We thank our correspondents for their interest and are happy to explain the problems with the pathological findings in greater detail:
In none of the Rx patients was their resection status reported by the pathologist. The classification as Rx was made by the investigators of the German Adrenocortical Carcinoma Registry (Nebennierenkarzinomregister) in cases where the pathology report did not contain information on the resection margin. In another context, Rx is obviously a correct diagnosis—for example, where the tumor capsule was damaged intraoperatively. Patients with a damaged tumor capsule were explicitly excluded from the survival analysis.
Figure 3 illustrates a Cox regression analysis and is not a Kaplan-Meier figure, as our correspondents seem to assume. Cox regression allows for the calculation of hazard ratios for the respective groups.
The misdiagnoses concerned metastases of extra-adrenal cancers (n=16), pheochromocytomas (n=2), sarcomas (n=2), and one adrenal adenoma. We are not clear what “marginal” adaptation of the diagnosis refers to—in all cases, treatment with mitotane, for example, would have constituted serious medical mistreatment. Today, the experienced pathologist is usually able to assess the potential malignancy of an adrenal mass and distinguish between primary adrenocortical tumors, adrenal medullary tumors, or metastases. Since most pathologists do not have any experience with the rare adrenal carcinoma they should consult an experienced colleague. We support the demand for expert panels rather than individual experts. The German Society of Pathology should presently appoint such a panel of competent adrenal pathologists.
In case of a hormone-inactive incidentaloma, surgery is indicated only if it is suspected to be malignant—in this setting, the pathological results are therefore of utmost importance. The fact that patients still undergo unnecessary surgery is no reason to compromise on the quality of the pathology report.
Footnotes
Conflict of interest statement
PD Dr Fassnacht and Professor Allolio are investigators of a study of the pharmacokinetics of mitotane that is being funded by HRA Pharma (France). PD Dr Fassnacht is also the principal investigator and Professor Allolio is the investigator of a study of sunitinib that is funded by Pfizer. PD Dr Fassnacht and Professor Allolio are investigators of a clinical study sponsored by OSI Pharma of OSI-9076 in adrenocortical carcinoma.
Dr Johanssen declares that no conflict of interest exists.
References
- 1.Johanssen S, Hahner S, Saeger W, et al. Deficits in the management of patients with adrenocortical carcinoma in Germany. Dtsch Arztebl Int. 2010;107(50):885–891. doi: 10.3238/arztebl.2010.0885. [DOI] [PMC free article] [PubMed] [Google Scholar]