Impact of en bloc extended R0 resections on oncological outcome of locally advanced adrenocortical carcinoma

In locally advanced adrenocortical carcinoma (ACC) (ENSAT stage III - S-III) R0 surgery, involving en bloc extended resections, is the only potential curative treatment. We evaluated oncological outcomes and complications rate in S-III patients who underwent extended resection in comparison with stage I/II (S-I/II). Among 1098 adrenalectomies over 27 years (1997 -2024) in a tertiary referral center, medical records of ACC patients were reviewed, excluding stage IV and not-multivisceral resections in S-III patients. Forty-eight patients met the inclusion criteria: 6 S-I (12.5%), 36 S-II (75%) and 6 S-III (12.5%) patients. The latter patients' cohort underwent multivisceral en bloc resections (3 total nephrectomies, one renal vein thrombectomy, one splenopancreasectomy associated with total nephrectomy, left hemicolectomy and omentectomy, one liver S6-S7-S8 resection). Open adrenalectomy was scheduled in all S-III patients. Minimally-invasive approach was scheduled in 21 (50%) S-I/II patients. Conversion to open adrenalectomy was registered in 5 out these 21 patients. Locoregional and distant disease recurrences were registered in 19% of S-I/II vs 33.3% of S-III patients and 28.6% of S-I/II vs 66.7% of S-III patients, respectively (p = 0.420, p = 0.064). Postoperative complications were observed in 21.4% of S-I/II patients and 16.7% of S-III patients (p = 0.788). Kaplan-Meier DFS and OS curves were comparable among the two groups (p = 0.255, p = 0.459, respectively). After univariable analysis, hyperfunction and chemotherapy were significantly associated with locoregional disease recurrence (p = 0.02, p = 0.04, respectively). OS and DFS of S-III ACC patients undergoing extended en bloc R0 resections were comparable to those of S-I/II patients, without increased postoperative morbidity.