ACC tumor biology is highly aggressive, so even patients with what appear to be complete resections need to be considered for adjuvant systemic therapy. Adjuvant mitotane has been used with moderate efficacy, historically, but surgical resection is key. If the tumor is borderline resectable, then consider moving the therapy upfront to shrink the tumor and maximize the chances of a complete resection.
Dr. Lee has created a classification system in his retrospective cohort of patients from MD Anderson1 with 3 useful categories of borderline resectable ACC: (A) multiorgan/vascular resection required, (B) potentially resectable oligometastases, and (C) poor performance status/highly comorbid. Patients treated with neoadjuvant therapy (combination of doxorubicin-based chemotherapy and mitotane) had a 33% overall response rate, but in the subset of patients with IVC thrombi, there was a regression of 87.5%. Unfortunately, neoadjuvant did not lead to improved survival (5yr OS 65a% v. 50%) or negative margin rate (92% v. 86%). He does make note that the survival curves do appear to be diverging and with further follow-up may demonstrate a benefit.
Presented by: Jeffrey E. Lee, MD, Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
1. Bednarski, B.K., M.A. Habra, A. Phan, et al., Borderline resectable adrenal cortical carcinoma: a potential role for preoperative chemotherapy. World J Surg, 2014. 38(6): p.1318-27.
Written by: Justin T. Matulay, MD, Urologic Oncology Fellow and Ashish M. Kamat, MD (@UroDocAsh), Professor, Department of Urology, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX at the 13th Update on the Management of Genitourinary Malignancies, The University of Texas (MDACC - MD Anderson Cancer Center) November 9-10, 2018, Dan L. Duncan Building, Houston, TX