Nomograms to Predict Recurrence-Free and Overall Survival After Curative Resection of Adrenocortical Carcinoma

IMPORTANCE Adrenocortical carcinoma (ACC) is a rare but aggressive endocrine tumor, and the prognostic factors associated with long-term outcomes after surgical resection remain poorly defined. OBJECTIVES To define clinicopathological variables associated with recurrence-free survival (RFS) and overall survival (OS) after curative surgical resection of ACC and to propose nomograms for individual risk prediction. DESIGN, SETTING, AND PARTICIPANTS Nomograms to predict RFS and OS after surgical resection of ACC were proposed using a multi-institutional cohort of patients who underwent curative-intent surgery for ACC at 13 major institutions in the United States between March 17, 1994, and December 22, 2014. The dates of our study analysis were April 15, 2015, to May 12, 2015. MAIN OUTCOMES AND MEASURES The discriminative ability and calibration of the nomograms to predict RFS and OS were tested using C statistics, calibration plots, and Kaplan-Meier curves. RESULTS In total, 148 patients who underwent surgery for ACC were included in the study. The median patient age was 53 years, and 65.5%(97 of 148) of the patients were female. One-third of the patients (35.1%[52 of 148]) had a functional tumor, and the median tumor size was 11.2 cm. Most patients (77.7%[115 of 148]) underwent R0 resection, and 8.8% (13 of 148) of the patients had N1 disease. Using backward stepwise selection of clinically important variables with the Akaike information criterion, the following variables were incorporated in the prediction of RFS: tumor size of at least 12 cm(hazard ratio [HR], 3.00; 95% CI, 1.63-5.70; P<.001), positive nodal status (HR, 4.78; 95% CI, 1.47-15.50; P=.01), stage III/IV (HR, 1.80; 95% CI, 0.95-3.39; P=.07), cortisol-secreting tumor (HR, 2.38; 95% CI, 1.27-4.48; P=.01), and capsular invasion (HR, 1.96; 95% CI, 1.02-3.74; P=.04). Factors selected as predicting OS were tumor size of at least 12 cm(HR, 1.78; 95% CI, 1.00-3.17; P=.05), positive nodal status (HR, 5.89; 95% CI, 2.05-16.87; P=.001), and R1 margin (HR, 2.83; 95% CI, 1.51-5.30; P=.001). The discriminative ability and calibration of the nomograms revealed good predictive ability as indicated by the C statistics (0.74 for RFS and 0.70 for OS). CONCLUSIONS AND RELEVANCE Independent predictors of survival and recurrence risk after curative-intent surgery for ACC were selected to create nomograms predicting RFS and OS. The nomograms were able to stratify patients into prognostic groups and performed well on internal validation.