In their article, Fassnacht et al reviewed the outcome relative to staging of a subset of 416 patients from the German Adrenocortical Carcinoma Registry.1 Although stage–specific, disease–specific survival (DSS) differences could be demonstrated using the International Union Against Cancer (UICC) staging system, improved discrimination was achieved by regrouping stage IV patients to take into account distant metastasis status. In this regrouping, patients with distant metastatic disease at presentation (M1) were found to have the poorest DSS, whereas patients with stage IV disease without distant metastasis (M0) were found to have a DSS that was no different from that of patients with stage III disease. Based on these findings, the authors introduced a “new” staging system for adrenocortical carcinoma (ACC), termed the European Network for the Study of Adrenal Tumors (ENSAT) classification. Their proposed staging system differs fundamentally from those of Macfarlane,2 Sullivan et al,3 and the UICC in that stage IV is reserved for patients with distant metastatic disease.
Although we wholeheartedly endorse a revision to the UICC staging system, it should be acknowledged that the authors' suggested revisions are not novel: they were introduced by Icard et al in 19924 and formally proposed by Lee et al in 1995.5 In the staging system proposed by Lee et al, locally invasive tumors (T3 or T4, including tumors with thrombus within the inferior vena cava or renal vein) were explicitly included in the stage III classification, and stage IV was limited to patients with distant metastasis (M1).5 This language is identical to that included in the proposed staging system of Fassnacht et al.1
The authors should be congratulated for formally evaluating ACC staging using a relatively large population of well–documented patients. We are reassured that their results confirm that the staging of ACC patients should be performed in a manner that is similar to that of patients with more common cancers. Their conclusion that surgical technique and extent of resection should be considered in ACC staging is potentially important. Their work can serve as a basis for the adoption of an international consensus regarding the staging of patients with ACC, with appropriate acknowledgement of the prior contributions of other investigators.