ENDOCRINE SOCIETY
OXFORD
Response to Letter to the Editor From de Ponthaud et al: “Cytoreductive Surgery of the Primary Tumor in Metastatic Adrenocortical Carcinoma: Impact on Patients’ Survival.”
Victor Srougi, 1,2,[D Mouhammed Amir Habra,3 Maria Candida Barisson Villares Fragoso4,5
1Division of Urology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brazil;
2Division of Urology, Hospital Moriah, São Paulo, 04083-002, Brazil
3Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA 4Unidade de Suprarrenal, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brazil 5Instituto do Câncer do Estado de São Paulo da Faculdade de Medicina da Universidade de São Paulo, São Paulo, 05403-000, Brazil
Correspondence: Victor Srougi, MD, Hospital das Clinicas de São Paulo, Av. Enéas de Carvalho Aguiar, 255, São Paulo, SP, Brazil 05403-000. Email: vsrougi@ gmail.com.
Key Words: adrenocortical carcinoma, cytoreduction surgical procedures, surgery, survival
Dear Editor,
We would like to thank de Ponthaud et al. for their interest and the opportunity to respond to the issues raised of our recently reported retrospective experience about the role of surgery in stage IV adrenocortical carcinoma (ACC) (1).
We agree that our study has several limitations related to its retrospective nature and selection bias. The paired assess- ment only attenuates the flaws of a retrospective comparison. Furthermore, our analysis did not consider many other prog- nostic features that could have influenced survival. However, pairing the cohort for so many variables would have reduced our sample size enormously and consequently the power of the study.
A randomized prospective trial comparing cytoreduction and no cytoreduction is desired. Still, it may not be feasible for multiple reasons, including the rarity of ACC and the limited efficacy of systemic therapy, which makes patient ran- domization inappropriate.
In daily practice, there is a well-known heterogeneity of ACC behavior regardless of stage. Currently, disease burden and patient performance are key components to drive the decision of treatment strategy. Incorporating other prog- nostic markers to select patients for surgery would be valu- able. Hence, the question is, who will benefit from surgery and respond to systemic therapy? Treatment choices based on molecular parameters in the advanced disease setting are well defined for other malignancies, such as breast cancer.
However, for ACC, it’s still precarious. Although we cannot refine the selection of patients, and systemic therapy has sub- optimal results, surgery seems the best alternative to prolong survival. As a result, most institutions worldwide deploy cytoreductive surgery empirically for patients with good performance status.
Considering these premises, instead of creating a treatment paradigm, our study aims to build a background to support a treatment choice for patients harboring metastatic ACC in a scenario with limited options. Aside from that, we aim to foster the debate of when is the best time for surgery. This would be an exciting topic for a prospective trial. Based on our findings, we believe that highly selected patients can still have surgery as a primary intervention, especially in the pres- ence of overwhelming hormonal abnormalities that can com- plicate the use of systemic therapy.
Conflicts of Interest
The authors declare neither conflicts of interest nor financial ties.
Reference
1. de Ponthaud C. Letter to the Editor from de Ponthaud et al. Cytoreductive surgery of the primary tumor in metastatic adrenocortical carcinoma: impact on patients’ survival. J Clin Endocrinol Metab. 2022.