Volume-outcome relationship in adrenal surgery: A review of existing literature

Dwindling dollars: The inflation-adjusted decline of Medicare reimbursement in endocrine surgery (2003-2023)

INTRODUCTION

Medicare determines reimbursement rates for medical services, often setting a benchmark that is followed by private insurers. Across various medical specialties, decreases in Medicare reimbursement have been observed. However, the extent of Medicare reimbursement for endocrine surgery remains unexplored. This study investigates the trajectory of reimbursement rates for endocrine surgical procedures.

METHODS

Data spanning 2003 to 2023 were gathered from the Physician Fee Schedule Look-Up Tool for 16 endocrine operations and procedures. Each operation's or procedure's relative value units and conversion factor, which accounts for geographic variation in relative value units, are determined annually by the Centers for Medicare and Medicaid Services. The total annual Medicare reimbursement for each operation or procedure was determined by multiplying procedure-specific relative value units with the conversion factor. Raw yearly percentage changes in reimbursement were computed and compared to changes in the general consumer price index. All data were then corrected for inflation. The compound annual growth rate for each procedure was calculated using inflation-adjusted data.

RESULTS

From 2003 to 2023, the mean unadjusted percentage change for all queried procedures was +14.14% (standard deviation 0.28). During this same time, the consumer price index increased by 69.15% (P < .001). After adjusting for inflation, the mean total adjusted percentage change for all queried procedures over the entire study period was -31% (standard deviation 0.17). The adjusted average yearly compound annual growth rate was -1.93% (standard deviation 0.92). Only 1 procedure showed an increase in reimbursement (image-guided fine-needle aspiration, +32%).

CONCLUSION

Inflation-adjusted Medicare reimbursement rates for endocrine surgical procedures have consistently declined. Stakeholders must address these trends to ensure access to quality surgical endocrine care in an evolving health care landscape.

Adrenalectomy approach and outcomes according to surgeon volume

BACKGROUND

This study assessed the relationship between surgeon volume, operative management, and resource utilization in adrenalectomy.

METHODS

Isolated adrenalectomies performed within our health system were identified (2016-2021). High-volume surgeons were defined as those performing ≥6 cases/year. Outcomes included indication for surgery, perioperative outcomes, and costs.

RESULTS

Of 476 adrenalectomies, high-volume surgeons (n ​= ​3) performed 394, while low-volume surgeons (n ​= ​12) performed 82. High-volume surgeons more frequently operated for pheochromocytoma (19% vs. 16%, p ​< ​0.001) and less frequently for metastasis (6.4% vs. 23%, p ​< ​0.001), more frequently used laparoscopy (95% vs. 80%, p ​< ​0.001), and had lower operative supply costs ($1387 vs. $1,636, p ​= ​0.037). Additionally, laparoscopic adrenalectomy was associated with shorter length of stay (-3.43 days, p ​< ​0.001), lower hospitalization costs (-$72,417, p ​< ​0.001), and increased likelihood of discharge to home (OR 17.03, p ​= ​0.008).

CONCLUSIONS

High-volume surgeons more often resect primary adrenal pathology and utilize laparoscopy. Laparoscopic adrenalectomy is, in turn, associated with decreased healthcare resource utilization.

Disparities in Access to High-Volume Surgeons and Specialized Care

The significant volume-outcome relationship has triggered interest in improving quality of care by directing patients to high-volume centers and surgeons. However, significant disparities exist for different racial/ethnic, geographic, and socioeconomic groups for thyroid, parathyroid, adrenal, and pancreatic neuroendocrine surgical diseases disease.

Characterization of indocyanine green fluorescence imaging patterns of pheochromocytomas

BACKGROUND

Indocyanine green (ICG) fluorescence is a new intraoperative imaging modality for adrenal tumors. Previous work suggested that pheochromocytomas did not show fluorescence, but experience is limited. The objective of this study is to analyze fluorescence imaging patterns of pheochromocytomas.

METHODS

This was an IRB-approved retrospective study. Patients who underwent adrenalectomy with ICG imaging were identified from a departmental database. Intraoperative fluorescence patterns were analyzed by reviewing surgical videos. Descriptive and comparative statistical analyses were performed to determine factors associated with different fluorescence patterns of pheochromocytomas.

RESULTS

Of the 46 pheochromocytomas included, 50% (n = 23) exhibited fluorescence. Parameters predicting fluorescence on univariate analysis were age, tumor size and hereditary. On multivariate analysis, tumor size was the only predictive parameter of ICG fluorescence, with loss of fluorescence at a threshold of > 3.2 cm (p = 0.004).

CONCLUSIONS

This is the largest cohort to date assessing fluorescence properties of pheochromocytomas. In contrast to previous studies, we demonstrated that smaller pheochromocytomas do exhibit fluorescence. This may support the application of intraoperative ICG imaging for smaller or bilateral pheochromocytomas, which may assist in identification and/or cortical-sparing during adrenalectomy.

Risk factors for intraoperative complications, postoperative complications, and prolonged length of stay after laparoscopic adrenalectomy by transperitoneal lateral approach: a retrospective cohort study of 547 procedures

BACKGROUND

Laparoscopic adrenalectomy (LA) is the gold standard for the resection of most adrenal lesions. A precise delineation of factors influencing its outcomes is lacking. The aim of this study was to assess factors associated with intraoperative complications, postoperative complications, and prolonged length of stay (LOS) after LA.

METHODS

Patients who underwent LA from 1999 to 2021 in a single-academic-institution were included. Patient and disease-specific data, intraoperative complications, postoperative complications according to Dindo-Clavien (DC) scale, and LOS were recorded. Predictive factors of complications and prolonged LOS were determined by logistic regression.

RESULTS

We identified 530 patients who underwent 547 LA. Intraoperative complications occurred in 33 patients (6.0%). Postoperative complications ≥  DC grade 2 occurred in 73 patients (13.35%); severe postoperative complications ≥ DC grade 3 in 14 patients (2.56%). Postoperative complications were positively associated with age ≥ 72 (OR 1.14 [95% CI 1.02-1.29]), intraoperative complications (OR 1.36 [95% CI 1.14-1.63]), and negatively associated with non functional adenomas (OR 0.88 [95% CI 0.7-0.99]), and right adrenalectomy (OR 0.91 [95% CI 0.86-0.97]). Severe postoperative complications were positively associated with chronic obstructive pulmonary disease (COPD, OR 1.08 [95% CI 1.00-1.17]), and negatively associated with right adrenalectomy (OR 0.97 [95% CI 0.92-0.99]). Prolonged LOS was associated with age ≥ 72 (OR 1.21 [95% CI 1.05-1.41]), and COPD (OR 1.20 [95% CI 1.01-1.44]).

CONCLUSIONS

LA remains safe when performed by surgeons with expertise. Right adrenalectomy resulted in less postoperative overall and severe complications. The risk-benefit equation should be carefully assessed before left LA in older patients with COPD.

Outcomes of adrenalectomy performed in regional New South Wales, Australia

BACKGROUND

Centralization of subspeciality procedures in Australia is difficult due to a vast geographical span and in the appropriate patient group, surgery in regional centres should be considered. Our study reviews the safety of adrenalectomy performed at a low-volume regional centre in regards to length of hospital admission, operative time, complication rate and conversion to open rate.

METHOD

A retrospective cross-sectional study was performed of consecutive patients undergoing laparoscopic or open adrenalectomy over a nine-year period (2012-2021) at Dubbo Base Hospital, a regional hospital in Western New South Wales, Australia. These operations were all performed by a single Urologist.

RESULTS

Thirteen patients underwent adrenalectomy at our institution over the nine-year period. The mean age was 51.7 years (SD10.1). There were seven women (53.8%) and six men (46.2%). Seven patients were considered low risk, four patients were medium risk and two patients were high risk as per the Charlson Comorbidity Index. All of our patients were overweight, with mean body mass index of 34.6 (SD 6.9). Mean operating time was 133.5 min (SD 36.3) and mean length of stay was 3.8 days (SD 2.2). There was one conversion to open (8.3%). Three patients (23.1%) had complications, of these complications, one was Clavien-Dindo grade II, and one was Clavien-Dindo grade IIIb. There were no mortalities.

CONCLUSION

Our outcomes demonstrate that adrenalectomy in our low volume regional centre is safe with comparable outcomes of operative time, length of hospital stay and complication rate with other centres.

The Therapeutic Intensity Score as Predictor of Clinical Outcomes after Total and Partial Adrenalectomy for Unilateral Primary Aldosteronism: Results of a Multicentric Series

BACKGROUND

To evaluate the ability of therapeutic intensity score (TIS) in predicting the clinical outcomes of partial (PA) and total adrenalectomy (TA) for UPA.

METHODS

Between 2011 and 2022, a four-center adrenalectomy dataset was queried for "unilateral adrenal mass" and "UPA" (n = 90). Preoperative TIS of each antihypertensive medication were individually calculated and merged to create a single, cumulative variable. Probability of complete clinical, partial, and absent pooled success rates according to TIS were assessed for the overall cohort by Kaplan-Meier. Cox analyses were used to identify predictors of complete clinical and partial/absent success, respectively. For all analyses, a two-sided p < 0.05 was considered significant.

RESULTS

At a median follow-up of 42 months (IQR 27-54) complete partial, and absent clinical success were observed in 60%, 17.7%, and 22.3%, respectively. On Kaplan-Meier analysis, TIS < 1 predicted higher complete success rates (p < 0.001), while TIS ≥ 1 was predictor of either partial and absent clinical success (p = 0.008). On multivariable analysis, TIS < 1 (HR 0.25; 95% CI 0.11-0.57; p = 0.001) and adenoma size (HR 1.11; 95% CI 1-1.23; p = 0.0049) were independent predictors of complete clinical success, while TIS ≥ 1 (HR 2.84; 95% CI 1.32-6.1; p = 0.007) was the only independent predictor of absent clinical success.

CONCLUSIONS

TIS score and adenoma size may help to identify patients who are likely to be at risk of persistent hypertension after surgery.

Is transperitoneal laparoscopic adrenalectomy for pheochromocytoma really more challenging? A propensity score-matched analysis

PURPOSE

Minimally invasive surgery is the gold standard treatment for adrenal masses, but it may be a challenging procedure in the case of pheochromocytoma (PHEO). The aim of the present study is to report the results of transperitoneal laparoscopic adrenalectomy (TLA) in cases of PHEO in comparison to other types of adrenal lesions.

METHODS

From 1994 to 2021, 629 patients underwent adrenalectomy. Twenty-two and thirty-five patients, respectively, were excluded because they underwent bilateral and open adrenalectomy, leaving 572 patients for inclusion. Of these, 114 patients had PHEO (Group A), and 458 had other types of lesions (Group B). To adjust for potential baseline confounders, a propensity score matching (PSM) analysis was conducted.

RESULTS

After PSM, 114 matched pairs of patients were identified from each group. Statistically significant differences were not observed when comparing the median operative time (85 and 90 min in Groups A and B, respectively, p = 0.627), conversion rate [6 (5.3%) in each group, p = 1.000], transfusion rate [4 (3.5%) and 3 (2.6%) in Groups A and B, respectively, p = 1.000], complication rate [7 (6.1%) and 9 (7.9%) in Groups A and B, respectively, p = 0.796), median postoperative hospital stay (3.9 and 3.6 days in Groups A and B, respectively, p = 0.110), and mortality rate [1 (0.9%) in each group, p = 1.000].

CONCLUSIONS

Based on this analysis, the results of TLA for PHEO are equivalent to those of TLA for other types of adrenal lesions, but the fundamental requirements are multidisciplinary patient management and adequate surgeon experience. Further prospective studies are required to draw definitive conclusions.

Analysis of adrenalectomy for the treatment of adrenal diseases performed by the Public Health Service in São Paulo between 2008 and 2019

INTRODUCTION

treating benign (hormonally active or nonfunctional) and malignant adrenal cancer includes adrenalectomy. The expertise of surgeons and surgery performed by high-volume surgeons were associated with fewer complications and lower cost. We aimed to describe and compare the number of surgeries, mortality rate, and length of hospital stay for adrenalectomies performed between 2008 and 2019 in the public health system of São Paulo.

METHODS

this was an ecological study. The data were collected using the TabNet Platform of the Unified Health System Department of Informatics. Outcomes analyzed included the number of surgeries performed, mortality rate during hospital stay, and length of hospital stay. Public hospitals in Sao Paulo were divided into three subgroups according to the surgical volume of adrenalectomies performed as well as hospitals with and without a residency program in Urology, and the results were compared among them.

RESULTS

a total of 943 adrenalectomies were performed in Sao Paulo between 2008 and 2019. Mortality rates during hospital stay according to hospital surgical volume were no reported deaths in low-volume, 0.015% in intermediate-volume, and 0.004% in high-volume hospitals. The average length of the ICU stay was 1.03 days in low-volume, 2.8 in intermediate-volume, and 1.12 in high-volume hospitals (analysis between intermediate and high volume centers with statistical significance, p=0.016).

CONCLUSIONS

despite no statistically significant differences among the groups analyzed, mortality rates were very low in all groups. ICU stay was shorter in high-volume centers than in intermediate-volume centers.

Differences in morbidity and mortality between unilateral adrenalectomy for adrenal Cushing's syndrome and bilateral adrenalectomy for therapy refractory extra-adrenal Cushing's syndrome

PURPOSE

In selected cases of severe Cushing's syndrome due to uncontrolled ACTH secretion, bilateral adrenalectomy appears unavoidable. Compared with unilateral adrenalectomy (for adrenal Cushing's syndrome), bilateral adrenalectomy has a perceived higher perioperative morbidity. The aim of the current study was to compare both interventions in endogenous Cushing's syndrome regarding postoperative outcomes.

METHODS

We report a single-center, retrospective cohort study comparing patients with hypercortisolism undergoing bilateral vs. unilateral adrenalectomy during 2008-2021. Patients with adrenal Cushing's syndrome due to adenoma were compared with patients with ACTH-dependent Cushing's syndrome (Cushing's disease and ectopic ACTH production) focusing on postoperative morbidity and mortality as well as long-term survival.

RESULTS

Of 83 patients with adrenalectomy for hypercortisolism (65.1% female, median age 53 years), the indication for adrenalectomy was due to adrenal Cushing's syndrome in 60 patients (72.2%; 59 unilateral and one bilateral), and due to hypercortisolism caused by Cushing's disease (n = 16) or non-pituitary uncontrolled ACTH secretion of unknown origin (n = 7) (27.7% of all adrenalectomies). Compared with unilateral adrenalectomy (n = 59), patients with bilateral adrenalectomy (n = 24) had a higher rate of severe complications (0% vs. 33%; p < 0.001) and delayed recovery (median: 10.2% vs. 79.2%; p < 0.001). Using the MTL30 marker, patients with bilateral adrenalectomy fared worse than patients after unilateral surgery (MTL30 positive: 7.2% vs. 25.0% p < 0.001). Postoperative mortality was increased in patients with bilateral adrenalectomy (0% vs. 8.3%; p = 0.081).

CONCLUSION

While unilateral adrenalectomy for adrenal Cushing's syndrome represents a safe and definitive therapeutic option, bilateral adrenalectomy to control ACTH-dependent extra-adrenal Cushing's syndrome or Cushing's disease is a more complicated intervention with a mortality of nearly 10%.

Surgical Quality, Antihypertensive Therapy, and Electrolyte Balance: A Novel Trifecta to Assess Long-Term Outcomes of Adrenal Surgery for Unilateral Primary Aldosteronism

BACKGROUND

To propose a trifecta that summarizes endpoints and predicts their maintenance after adrenalectomy (n = 90) for unilateral primary aldosteronism (UPA).

METHODS

Trifecta was defined as coexistence of: ≥50% antihypertensive therapeutic intensity score reduction (∆TIS), no hypokalemia at 3 months, and no Clavien grade 2-5. Logistic regression was used to identify predictors of trifecta. Probability of clinical, biochemical, and simultaneous success according to trifecta were assessed by Kaplan-Meier. Cox regression was used to identify predictors of long-term clinical, biochemical, and simultaneous success. For all analyses, a two-sided p < 0.05 was considered significant.

RESULTS

Simultaneous success rate was 50%. On multivariable analysis, TIS was an independent predictor of trifecta achievement (HR 3.28; 95% CI 1.07-10.9; p = 0.03). At Kaplan-Meier, trifecta predicted higher success for all endpoints (each p < 0.03). On multivariable Cox analysis, adenoma size (AS) ≥6 cm and trifecta were independent predictors of biochemical (AS: HR 2.87; 95% CI 1.53-5.36; trifecta: HR 2.1; 95% CI 1.13-3.90; each p < 0.02) and simultaneous success (AS: HR 3.81; 95% CI 1.68-8.65; trifecta: HR 4.29; 95% CI 2.08-8.86; each p < 0.01), while trifecta was an independent predictor of complete clinical success (HR 2.84; 95% CI 1.45-5.58; p < 0.01).

CONCLUSIONS

Trifecta and AS are independent predictors of either long-term complete clinical, biochemical, or combined success after adrenalectomy for UPA.

Análise da adrenalectomia para tratamento de doenças adrenais realizadas pelo Serviço Público de Saúde de São Paulo entre 2008 e 2019

RESUMO Introdução: o tratamento do câncer de adrenal benigno (hormonalmente ativo ou não funcional) e maligno inclui a adrenalectomia. A experiência dos cirurgiões e a cirurgia realizada por cirurgiões de alto volume foram associadas a menos complicações e menor custo. O objetivo do estudo foi descrever e comparar o número de cirurgias, a taxa de mortalidade e o tempo de internação para adrenalectomias realizadas entre 2008 e 2019 na rede pública de saúde de São Paulo. Métodos: trata-se de um estudo ecológico. Os dados foram coletados da Plataforma TabNet do Departamento de Informática do Sistema Único de Saúde. Os hospitais foram divididos em três subgrupos de acordo com o volume cirúrgico e hospitais com e sem programa de residência médica em Urologia. Os resultados foram comparados entre os grupos. Resultados: no período estudado, 943 adrenalectomias foram realizadas em São Paulo. As taxas de mortalidade durante a internação de acordo com o volume cirúrgico hospitalar foram: não foram relatados óbitos em hospitais de baixo volume; 0,015% em hospitais de volume intermediário e 0,004% em alto volume. O tempo médio de permanência na UTI foi de 1,03 dias nos hospitais de baixo volume; 2,8 nos de médio volume e 1,12 nos de alto volume (análise entre centros de médio e alto volume com significância estatística, p=0,016). Conclusão: as taxas de mortalidade foram muito baixas em todos os grupos. A permanência na UTI foi menor em centros de alto volume do que em centros de volume intermediário.

Adrenocortical carcinoma: current state of the art, ongoing controversies, and future directions in diagnosis and treatment

Adrenocortical carcinoma (ACC) is a rare, aggressive malignancy with an annual incidence of ~1 case per million population. Differentiating between ACC and benign adrenocortical tumors can be challenging in patients who present with an incidentally discovered adrenal mass, due to the limited specificity of standard diagnostic imaging. Recently, urine steroid metabolite profiling has been prospectively validated as a novel diagnostic tool for the detection of malignancy with improved accuracy over current modalities. Surgery represents the only curative treatment for ACC, although local recurrence and metastases are common, even after a margin-negative resection is performed. Unlike other intra-abdominal cancers, the role of minimally invasive surgery and lymphadenectomy in ACC is controversial. Adjuvant therapy with the adrenolytic drug mitotane is used to reduce the risk of recurrence after surgery, although evidence supporting its efficacy is limited; it is also currently unclear whether all patients or a subset with the highest risk of recurrence should receive this treatment. Large-scale pan-genomic studies have yielded insights into the pathogenesis of ACC and have defined distinct molecular signatures associated with clinical outcomes that may be used to improve prognostication. For patients with advanced ACC, palliative combination chemotherapy with mitotane is the current standard of care; however, this is associated with poor response rates (RR). Knowledge from molecular profiling studies has been used to guide the development of novel targeted therapies; however, these have shown limited efficacy in early phase trials. As a result, there is an urgent unmet need for more effective therapies for patients with this devastating disease.

Optimal surgeon-volume threshold for neck dissections in the setting of primary thyroid malignancies

BACKGROUND

Although the surgeon-volume relationship is well documented for thyroidectomy, less is known about central neck and lateral neck dissections. The aim of this study was to evaluate and determine the surgeon-volume threshold for central neck and lateral neck dissections for thyroid cancer.

METHODS

A retrospective analysis of patients with thyroid malignancies who received a central or lateral neck dissection in the New York Statewide Planning and Research Cooperative System was performed (2007-2017). Demographic variables included age, sex, race, and a Charlson Comorbidity Score. Thirty-day complications were identified using International Classification of Diseases (ICD) codes for central neck, lateral neck, and other surgical complications. Optimal surgeon-volume threshold was estimated using a change-point logistic regression. Using the identified threshold, surgeons were then classified to low versus high volume surgeons. Logistic regression analysis was conducted to examine the effect of high-volume status on outcomes.

RESULTS

In total, 3,808 patients who underwent neck dissections (3,485 central neck dissections and 977 lateral neck dissections) were analyzed. Surgeon-volume threshold to distinguish high volume surgeons for central neck dissections and lateral neck dissections was 7.0 (95% bootstrap confidence interval 1.3-7.5) and 3.3 (1.2-4.8) neck dissections/year, respectively. For central neck dissection, high volume surgeons were associated with a lower rate of vocal cord paralysis (odds ratio 0.45 [0.24-0.82]), hypocalcemia (0.31 [0.14-0.65]), and all-cause complications (0.42 [0.29-0.59]). For lateral neck dissection, high volume surgeons were associated with a lower odds all-cause complications (0.42 [0.23-0.74]) but not lateral neck specific complications (0.18 [0.01-1.07]).

CONCLUSION

A threshold of 7.0 central neck dissections and 3.3 lateral neck dissections for thyroid cancer per year improves outcomes. Guidelines for training and centralization of care can be guided by these results to reduce complications.

Volume Matters: Longitudinal Retrospective Cohort Study of Outcomes Following Consultation and Standardization of Adrenal Surgery

PURPOSE

Subspecialization of adrenal surgery through regionalization has not been adequately evaluated. We assessed implementation of subspecialization and the association of regionalization with adrenalectomy outcomes in a community-based setting.

METHODS

In this longitudinal retrospective cohort study, we used an interrupted time series analysis on consecutive adrenal surgeries at Kaiser Permanente Northern California, 2010-2019. The intervention was regionalization of surgery in 2016. Main outcomes include surgical volumes, operative time, length of stay, 30-day return-to-care, and 30-day complications obtained from the electronic medical record. t-Tests and multivariable models were used to analyze time trends in outcomes after accounting for changes in patient and disease characteristics.

RESULTS

In total, 850 adrenal surgery cases were eligible. Between 2010 and 2019, the annual incidence of surgery (per 100,000 persons) increased from 2.4 (95% CI 1.9-3.1) to 4.1 (95% CI 3.5-4.8). Average annual surgeon volume increased from 2.4 (95% CI 1.6-3.1) to 9.9 (95% CI 4.9-14.9), while hospital volume increased from 3.5 (95% CI 2.3-4.6) to 15.4 (95% CI 6.9-24.0). Operative time was 34 (23-45) min faster in 2018-2019 compared with 2010-2011. After regionalization, same-day discharges increased to 64% in 2019 (p < 0.0001). The frequency of return-to-care (p = 0.69) and the overall complication rate (p = 0.31) did not change.

CONCLUSIONS

Regionalizing adrenal surgery through surgical subspecialization and standardized care pathways was feasible and decreased operative time, and hospital stay, while increasing the frequency of same-day discharges without increasing return-to-care or complications.

Volume-outcome relationship for adrenalectomy: analysis of an administrative dataset for the Getting It Right First Time Programme

BACKGROUND

A minimum volume threshold of at least six procedures per annum per surgeon has been set in UK and European guidelines for adrenal surgery. The aim of this study was to investigate outcomes for adrenal surgery in England relative to annual surgeon and hospital trust volume.

METHODS

Data were extracted from the Hospital Episodes Statistics database for England. A 6-year period (January 2013 to December 2018 inclusive) for all adult admissions for unilateral adrenal surgery was used. The primary outcome measure was an emergency readmission within 30 days of discharge following surgery. Procedures were categorized as open or minimally invasive surgery for analysis. Multilevel modelling was used to adjust for hierarchy and potential confounders.

RESULTS

Data for 4189 adrenalectomies were identified. Only one third of surgeons (who operated on just over a half of all patients) performed at least six procedures in the year prior to the index procedure. For open surgery, emergency readmission rates fell significantly from 15.2 to 6.4 per cent for surgeons and from 13.2 to 6.1 per cent for trusts between the lowest- and highest-volume categories. Significant, but less dramatic falls were also seen for minimally invasive surgery.

CONCLUSION

A volume-outcome effect was identified for adrenal surgery in England. Minimum volume thresholds should be set, although these may need to be more ambitious than the current threshold if outcomes are to be optimized.

Surgery for adrenocortical carcinoma: When and how?

Adrenocortical carcinoma (ACC) is a rare malignancy that is frequently asymptomatic at presentation, yet has a high rate of metastatic disease at the time of diagnosis. Prognosis is overall poor, particularly with cortisol-producing tumors. While the treatment of ACC is guided by stage of disease, complete surgical resection is the most important step in the management of patients with primary, recurrent, or metastatic ACC. Triphasic chest, abdomen, and pelvis computer tomography (CT) scans and 18F flourodeoxyglucose positron emission tomography CT scanning are essential for accurate staging; moreover, MRI may be helpful to identify liver metastasis and evaluate the involvement of adjacent organs for operative planning. Surgical resection with negative margins is the single most important prognostic factor for survival in patients with ACC. To achieve the highest rate of R0 resection, open adrenalectomy is the gold standard surgical approach for confirmed or highly suspected ACC. It is extremely important that the tumor capsule is not ruptured, regardless of the surgical approach used. The best post-operative outcomes (complications and oncologic) are achieved by high-volume surgeons practicing at high-volume centers.