, CA
PAST
Adrenocortical carcinoma (ACC) is a rare, yet highly aggressive malignancy. Complete radical extirpation with negative margins remains the mainstay of treatment; however, local recurrence is common.1 With limited options for efficacious systemic therapies, adjuvant radia- tion has been proposed as a means to reduce high recurrence rates following surgery with curative intent.2 Although historically considered a relatively radiation resistant cancer, recent retrospective series have demon- strated that tumor bed irradiation utilizing modern radiation technology is associated with improved local recurrence rates.3 Due to the infrequency of this disease, most series exploring the role of adjuvant radiation have been limited by small sample size. Therefore, this study examined the utility of adjuvant radiation in the treatment of ACC uti- lizing a large, population-based dataset.
ASO Author Reflections is a brief invited commentary on the article, “Adjuvant Radiation is Associated with Improved Survival for Select Patients with Non-Metastatic Adrenocortical Carcinoma,” Ann Surg Oncol. 2018;25:2060-6.
@ Society of Surgical Oncology 2018
First Received: 4 October 2018
M. Goldfarb, MD, MSc, MS, FACS, FACE e-mail: melaniegoldfarbmd@gmail.com; goldfarbm@jwci.org
PRESENT
In this study, 1184 patients with nonmetastatic ACC treated with either surgery alone or surgery followed by adjuvant radiation were identified in the 2004-2013 National Cancer Database (NCDB).4 Following surgical resection, a minority (14.4%) of patients received adjuvant radiation. Radiation therapy did not confer a difference in median overall survival in the general cohort. However, for patients with positive margins, adjuvant radiation was associated with a 40% decreased yearly risk of death after adjustment for concurrent chemotherapy. This survival advantage was not evident for other traditional high risk features. This represents the largest series of ACC com- paring outcomes for patients undergoing surgery alone versus surgery with adjuvant radiation, and it highlights the infrequent use of adjuvant radiation, even in those patients that would experience a survival benefit.
FUTURE
Despite their limitations, population-based datasets provide an opportunity to study outcomes for rare diseases where it often is difficult to assemble a large enough cohort of patients to provide adequate power to truly study treat- ment effects. In this series, although disease-specific survival outcomes could not be assessed, because the NCDB lacks data related to disease recurrence, this study demonstrated a significant survival advantage in a select groups of patients with ACC, namely those with positive margins. These results along with those of modern retro- spective case series, collectively affirm the need for collaborative prospective investigation to clarify the role of adjuvant radiation in ACC.
DISCLOSURE The authors have no conflicts of interest to disclose.
REFERENCES
1. Pommier RF, Brennan MF. An eleven-year experience with adrenocortical carcinoma. Surgery. 1992;112(6):963-70 (discus- sion 970-1).
2. Polat B, Fassnacht M, Pfreundner L, et al. Radiotherapy in adrenocortical carcinoma. Cancer. 2009;115(13):2816-23.
3. Sabolch A, Else T, Griffith KA, et al. Adjuvant radiation therapy improves local control after surgical resection in patients with localized adrenocortical carcinoma. Int J Radiat Oncol Biol Phys. 2015;92(2):252-9.
4. Nelson DW, Chang SC, Bandera BC, Fischer TD, Wollman R, Goldfarb M. Adjuvant radiation is associated with improved survival for select patients with non-metastatic adrenocortical carcinoma. Ann Surg Oncol. 2018;25(7):2060-6.