Pulmonary Metastasectomy for Adrenocortical Carcinoma-Not If, but When

Simple Summary Adrenocortical carcinoma is a rare tumor with a very high propensity to metastasize to the lungs. There are limited systemic options once it does metastasize. Pulmonary metastasectomy has been utilized in these patients as part of a treatment paradigm. However, there is little information available to help guide patient selection for pulmonary metastasectomy. Herein, our experience treating adrenocortical patients with only lung metastases was reviewed to try and identify associations between different variables (e.g., number of metastases, time to resection) and outcomes. The results demonstrated that, unlike other malignancies, the total number of nodules should not preclude patients who have adequate pulmonary reserve. Additionally, the time from original surgery to the development of lung metastases may have prognostic implications. Future work should focus on identifying genetic markers associated with outcomes that can be used independently or in combination with other clinical variables.Abstract Background: Adrenocortical carcinoma (ACC) commonly metastasizes to the lungs, and pulmonary metastasectomy (PM) is utilized due to limited systemic options. Methods: All ACC patients with initially only lung metastases (LM) from a single institution constituted this observational case series. Kaplan-Meier and Cox proportional hazard analyses evaluated the association with potential prognostic factors and outcomes. Overall survival (OS) was calculated from the date of the PM or, in those patients who did not undergo surgery, from the development of LM. Results: A total of 75 ACC patients over a 45-year period met the criteria; 52 underwent PM, and 23 did not. The patients undergoing PM had a median OS of 3.1 years (95% CI: 2.4, 4.7 years) with the 5- and 10-year OS being 35.5% and 32.8%, respectively. The total resected LM did not impact the OS nor the DFS. The patients who developed LM after 11 months from the initial ACC resection had an improved OS (4.2 years; 95% CI: 3.2, NR; p = 0.0096) compared to those developing metastases earlier (2.4 years; 95% CI: 1.6, 2.8). Patients who underwent PM within 11 months of adrenalectomy demonstrated a reduced OS (2.2 years; 95% CI: 1.0, 2.7) compared to those after 11 months (3.6 years, 95% CI: 2.6, NR; p = 0.0045). PM may provide benefit to those patients with LM at presentation (HR: 0.5; p = 0.2827), with the time to first PM as a time-varying covariate. Conclusions: PM appears to have a role in ACC patients. The number of nodules should not be an exclusion factor. Patients developing LM within a year of primary tumor resection may benefit from waiting before further surgeries, which may provide additional insight into who may benefit from PM.