Adrenocortical Carcinoma: The Value of Lymphadenectomy

Background: Adrenocortical carcinoma (ACC) staging does not account for the number of positive nodes. The prognostic value of quantitative metastatic nodal burden is unknown. Methods: The National Cancer Database was retrospectively queried from 2004–2016 to identify patients with Stage I–III ACC undergoing adrenalectomy. Patients who underwent lymphadenectomy (LAD) were further studied. Demographics, TNM staging, tumor characteristics, and surgical approach were analyzed. Results: 386 LADs were identified. The median number of nodes examined was 2 (IQR 2-6), with no difference by surgical approach ‘[laparoscopic, 3 (1–3); robotic, 1.5 (1–4.5); open, 2 (1–7), p = 0.493]. In LADs with cN0 disease, positive nodes were seen in 17.5% of patients; an average of 6 (1–12) nodes were examined in patients who upstaged to pN1 disease compared with an average of 2 (1–6) nodes in those who remained pN0. Median survival was incrementally worse for patients with more positive nodes (62.8 vs. 21.9 vs. 13.7 vs. 11.3 vs. 10.7 months for 0, 1, 2, 3, and ≥ 4 positive nodes, respectively, p < 0.01). On multivariate analysis, significant prognostic factors for poor survival included older age, ≥ 2 comorbidities, pT3, and pT4. The strongest prognostic factor for poor survival was the number of positive nodes (1 node, hazards ratio [HR] 2.3, 95% confidence interval [CI] 1.5–3.6; 2 nodes, HR 1.3, 95% CI 0.6–3.0; 3 nodes, HR 3.0, 95% CI 1.1–8.0; ≥ 4 nodes, HR 4.0, 95% CI 2.5–6.2). Lymphadenectomy was associated with improved survival (HR 0.82, 95% CI 0.67–0.99). Conclusions: Higher quantitative metastatic nodal burden is a robust prognostic factor for worse survival in ACC.