Deficits in the management of patients with adrenocortical carcinoma in Germany. Statements cannot be substantiated.

The Wurzburg registry&'s work has many merits and deserves praise; the number of tumors captured is impressive. However, the authors report alleged deficits in the histopathological reports of adrenocortical tumors without proving these to a satisfactory degree. The authors state that for 11% of the cases, the histopathology report contained only insufficient information about resection status (Rx). Rx is a correct description if findings, especially for reasons related to the specimen, do not enable substantiated evaluation of the resection status (for example, a fragmented specimen, tissue sampled by a non-pathologist, missing details on localization, etc). Since this situation is not distinguished from true deficits of the diagnostic report, the current evaluation does not allow for assessing the quality of the histopathological reporting. Figure 3 shows the survival of the patients with an Rx status. The graphical representation is not correct because the events of the Rx and R1 curves by far exceed the “n” numbers (16 and 19). The figure does therefore not show an intermediary survival in Rx patients (heterogeneous group). The diagnosis reportedly had to be revised in 13% of cases; but plausible evidence is missing. Furthermore it was not shown whether the diagnosis was fundamentally or marginally adapted. In adrenocortical carcinoma, plausible reasons may in individual cases lead to a change in the primary diagnosis without any real errors having been committed. Dignity assessment may be impossible, as may in individual cases the definite differentiation from metastases in an isolated adrenal specimen. Claiming a high rate of misdiagnoses without categorical evaluation of individual cases cannot be justified. Furthermore, individual reference pathologies are insufficient in complex diagnostic studies. The German Society of Pathology rightly asks for expert panels rather than individual experts. Demanding reference histology as a default in endocrine-inactive tumors of the adrenal cortex is unjustifiable because this would mean that any incidentaloma of the adrenal cortex would have to be sent out for reference pathology, and many patients would be exposed to worry quite unnecessarily. A need for improvement should be argued and proved stringently, and studies that postulate deficits should themselves meet particularly stringent quality criteria.