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Journal of Peking University (Health Sciences) ›› 2024, Vol. 56 ›› Issue (4): 624-630. doi: 10.19723/j.issn.1671-167X.2024.04.013

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Clinical treatment and prognosis of adrenocortical carcinoma with venous tumor thrombus

Shuai LIU,Lei LIU,Zhuo LIU,Fan ZHANG,Lulin MA,Xiaojun TIAN,Xiaofei HOU,Guoliang WANG,Lei ZHAO,Shudong ZHANG*()   

  1. Department of Urology, Peking University Third Hospital, Beijing 100191, China
  • Received:2024-03-16 Online:2024-08-18 Published:2024-07-23
  • Contact: Shudong ZHANG E-mail:zhangshudong@bjmu.edu.cn
  • Supported by:
    the National Natural Science Foundation of China(82273389)

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Abstract:

Objective: To analyze the clinicopathological features, prognostic value and surgical treatment experience in patients with adrenocortical carcinoma with venous tumor thrombus. Methods: We collected relevant data of the patients with adrenocortical carcinoma who had undergone surgery in Peking University Third Hospital from 2018 to 2023. The patients were divided into venous tumor thrombus group and non-tumor thrombus group. The Wilcoxon rank sum test was used to compare the quantitative variables. The chi-squared test and Fisher's exact test were used to compare the categorical variables. The Kaplan-Meier method was used to estimate the survival rate. Results: A total of 27 patients with adrenocortical carcinoma were included, of whom 11 cases (40.7%) had venous tumor thrombus. In the patients with venous tumor thrombus, 8 patients were female and 3 were male. The median age was 49 (36, 58) years. The median body mass index was 26.0 (24.1, 30.4) kg/m2. Seven patients presented with symptoms at their initial visit. Six patients had a history of hypertension. Elevated levels of cortisol were observed in 2 cases. Three tumors were found on the left side, while 8 were found on the right side. Median tumor diameter was 9.4 (6.5, 12.5) cm. On the left, there was a case of tumor thrombus limited to the central vein of the left adrenal gland without invasion into the left renal vein, and two cases of tumor thrombus growth extending into the inferior vena cava below the liver. One case of tumor thrombus on the right adrenal central vein did not invade the inferior vena cava. Four cases of tumor thrombus invaded the inferior vena cava below the liver and three cases extended to the posterior of the liver. Ten patients were in European Network for the Study of Adrenal Tumors (ENSAT) stage Ⅲ and one was in ENSAT stage Ⅳ. Open surgery was performed in 6 cases, laparoscopic surgery alone in 4 cases and robot-assisted laparoscopic surgery in 1 case. Two patients underwent ipsilateral kidney resection. Median operative time was 332 (261, 440) min. Median intraoperative bleeding was 900 (700, 2 200) mL. Median hospital stay was 9 (5, 10) days. Median survival time for the patients with tumor thrombus was 24.0 months and median time to recurrence was 7.0 months. The median survival and recurrence time of 16 patients without tumor thrombus were not reached. The patients with tumor thrombus had worse 3-year overall survival (OS) rate (40.9% vs. 71.4%; Log-rank, P=0.038) and 2-year recurrence-free survival (RFS) (9.1% vs.53.7%; Log-rank, P=0.015) rates compared with the patients with non-tumor thrombus. Conclusion: Patients with adrenocortical carcinoma with venous tumor thrombus have poor prognosis. Different adrenal tumor resections and venous tumor thrombus removal procedures based on different tumor thrombus locations are safe and effective in treating this disease.

Key words: Adrenocortical carcinoma, Tumor thrombus, Clinicopathological features, Prognosis

CLC Number: 

  • R699.3

Table 1

Clinical characteristics of ACC with or without tumor thrombus"

Feature With tumor thrombus (n=11) Without tumor thrombus (n=16) P value
Age/years 49 (36, 58) 48 (37, 62) 0.8
Female 8 (72.7) 7 (56.3) 0.4
BMI/(kg/m2) 26.0 (24.1, 30.4) 25.1 (23.3, 27.6) 0.3
Clinical symptoms 0.3
  No 4 (36.4) 11 (68.8)
  Local symptoms 5 (45.5) 3 (18.8)
  Systemic symptoms 2 (18.2) 2 (12.5)
Hypercortisolism 2 (18.2) 2 (12.5) 1.0
Hypertension 6 (54.5) 6 (37.5) 0.5
Side 0.5
  Left 3 (27.3) 7 (43.8)
  Right 8 (72.7) 8 (50.5)
  Bilateral 0 1 (6.3)
Tumor size/cm 9.4 (6.5, 12.5) 10.5 (6.1, 13.0) 1.0
ENSAT stage 0.1
  Ⅰ 0 2 (12.5)
  Ⅱ 0 4 (25.0)
  Ⅲ 10 (90.9) 9 (56.3)
  Ⅳ 1 (9.1) 1 (6.3)
pN1 1 (9.1) 2 (12.5) 1.0
M1 1 (9.1) 1 (6.3) 1.0
Thrombus length/cm 3.0 (1.6, 4.0)
Mayo grade
  0 2 (18.2)
  Ⅰ 2 (18.2)
  Ⅱ 6 (54.5)
  Ⅲ 1 (9.1)
PUTH-RT grading system
  1a 2 (18.2)
  2 6 (54.5)
  3 3 (27.3)
Operative time/min 332.0 (261.0, 440.0) 223.5 (137.8, 308.5) 0.08
Estimated blood loss/mL 900 (700, 2 200) 450 (20, 1 200) 0.09
Patients receiving transfusion 7 (63.6) 8 (50.0) 0.7
Postoperative hospital stay/d 9 (5, 10) 8 (6, 12) 0.9
Postoperative complication 4 (36.4) 4 (25.0) 0.7

Table 2

Clinical and pathological characteristics of all 11 patients with ACC with tumor thrombus"

Patient PUTH-RT grade Mayo grade Age/years Gender BMI/(kg/m2) Hypertension Symptoms Side Diameter/cm ENSAT stage cT stage cN stage cM stage Thrombus length/cm
1 3 Ⅲ 31 F 30.4 No Local R 15.0 Ⅲ T3 N0 M0 5.0
2 2 Ⅰ 58 M 24.1 Yes No R 9.4 Ⅲ T3 N0 M0 3.0
3 2 Ⅱ 56 F 36.2 Yes No R 6.5 Ⅲ T3 N0 M0 4.0
4 2 Ⅱ 49 F 21.5 No Local L 12.2 Ⅲ T4 N0 M0 4.0
5 2 Ⅱ 54 F 26.0 No No R 7.1 Ⅲ T3 N0 M0 3.3
6 3 Ⅱ 69 F 23.1 Yes Systemic R 12.5 Ⅳ T3 N1 M1 3.0
7 1a 0 71 F 26.9 Yes No R 4.5 Ⅲ T3 N0 M0 0.5
8 1a 0 39 M 24.9 No Local L 12.0 Ⅲ T3 N0 M0 0.8
9 2 Ⅱ 23 F 27.7 No Local L 16.3 Ⅲ T4 N0 M0 2.8
10 3 Ⅱ 36 M 24.5 Yes Local R 8.3 Ⅲ T3 N0 M0 2.5
11 2 Ⅰ 49 F 35.9 Yes Systemic R 5.5 Ⅲ T3 N0 M0 1.6

Table 3

Operation and prognosis data of patients with adrenocortical carcinoma with tumor thrombus"

Patient Operation approach Operative time/min Blood loss/mL RCS transfusion/mL LN resection Hospital stay/d Complication Follow-up/months Status Recurrence
1 Open 504 3 500 3 200 No 9 Anemia 14.0 Dead Liver, lung, retroperitoneal
2 Laparoscopic 193 200 0 No 5 12.0 Dead Liver, lung
3 Laparoscopic 335 800 400 No 8 9.0 Dead Liver, lung, retroperitoneal
4 Open 440 2 000 1 600 Yes 9 20.0 Dead Diaphragmatic, lymph node
5 Laparoscopic 261 900 0 No 5 11.0 Dead Liver, lung, retroperitoneal
6 Open 355 3 500 2 800 Yes 10 9.0 Dead Liver
7 Laparoscopic 71 10 0 No 3 24.0 Dead Liver, lung
8 Robot 332 700 0 No 12 Ascites 32.0 Alive
9 Open 477 2 200 1 600 Yes 13 Anemia 19.0 Dead Lung
10 Open 322 1 500 800 No 10 Infection 15.0 Alive Lung
11 Open 282 800 400 No 10 14.0 Alive Lung

Figure 1

Kaplan-Meier curves of overall survival (A) and recurrence-free survival (B) in patients with ACC with or without VTT ACC, adrenal cortical carcinoma."

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