A Novel T-Stage Classification System for Adrenocortical Carcinoma: Proposal from the US Adrenocortical Carcinoma Study Group

Caroline E. Poorman, Cecilia G. Ethun, Lauren M. Postlewait, Thuy B. Tran, Jason D. Prescott, Timothy M. Pawlik, Tracy S. Wang, Jason Glenn, Ioannis Hatzaras, Rivfka Shenoy, John E. Phay, Kara Keplinger, Ryan C. Fields, Linda X. Jin, Sharon M. Weber, Ahmed Salem, Jason K. Sicklick, Shady Gad, Adam C. Yopp, John C. MansourQuan Yang Duh, Natalie Seiser, Carmen C. Solórzano, Colleen M. Kiernan, Konstantinos I. Votanopoulos, Edward A. Levine, Charles A. Staley, George A. Poultsides, Shishir K. Maithel

Research output: Contribution to journalArticlepeer-review

15 Scopus citations


Background: The 7th AJCC T-stage system for adrenocortical carcinoma (ACC), based on size and extra-adrenal invasion, does not adequately stratify patients by survival. Lymphovascular invasion (LVI) is a known poor prognostic factor. We propose a novel T-stage system that incorporates LVI to better risk-stratify patients undergoing resection for ACC. Method: Patients undergoing curative-intent resections for ACC from 1993 to 2014 at 13 institutions comprising the US ACC Group were included. Primary outcome was disease-specific survival (DSS). Results: Of the 265 patients with ACC, 149 were included for analysis. The current T-stage system failed to differentiate patients with T2 versus T3 disease (p = 0.10). Presence of LVI was associated with worse DSS versus no LVI (36 mo vs. 168 mo; p = 0.001). After accounting for the individual components of the current T-stage system (size, extra-adrenal invasion), LVI remained a poor prognostic factor on multivariable analysis (hazard ratio 2.14, 95% confidence interval 1.05–4.38, p = 0.04). LVI positivity further stratified patients with T2 and T3 disease (T2: 37 mo vs. median not reached; T3: 36 mo vs. 96 mo; p = 0.03) but did not influence survival in patients with T1 or T4 disease. By incorporating LVI, a new T-stage classification system was created: [T1: ≤ 5 cm, (−)local invasion, (+/−)LVI; T2: > 5 cm, (−)local invasion, (−)LVI OR any size, (+)local invasion, (−)LVI; T3: > 5 cm, (−)local invasion, (+)LVI OR any size, (+)local invasion, (+)LVI; T4: any size, (+)adjacent organ invasion, (+/−)LVI]. Each progressive new T-stage group was associated with worse median DSS (T1: 167 mo; T2: 96 mo; T3: 37 mo; T4: 15 mo; p < 0.001). Conclusions: Compared with the current T-stage system, the proposed T-stage system, which incorporates LVI, better differentiates T2 and T3 disease and accurately stratifies patients by disease-specific survival. If externally validated, this T-stage classification should be considered for future AJCC staging systems.

Original languageEnglish
Pages (from-to)520-527
Number of pages8
JournalAnnals of Surgical Oncology
Issue number2
StatePublished - Feb 1 2018


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