A new prognostic factor for the survival of patients with renal cell carcinoma developing metastatic spinal cord compression

Background and purpose

This study aimed to identify a potential association of the number of involved extraspinal organs with the survival of patients with metastatic spinal cord compression (MSCC) from renal cell carcinoma.

Patients and methods

Data of 69 patients irradiated for MSCC from renal cell carcinoma were retrospectively evaluated for survival. The prognostic value of the number of involved extraspinal organs and eight additional factors were investigated. These additional factors included age, gender, performance status, number of involved vertebrae, interval from cancer diagnosis to radiotherapy (RT) of MSCC, ambulatory status prior to RT, time developing motor deficits, and the fractionation regimen (30 Gy in 10 fractions vs. higher doses).

Results

The 6-month survival rates for involvement of 0, 1, and ≥?2 extraspinal organs were 93, 57, and 21?%, respectively (p?<?0.001). In the multivariate analysis, the number of involved extraspinal organs maintained significance (risk ratio 2.65; 95?% confidence interval 1.64–4.52; p?<?0.001). The interval from cancer diagnosis to RT of MSCC (p?=?0.013) and ambulatory status prior to RT (p?=?0.002) were also independent predictors of survival.

Conclusion

The number of involved extraspinal organs is a new prognostic factor of survival in patients with MSCC from renal cell carcinoma and should be considered in future clinical trials.

     

Imaging in metastatic renal cell carcinoma

OBJECTIVE: Metastatic disease occurs in a significant percentage of patients with renal cell carcinoma. Recent advances in systemic therapies for metastatic renal cell carcinoma are likely to have a significant effect on the way patients with advanced disease are imaged. These new therapies have shown a significant increase in progression-free survival. CONCLUSION: Imaging is likely to play an increasing role in the management, diagnosis, and monitoring of response to treatment of metastatic renal cell carcinoma.     

Fatty metastatic lesions in 2 patients with renal clear-cell carcinoma

This is a case report of 2 patients with previously resected renal cell carcinoma who present with unusual fatty lesions that proved to be metastases.     

Five-year survival of patients with larynx carcinoma treated with irradiation

182 cases of laryngeal carcinoma treated with irradiation alone or combined surgery and radiotherapy are presented. The five-year survival of the whole series was 56%. 109 (60%) of the cases had a glottic, and 73 (40%) a supraglottic tumour. Of the patients with glottic tumour 58% and of those with supraglottic tumour 53% survived five years. There was no significant difference between cases treated with conventional X-rays and cobalt therapy except in T1 cases which were treated with radiotherapy alone: of the 21 cases treated with X-rays eleven (52%), and of 29 treated with cobalt 24 (83%) survived five years.     

Mediastinal adenopathy and endobronchial involvement in metastatic renal cell carcinoma

Mediastinal adenopathy and endobronchial metastases are sometimes the only radiological manifestation of metastatic disease from extrathoracic neoplasms. We report on four patients in whom hilar and paratracheal adenopathy (n = 3) and endobrochial involvement (n = 1) were the only intrathoracic manifestations of metastatic renal cell carcinoma. Three of the patients had nephrectomies 9 months to 4 years before the appearance of intrathoracic disease; another patient presented with medastinal disease as the initial manifestation of renal cell carcinoma. If a patient with a history of renal cell carcinoma develops pulmonary hilar adenopathy, metastatic disease should be suspected and appropriate diagnostic measures should be taken.     

Computed tomography of renal cell carcinoma in patients with terminal renal impairment

Purpose

An increased incidence of renal tumors has been observed in patients with end-stage-renal-disease (ESRD). The very strong association with acquired renal cystic disease (ACRD) and increased incidence of the renal tumors (conventional renal cell carcinoma (CRCC), papillary renal cell carcinoma (PRCC) or papillary renal cell adenoma (PRCA)) was reported. This study discusses the role of computed tomography (CT) in detecting renal tumors in patients with renal impairment: pre-dialysis, those receiving dialysis or with renal allograft transplants.

Materials and methods

Ten patients (nine male, one female) with renal cell tumors were enrolled into a retrospective study; two were new dialysis patients, three on long-term dialysis, and five were renal transplant recipients with history of dialysis. All patients underwent helical CT, a total of 11 procedures were performed. Sixteen-row detector system was used five times, and a 64-row detector system for the six examinations. All patients underwent nephrectomy of kidney with suspected tumor, 15 nephrectomies were performed, and 1 kidney was assessed during autopsy. CT findings were compared with macroscopic and microscopic assessments of the kidney specimen in 16 cases.

Results

Very advanced renal parenchyma atrophy with small cysts corresponding to ESRD was found in nine patients, chronic pyelonephritis in remained one. A spontaneously ruptured tumor was detected incidentally in one case, patient died 2 years later. In the present study, 6.25% (1/16) were multiple PRCA, 12.5% (2/16) were solitary PRCC, 12.5% tumors (2/16) were solitary conventional renal cell carcinomas (CRCC's), 12.5% tumors (2/16) were multiple conventional renal cell carcinomas (CRCC's), 25% (4/16) were CRCC's combined with multiple papillary renal cell carcinomas with adenomas (PRCC's and PRCA's), and 25% (4/16) of the tumors were multiple PRCC's combined with PRCA's without coexisting CRCC's. Bilateral renal tumors were found in our study in 60% (6/10) confirmed in six cases, one kidney left on follow-up due to the small tumors.

Conclusions

With the use of a multi-detector row system, it is possible to detect smaller foci suspected to originate in multiple tumors, especially when up to 3-mm thin multi-planar reconstructions are used. Two cases demonstrated the possibility the development of RCC in impaired kidneys may start before dialysis initiation.     

Computed tomography of renal cell carcinoma in patients with terminal renal impairment

PURPOSE: Current kidney surgery uses less invasive laparoscopic and nephron-sparring procedures. Thus, perfect imaging of the renal vasculature is essential for surgery planning. The aim of our retrospective study was to evaluate the accuracy of 16-detector-row CT-angiography in assessing the vascular anatomy of the kidney with a tumor. SUBJECTS AND METHODS: Referred for computed tomography (CT) because of a suspected renal tumor, 50 consecutive patients (mean age 58.6 years; range 43-82) were enrolled into our retrospective study. All examinations were performed with 16x0.75 mm collimation after the intravenous application of 80 ml of a non-ionic contrast material. The imaging protocol contained two-phase scanning in the arterial and then in the venous phase. The vascular anatomy of the kidney with tumor was evaluated using volume rendered (VRT) and maximum intensity images (MIP). Findings were compared with the anatomy found during surgery. RESULTS: Forty-seven patients underwent nephrectomy, with an advanced clinical stage (IV) found in the three remaining ones. Correct topography of the renal hilus, including a number of arteries and veins, and the anatomy of their branching, was described in 46 patients. A very small upper polar artery was overlooked in one patient. The accuracy for the only-arterial was 97.9% and only-venous anatomy was 100%. The parasitic vasculature of the tumor was discovered in 10 cases and all of them were confirmed by surgery (100% accuracy). Macroscopic intravenous spread of the tumor was discovered in two cases, but microscopic intravenous invasion was confirmed during histology of the kidney specimens in another two cases, the overall tumor staging accuracy reaching 95.7%. CONCLUSION: Two-phase multidetector CT is a valuable tool for assessing vascular supply of the kidney before surgery due to the tumor and can fully replace catheter-based angiography.     

Tumor response and clinical outcome in metastatic gastrointestinal stromal tumors under sunitinib therapy: Comparison of RECIST,Choi and volumetric criteria

Purpose

Purpose of the study was to compare radiological treatment response according to RECIST, Choi and volumetry in GIST-patients under 2nd-line-sunitinib-therapy and to correlate the results of treatment response assessment with disease-specific survival (DSS).

Patients and methods

20 patients (mean: 60.7 years; 12 male/8 female) with histologically proven GIST underwent baseline-CT of the abdomen under imatinib and follow-up-CTs 3 months and 1 year after change to sunitinib. 68 target lesions (50 hepatic, 18 extrahepatic) were investigated. Therapy response (partial response (PR), stable disease (SD), progressive disease (PD)) was evaluated according to RECIST, Choi and volumetric criteria. Response according to the different assessment systems was compared and correlated to the DSS of the patients utilizing Kaplan–Meier statistics.

Results

The mean DSS (in months) of the response groups 3 months after therapy change was: RECIST: PR (0/20); SD (17/20): 30.4 (months); PD (3/20) 11.6. Choi: PR (10/20) 28.6; SD (8/20) 28.1; PD (2/20) 13.5. Volumetry: PR (4/20) 29.6; SD (11/20) 29.7; PD (5/20) 17.2.Response groups after 1 year of sunitinib showed the following mean DSS: RECIST: PR (3/20) 33.6; SD (9/20) 29.7; PD (8/20) 20.3. Choi: PR (10/20) 21.5; SD (4/20) 42.9; PD (6/20) 23.9. Volumetry: PR (6/20) 27.3; SD (5/20) 38.5; PD (9/20) 19.3.

Conclusion

One year after modification of therapy, only partial response according to RECIST indicated favorable survival in patients with GIST. The value of alternate response assessment strategies like Choi criteria for prediction of survival in molecular therapy still has to be demonstrated.     

Hemangiomas of the liver in patients with renal cell carcinoma

Five patients with renal cell carcinoma were noted at angiography to have vascular hepatic lesions which resembled metastatic renal cell carcinoma but which proved to be benign hepatic hemangiomas. The angiographic differentiation between small hemangiomas and metastatic vascular neoplasms of the liver can be difficult; angiographic characteristics may not be definitive. Surgery to remove the renal tumor should not be deferred solely on the basis of vascular hepatic lesions found at angiography.     

The prognostic and predictive value of vascular response parameters measured by dynamic contrast-enhanced-CT, -MRI and -US in patients with metastatic renal cell carcinoma receiving sunitinib

Objectives

To identify dynamic contrast-enhanced (DCE) imaging parameters from MRI, CT and US that are prognostic and predictive in patients with metastatic renal cell cancer (mRCC) receiving sunitinib.

Methods

Thirty-four patients were monitored by DCE imaging on day 0 and 14 of the first course of sunitinib treatment. Additional scans were performed with DCE-US only (day 7 or 28 and 2 weeks after the treatment break). Perfusion parameters that demonstrated a significant correlation (Spearman p < 0.05) with progression-free survival (PFS) and overall survival (OS) were investigated using Cox proportional hazard models/ratios (HR) and Kaplan-Meier survival analysis.

Results

A higher baseline and day 14 value for Ktrans (DCE-MRI) and a lower pre-treatment vascular heterogeneity (DCE-US) were significantly associated with a longer PFS (HR, 0.62, 0.37 and 5.5, respectively). A larger per cent decrease in blood volume on day 14 (DCE-US) predicted a longer OS (HR, 1.45). We did not find significant correlations between any of the DCE-CT parameters and PFS/OS, unless a cut-off analysis was used.

Conclusions

DCE-MRI, -CT and ultrasound produce complementary parameters that reflect the prognosis of patients receiving sunitinib for mRCC. Blood volume measured by DCE-US was the only parameter whose change during early anti-angiogenic therapy predicted for OS and PFS.

Key Points

? DCE-CT, -MRI and ultrasound are complementary modalities for monitoring anti-angiogenic therapy. ? The change in blood volume measured by DCE-US was predictive of OS/PFS. ? Baseline vascular heterogeneity by DCE-US has the strongest prognostic value for PFS.

     

Quantitative methodology using CT for predicting survival in patients with metastatic colorectal carcinoma: a pilot study

ObjectiveTo develop a methodology which quantifies multiple changing lesion features resulting in an optimized computed tomography (CT) response score (CRS) for prediction of overall survival (OS) in response to treatment for metastatic colorectal carcinoma (MCRC).Subjects and MethodsThis Health Insurance Portability and Accountability Act-compliant, institutional review board-approved retrospective study evaluated multiple changing imaging findings and their correlation with OS with a new methodology comparing the baseline and first post-treatment CT scans in 38 MCRC patients on last-line chemotherapy (cetuximab and irinotecan). Tumor size/enhancement changes and interval development of new lesions were quantified with either Likert-type scales (all parameters) or Response Evaluation Criteria in Solid Tumors (RECIST) (size change only). The most predictive parameters for OS were used to generate the CRS with an overall range of ?3 (complete disappearance) to +2 (definite tumor increase). The Cox Hazard Ratio was used to assess prediction of survival. Reader agreement was evaluated by the kappa statistic.ResultsTumor size was the best predictor of OS using the Likert-type scale or RECIST. The CRS was not improved combining size change with other parameters. Use of the Likert-type scale resulted in predicting OS with a Cox hazard ratio of 1.697 (P=.0004) and good agreement (kappa=0.73, 95% CI=0.41–1.10) between observers with no significant difference using RECIST.ConclusionThe methodology produces a CRS for MCRC predicting OS resulting from therapy which expands standard RECIST guidelines to allow critical evaluation of multiple additional imaging parameters. Size change alone was found to be the best parameter of those considered in terms of maximizing agreement and prediction of OS.