Long-term outcomes of combined surgery for locally advanced and metastatic adrenocortical carcinoma: a 35-year experience analysis

Background. Adrenocortical carcinoma (ACC) is a rare malignancy characterized by aggressive behavior and poor prognosis. Radical resection remains the only curative treatment, yet locally advanced disease with invasion of adjacent organs and major vessels frequently necessitates combined and multiorgan resections. Evaluating the outcomes and safety of such aggressive surgical approaches is essential to refine treatment strategies and indications. Aim. To evaluate the outcomes and prognostic factors of combined resections in patients with stage III–IV adrenocortical carcinoma, including procedures with vascular and multiorgan involvement. Materials and methods. This retrospective study was conducted at the Blokhin National Medical Research Center of Oncology and included 192 patients with stage III–IV adrenocortical carcinoma who underwent surgery between 1987 and 2022. A detailed analysis was performed for 115 patients who underwent combined resections involving adjacent organs and/or major vessels. For comparison, data from 42 standard adrenalectomies and 13 exploratory interventions were analyzed; an additional group of 20 patients received non-surgical treatment. Survival was assessed using the Kaplan–Meier method, and independent prognostic factors were identified using Cox proportional hazards regression (p 0.05). Results. Among 115 patients who underwent combined resections, postoperative complications occurred in 55.6% versus 16.6% after standard operations (p = 0.0001); postoperative mortality rates were 11.4% and 2.4%, respectively. Radical (R0) resections were associated with significantly better survival: median overall survival reached 84 months versus 4 months after palliative procedures (p 0.01). In stage IV disease, the best outcomes were observed in patients who achieved R0 resection limited to the abdominal cavity (median 41 months), compared to 8 and 11 months after conditionally radical and R2 resections, respectively (p = 0.004). Multivariate analysis confirmed the prognostic significance of resection radicality as prognostic factor. Conclusion. Radical resection remains the key determinant of survival in patients with stage III–IV adrenocortical carcinoma. Our analysis confirms that combined surgical procedures, despite their technical complexity and higher risk of complications, are justified and provide a significant improvement in long-term outcomes for this patient population.