Relationship between age at diagnosis and clinicopathologic features of renal cell carcinoma

OBJECTIVES: To analyse the influence of age at diagnosis on tumour characteristics and cancer-specific survival in renal cell carcinoma (RCC). METHODS: Data on age, tumour characteristics, and survival for 4774 patients from 12 European RCC databases were recorded. Patients were divided into four groups according to age at diagnosis: < or =40, >40 and <60, > or =60 and <80, and > or =80 yr. The following variables were analysed: TNM stage, Fuhrman grade, tumour size, symptoms at diagnosis, ECOG performance status (PS), and cancer-specific survival. The groups were compared for usual clinical and pathologic variables, and cancer-specific survival. RESULTS: The four groups accounted for 288 (6%), 1839 (38.5%), 2499 (52.3%), and 148 cases (3.2%), respectively. Differences were found among groups for tumour stage, symptoms at diagnosis, ECOG PS, Fuhrman grade (p<0.001), tumour size, M stage, and histologic subtype (p: 0.02). Patients < or =40 yr were more likely to have papillary or chromophobe RCCs and less likely to have clear-cell RCCs. No significant difference was found among groups for N stage (p: 0.15). The 5-yr cancer-specific survival rates for the four age categories were 85%, 74%, 70%, and 69%, respectively. In multivariate analysis age category remained an independent prognostic parameter (p<0.001). CONCLUSIONS: Renal tumours diagnosed in younger age are characterized by lower tumour stages and grades as well as favourable histologic patterns compared with tumours in older patients. Basic research is required for explaining such a relationship between age, tumour aggressiveness, and therefore tumour biology.     

Changes in the stage and surgical management of renal tumours during 1995-2005: an analysis of the Dutch national histopathology registry

OBJECTIVE

To evaluate changes in the pathological characteristics, stage of primary renal tumours and their surgical management in the Netherlands during the period 1995–2005.

METHODS

Extracts from the records of all patients who had surgery for primary renal tumours in the Netherlands during the period 1995–2005 were reviewed. Data were collected from PALGA, the nationwide network and archive of histocytopathology. The 2002 Tumour‐Node‐Metastasis and the three‐tier Fuhrman grade were used for staging and grading.

RESULTS

In all there were 12 471 operations for primary renal masses during the study period. The incidence of surgically removed renal cancers increased from 6.2 in 1995 to 7.5 cases per 100 000 inhabitants (P = 0.005) in 2005. The mean (sd , median) age of the patients was 63.3 (11.9, 65.0) years, with a male‐to‐female ratio of 3:2. The mean (sd ) tumour size of malignant tumours decreased from 7.3 (3.6) to 6.9 (3.7) cm (P = 0.301). The percentage of benign removed tumours remained relatively stable (P = 0.056), with a mean of 5.4% of all resected tumours. There was an increase of grade 1 tumours; the incidence of T1 tumours increased from 36.6% to 44.2%, and advanced tumours decreased from 46.4% to 33.7%, respectively. The percentage of nephron‐sparing surgery increased from 3.5% in 1995 to 10.1% (P = 0.003) in 2005, mainly in the T1a tumours.

CONCLUSIONS

During the last decade there was an increase in the incidence of surgically treated renal tumours in the Netherlands. Tumours with favourable histopathological characteristics, low stage and grade, accounted for most of this increase. The percentage of surgically removed benign tumours remained stable. The use of nephron‐sparing surgery increased during the last decade, especially in T1a tumours.     

Renal cell carcinoma: a clinicopathological follow-up study after radical nephrectomy

OBJECTIVE: To examine the prognostic significance of performance status, tumour stage, histological subtype, nuclear grade and histological tumour necrosis (HTN) in a population of consecutive patients subjected to radical nephrectomy for renal cell carcinoma (RCC). MATERIAL AND METHODS: The cohort consisted of 110 males and 86 females with a mean age of 66 years (range 39-88 years). The Eastern Cooperative Oncology Group performance status (ECOG PS) was determined in all cases. The tumours were staged according to the 2002 TNM classification of the American Joint Committee on Cancer. Histological subtype was diagnosed using the Heidelberg classification. Nuclear grading was performed by means of Fuhrman's method. The median follow-up period was 65 months (mean 83 months; range 1-232 months). RESULTS: Median overall survival (OS) was 65 months and median cancer-specific survival (CSS) was 171 months. CSS was correlated with TNM classification, with the longest survival occurring for stage I and II tumours, shorter survival for stage III tumours and shortest survival for stage IV tumours (p<0.001). A significant difference in CSS was found between T1N0M0 and T2N0M0 tumours (p<0.01). A 15-year CSS of 100% was revealed in patients with tumours 相似文献   

Renal cell carcinoma (RCC) in patients with end-stage renal disease exhibits many favourable clinical, pathologic, and outcome features compared with RCC in the general population

Background

Patients with end-stage renal disease (ESRD) are at risk of developing renal tumours.

Objective

Compare clinical, pathologic, and outcome features of renal cell carcinomas (RCCs) in ESRD patients and in patients from the general population.

Design, setting, and participants

Twenty-four French university departments of urology participated in this retrospective study.

Intervention

All patients were treated according to current European Association of Urology guidelines.

Measurements

Age, sex, symptoms, tumour staging and grading, histologic subtype, and outcome were recorded in a unique database. Categoric and continuous variables were compared by using chi-square and student statistical analyses. Cancer-specific survival (CSS) was assessed by Kaplan-Meier and Cox methods.

Results and limitations

The study included 1250 RCC patients: 303 with ESRD and 947 from the general population. In the ESRD patients, age at diagnosis was younger (55 ± 12 yr vs 62 ± 12 yr); mean tumour size was smaller (3.7 ± 2.6 cm vs 7.3 ± 3.8 cm); asymptomatic (87% vs 44%), low-grade (68% vs 42%), and papillary tumours were more frequent (37% vs 7%); and poor performance status (PS; 24% vs 37%) and advanced T categories (≥3) were more rare (10% vs 42%). Consistently, nodal invasion (3% vs 12%) and distant metastases (2% vs 15%) occurred less frequently in ESRD patients. After a median follow-up of 33 mo (range: 1-299 mo), 13 ESRD patients (4.3%), and 261 general population patients (27.6%) had died from cancer. In univariate analysis, histologic subtype, symptoms at diagnosis, poor PS, advanced TNM stage, high Fuhrman grade, large tumour size, and non-ESRD diagnosis context were adverse predictors for survival. However, only PS, TNM stage, and Fuhrman grade remained independent CSS predictors in multivariate analysis. The limitation of this study is related to the retrospective design.

Conclusions

RCC arising in native kidneys of ESRD patients seems to exhibit many favourable clinical, pathologic, and outcome features compared with those diagnosed in patients from the general population.     

Prognostic significance of the mode of detection in renal tumours

OBJECTIVE: To evaluate the mode of detection of 400 renal tumours as a prognostic factor compared with the usual clinical and pathological prognostic variables. PATIENTS AND METHODS: The data were reviewed for 400 patients operated for a renal tumour at our institution between 1984 and 1999, analysing the prognostic value of age, sex, tumour size, stage, grade, vein invasion, adrenal gland invasion, lymph node invasion, metastasis, and mode of detection (incidental or not). The survival rates were assessed using the Kaplan-Meier method and log-rank test, and the data evaluated using multivariate analysis with the Cox proportional-hazard model. RESULTS: In all, 151 (38%) renal tumours were discovered incidentally. There was no significant difference in the percentage of renal cell carcinoma found between the groups of patients discovered incidentally or not (94.4% vs 93.9%). Tumours were smaller in the incidental group (5.7 cm vs 8.7 cm, P < 0.001). In the incidental group, 15.2% of the tumours were treated with partial nephrectomy, against 1.2% in the symptomatic group (P < 0.001). The specific survival was significantly better in patients with renal tumours discovered incidentally (log-rank test, P < 0.001). The multivariate analysis showed that the mode of detection, stage, grade, metastasis (all P < 0.001), and lymphatic extension (P = 0.005) were independent prognostic factors. CONCLUSION: The incidental discovery of renal tumours gives a supplementary benefit to patients in terms of survival, and should be considered as a prognostic factor in addition to stage and grade.     

Prognostic factors in a large multi-institutional series of papillary renal cell carcinoma

Study Type – Prognosis cohort series (multi‐centre) Level of Evidence 2b What's known on the subject? and What does the study add? The relatively low prevalence of papillary RCC and the limited number of patients enrolled in most of the surgical series limit meaningful conclusions with respect to cancer‐related outcome and independent prognostic information. Patients with papillary RCC have relatively a low risk of tumour recurrence and cancer‐related death after surgery. Pathological lymph node stage, presence of metastases and Fuhrman nuclear grade were the main independent predictors of cancer‐related outcomes, whereas only a non‐statistically significant trend was found for the 2009 pathological T stage.

OBJECTIVES

• ? To investigate cancer‐related outcomes and prognostic factors of papillary renal cell carcinoma (pRCC) in a large multicentre data set.
• ? Oncological outcome and prognostic factors of pRCC have been limitedly evaluated in comparison with the most common RCC subtype, clear cell RCC.

PATIENTS AND METHODS

• ? From a multicentre retrospective database, including 5463 patients who were surgically treated for RCC at 16 Italian academic centres between 1995 and 2007, 577 patients with pRCC were identified.
• ? Univariable and multivariable Cox regression models were performed to identify prognostic factors predictive of recurrence‐free survival (RFS) and cancer‐specific survival (CSS) after surgery.

RESULTS

• ? At a median (interquartile range) follow‐up of 39.2 (21.7–72) months, 81 (14%) patients had experienced disease progression and 63 (11%) patients had died from disease; the 5‐year RFS estimate was 85.5%.
• ? In multivariable analysis, pathological N stage (pooled P < 0.001), M stage (hazard ratio, 2.9; P= 0.007) and Fuhrman nuclear grade (pooled P= 0.039) were all independent predictors of RFS; the 5‐year CSS estimate was 87.9%.
• ? In Cox multivariable analysis, an independent predictive role was reconfirmed for mode of presentation (pooled P= 0.038), pathological N stage (pooled P < 0.001), M stage (hazard ratio, 2.4; P= 0.049) and Fuhrman nuclear grade (pooled P= 0.037).

CONCLUSIONS

• ? Patients with pRCC have a low risk of tumour recurrence and cancer‐related death after surgery.
• ? Fuhrman nuclear grade was found to be a stronger predictor of both RFS and CSS, whereas only a non‐statistically significant trend was found for the 2009 pathological T stage.

     

Multi-institutional validation of a symptom based classification for renal cell carcinoma

PURPOSE: We validate the prognostic value of a symptom based classification (S classification) in a multi-institutional study. MATERIALS AND METHODS: A total of 2,242 patients from 5 European centers were included in this study. Based on symptoms at diagnosis, patients were stratified into 3 groups of S1-asymptomatic tumors, S2-tumors with local symptoms and S3-tumors with systemic symptoms. Variables such as age, gender, tumor size, TNM stage, Fuhrman grade, Eastern Cooperative Oncology Group (ECOG) performance status, perinephric fat, renal vein and adrenal invasion were also considered for prognostic value. The end point of the study was cancer specific survival. Survival assessment was made with univariate and multivariate analyses using the Kaplan-Meier method and Cox regression analysis. RESULTS: Of the patients 1,018 (45.4%) were classified as S1, 865 (38.6%) S2 and 339 (16.0%) S3. The S classification correlated to tumor stage, grade and ECOG (p <0.001). On univariate analysis ECOG performance status, S classification, tumor size, TNM stage, Fuhrman grade, and adrenal, perinephric fat or vein invasion were significant prognostic factors (p <0.001). The S classification provided a significant prognostic stratification in the aggregate as well at each of the 5 centers. On multivariate analysis the S classification, TNM stage, Fuhrman grade, and perinephric fat and renal vein invasion remained independent prognostic factors (p <0.001). CONCLUSIONS: This study confirms that it is possible to graduate symptoms for a prognostic purpose. The proposed symptom score should be evaluated for its integration in prognostic algorithms.     

Partial nephrectomy in two patients with known T3a tumours involving the renal vein

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Although nephron‐sparing surgery (NSS) has became accepted therapy for T1 tumours, radical nephrectony is considered the best therapy for T3a tumours involving the renal vein. NSS can be considered in T3a or greater tumours if imperative indications exist, such as bilateral disease or solitary kidney. However, there is little published data on the characteristics of these patients, the impact of surgery on their renal function, and long‐term oncologic outcomes. This study profiles single‐institution experience with nephron‐sparing surgery for known T3a tumours involving the renal vein, including patient characteristics, tumour characteristics, preoperative and follow‐up imaging, preoperative and follow‐up estimated glomerular filtration rate, length of temporary postoperative haemodialysis, and oncologic outcome. Additionally, we compare this to other published data on nephron‐sparing surgery for similar tumors.

OBJECTIVE

• ? To present two patients with T3a tumours involving the renal vein who underwent nephron‐sparing surgery (NSS) for imperative reasons.

PATIENTS AND METHODS

• ? Retrospective chart review of patients who underwent NSS for renal cell carcinoma (RCC) with known renal vein tumour thrombus (RVTT).
• ? Both patients underwent open partial nephrectomy and renal vein thrombectomy of a solitary kidney.
• ? Primary outcomes of the study include radiographic evidence of recurrence, haemodialysis requirement and estimated glomerular filtration rate (eGFR) before and after surgery.

RESULTS

• ? Patient 1 is 24 months from NSS and has no evidence of recurrence based on CT scan. His final pathology revealed a 9‐cm, T3a, clear cell, Fuhrman grade II carcinoma. He spent 42 days on haemodialysis and is now off all dialysis. His preoperative and most recent eGFR are 48 and 23 mL/min/1.73 m² based on the Modification of Diet in Renal Disease (MDRD) equation and 69.4 and 29.8 mL/min by the Cockcroft–Gault equation.
• ? Patient 2 is 9 months from NSS and has no evidence of recurrence based on CT scan. Her final pathology revealed a 6‐cm, T3a, clear cell, Fuhrman grade II–III carcinoma. She spent 30 days on haemodialysis and is now off all dialysis. Her preoperative and most recent eGFR are 58 and 30 mL/min/1.73 m² based on the MDRD equation and 62.2 and 32.8 mL/min by the Cockcroft–Gault equation.

CONCLUSION

• ? Based on our review, preservation of renal function and favourable oncological outcome can be accomplished with NSS in patients with known stage T3a RCC with RVTT and should be considered in carefully selected patients.

     

The relationship between the local and systemic inflammatory responses and survival in patients undergoing resection for localized renal cancer

OBJECTIVE

To examine the relationship between the systemic inflammatory response (C‐reactive protein, CRP), tumour interleukin‐6 receptor and cyclooxygenase (COX)‐2 expression, tumour T‐lymphocytic (CD4+, CD8+) infiltration and cancer survival in patients undergoing resection for renal cell carcinoma (RCC), as both the local and systemic inflammatory responses appear to predict the outcome in these patients.

PATIENTS AND METHODS

The study included 60 patients undergoing nephrectomy for localized RCC. Pre‐operative circulating CRP levels were measured and tumour interleukin‐6 receptor and COX‐2 expression, tumour CD4+ and CD8+ T lymphocytes were assessed using immunohistochemical analysis.

RESULTS

The median follow‐up was 78 months, with 14 patients relapsing from their disease and nine cancer‐specific deaths. On univariate and multivariate survival analysis, tumour stage and grade and CRP levels were identified as significant factors associated with relapse‐free and cancer‐specific survival. There was a significant direct relationship between Fuhrman grade and CD4+ T‐lymphocytic infiltrate (P < 0.05). An increase in tumour expression of interleukin‐6 receptor was weakly associated with an increase in tumour CD8+ T‐lymphocytic infiltration (P = 0.057). An increase in tumour CD4+ T‐lymphocytic infiltration was associated with an increase in CD8+ T‐lymphocytic infiltration (P < 0.01).

CONCLUSIONS

The present results suggest that tumour‐based factors such as interleukin‐6 receptor and COX‐2 expression or T‐lymphocytic subset infiltration are subordinate to systemic factors such as CRP level in determining survival in patients with localized RCC.     

International validation of the prognostic value of subclassification for AJCC stage pT3 upper tract urothelial carcinoma of the renal pelvis

Study Type – Prognosis (inception cohort) Level of Evidence 2a What's known on the subject? and What does the study add? Tumour stage is a powerful predictor of clinical outcomes and the most important factor driving clinical decision‐making after radical nephroureterectomy (RNU) in upper tract urothelial carcinoma (UTUC). It has been suggested that renal pelvic pT3 subclassification into microscopic infiltration of the renal parenchyma (pT3a) versus macroscopic infiltration or invasion of peripelvic adipose tissue (pT3b) has strong prognostic value. This is an external validation study of the prognostic value of pT3 subclassification of renal pelvic UTUC in a large international cohort of patients treated with RNU. pT3b UTUC is associated with features of aggressive tumour biology, disease recurrence and cancer‐specific mortality. However, pT3 subclassification is not an independent predictor of clinical outcomes.

OBJECTIVE

• ? To externally validate the prognostic value of subclassification of pT3 renal pelvic upper tract urothelial carcinoma (UTUC) in a large international cohort of patients treated with radical nephroureterectomy (RNU).

PATIENTS AND METHODS

• ? The RNU specimens with pT3 UTUC of the renal pelvis from 284 patients at 11 centres located in Asia, North America and Europe were retrospectively evaluated. All specimens were reviewed by genitourinary pathologists at each institution. Tumours were categorized as pT3a (microscopic infiltration of the renal parenchyma) or pT3b (macroscopic infiltration of the renal parenchyma and/or infiltration of peripelvic adipose tissue).

RESULTS

• ? Overall, 148 (52%) tumours were classified as pT3a and 136 (48%) as pT3b. Patients with pT3b disease were more likely to have high‐grade tumours and sessile tumour architecture (all P≤ 0.02). Patients with pT3b tumours were at increased risk of disease recurrence (5‐year estimates: 55% versus 42%, P= 0.012) and cancer‐specific mortality (CSM) (5‐year estimates: 48% versus 40%, P= 0.04). Lymph node status, tumour architecture and tumour grade were independently associated with disease recurrence, whereas lymph node status, tumour architecture and lymphovascular invasion were independently associated with CSM. Subclassification of pT3 tumours was not associated with recurrence or CSM in multivariable analyses.

CONCLUSION

• ? Patients with pT3b UTUC were more likely to have tumours with aggressive pathological features and were at higher risk of disease recurrence and CSM after RNU compared with patients with pT3a disease. However, the pT3 subclassification did not remain an independent predictor of disease recurrence or CSM after controlling for tumour grade, lymph node status, tumour architecture and lymphovascular invasion.

     

Bladder carcinoma among live-donor renal transplant recipients: a single-centre experience and a review of the literature

OBJECTIVES

To present our experience with bladder cancer among a renal transplant population and to review critically the relevant literature.

PATIENTS AND METHODS

In all, 1865 renal graft recipients were followed for a mean (sd ) of 6.5 (5) years. Seven recipients (all men) developed a urothelial bladder tumour. The stage and grade of the tumours were determined. The method of the treatment was selected on the basis of the tumour characteristics and graft function. Patients were regularly followed; the endpoints were cancer‐specific survival, recurrence or metastasis.

RESULTS

All patients presented with gross haematuria. There was non‐muscle‐invasive disease in two patients who were treated by transurethral resection and adjuvant intravesical bacille Calmette‐Guérin immunotherapy. One patient died 24 months later due to complications of end‐stage renal disease. To date the second patient is alive and free of the recurrence. Five recipients with muscle‐invasive disease had a radical cystectomy and orthotopic bladder substitution. The mean (sd ) time to the last follow‐up or death was 14.6 (3.1) months. Three patients died with stable graft function; two from distant metastasis and one from a cerebrovascular stroke. The remaining two patients are still alive, free of disease and with good graft function.

CONCLUSIONS

Urothelial bladder tumours are generally uncommon. The presence of haematuria in renal allograft recipients should be thoroughly investigated. Early diagnosis and prompt treatment are required for managing such tumours, because they are aggressive. Orthotopic bladder substitution is feasible with a good functional outcome for patients in whom cystectomy is indicated.     

Robot-assisted partial nephrectomy for sporadic ipsilateral multifocal renal tumours

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Although laparoscopic excision of ipsllateral multifocal renal tumours is feasible, the average warm ischemia time is prolonged. Robotic partial nephrectomy in this subset of patients using blunt dissection to enucleate the tumour is feasible and safe. This study demonstrates further that robot‐assisted partial nephrectomy with a small margin of normal tissue is feasible and safe with an acceptable range of warm ischemia time in patients with sporadic ipsilateral multifocal renal tumours. This study also suggest that robotic partial nephrectomy for this particular group of patients may better preserve renal function compared to laparoscopic approach, however this needs to be confirmed with prospective comparative studies.

OBJECTIVE

? To report our short‐term results of robot‐assisted partial nephrectomy for treating sporadic multiple ipsilateral renal tumours.

METHODS

? Over a 3‐year period, eight patients with two or more ipsilateral renal masses underwent nine robotic partial nephrectomies in our institution. ? We evaluated the PADUA and R.E.N.A.L. nephrometry scores, intraoperative outcomes, histopathological characteristics, complications according to Clavien classification and renal function outcomes.

RESULTS

? In total, 19 tumours were removed from eight patients in nine procedures. Mean operative time was 199 ± 47 min (median 200; range 150–300). Mean size of the dominant lesion was 3.0 ± 1.1 cm (2.7; 1.6–4.8) and overall mean tumour size was 2.2 ± 1.2 cm (1.9; 0.4–4.8). Mean number of tumours removed per patient was 2.4. ? Median PADUA and R.E.N.A.L. scores were 7 and 6 (with the predominance of an anterior, non‐hilar position), respectively. ? Excluding the six off‐clamp resected tumours, the mean warm ischaemia time was 21 ± 9.2 min (21; 10–35). Mean estimated blood loss was 250 ± 154 mL (200; 100–500) and no patient required transfusion. There were no intraoperative complications or conversion to open surgery. One patient had atrial fibrillation, resolved with anti‐arrhythmic drugs. Mean length of stay was 4.2 ± 0.97 days. ? Sixteen of the nineteen tumours were malignant, most of papillary type and Fuhrman grade II. ? The mean decrease in glomerular filtration rate was 4%, with a mean follow‐up of 14 months.

CONCLUSIONS

? Robotic partial nephrectomy for sporadic ipsilateral multifocal renal tumours is feasible and safe. ? Off‐clamp resection of multiple tumours can also be safely performed in carefully selected lesions.     

Renal cell carcinoma: stage, grade and histology migration over the last 15 years in a large Australian surgical series

Study Type – Therapy (case series)
Level of Evidence 4 What’s known on the subject? and What does the study add? Recent studies suggest that the incidence of RCC is increasing among early‐stage, incidentally discovered tumours, presumably detected because of the increased use of soft tissue imaging for evaluating a wide variety of abdominal and pelvic symptoms. This study did not show migration towards earlier stage and smaller RCCs.

OBJECTIVE

? To verify whether migration towards earlier‐stage renal cell carcinoma (RCC), which has been observed in the USA over the last decade, also applies to Australia.

PATIENTS AND METHODS

? Between January 1993 and December 2007, 547 nephrectomies performed in public and private hospitals in western Sydney were analysed from a retrospectively collected database. ? Data were divided into three consecutive time groups. ? Tumour‐node‐metastasis (TNM) stage as well as patient demographics, size, grade and histology of tumours and proportion of benign tumours were also assessed.

RESULTS

? In all, 499 nephrectomies were performed for RCC. The median age was 62 years, with a male:female ratio of 1.9 : 1. Similarly sized tumours were identified in each time group [group 1 (1993–1997), 54.8 mm; group 2 (1998–2002), 52.0 mm; group 3 (2003–2007), 52.2 mm, P= 0.6]. ? Pathological stage II disease decreased from 18.1 to 11.1%, but stage III disease showed an increase from 13.9 to 21.5% over that time period (P= 0.02). ? The proportion of stage I and stage IV disease has remained relatively the same. There has been a statistically significant upward histological migration for the papillary subtype from 1.3 to 10.2% (P= 0.01). ? There has also been an increasing representation of Fuhrman grade III tumours over time, from 17.6 to 30.8%, and a decreasing proportion of Fuhrman grade I tumours from 16.2 to 7.1% (P= 0.03). ? There was a decrease in the incidence of benign tumours originally thought to be malignant on preoperative investigations, from 10% in group 1 to 4% in group 3 (P= 0.03).

CONCLUSION

? The recent US phenomenon of migration towards earlier‐stage, smaller RCCs as well as increased representation of benign tumours was not observed in the present study. The results of the present study, however, show an upward histological migration for papillary RCCs and an increasing representation of more aggressive Fuhrman grade III tumours.     

Stage-specific effect of nodal metastases on survival in patients with non-metastatic renal cell carcinoma

OBJECTIVE

To quantify the survival disadvantage related to the presence of exclusive nodal metastases (eNM) in patients with otherwise non‐metastatic (M0) renal cell carcinoma (RCC).

PATIENTS AND METHODS

Data were retrieved from 12 institutional databases and yielded 3507 patients with T1‐3N1‐2M0 RCC treated with partial or radical nephrectomy. Cox regression analyses relied on T stage, Fuhrman grade and presence of eNM. Data were analysed using univariable, multivariable and stratified analyses.

RESULTS

Overall 165 (4.7%) patients had eNM; of 2023 patients of stage T1, 23 (1.1%) had eNM, vs 20 of 448 (4.5%) for T2 and 122 of 993 (12.3%) for T3. In univariable analyses the presence of eNM increased the rate of cancer specific mortality (CSM) by 7.1 times. After adjusting for T stage and Fuhrman grade, in all patients eNM increased the rate of CSM by 3.2 times. In stratified analyses adjusted for Fuhrman grade, the increase in CSM related to the presence of eNM was 28.9, 4.3 and 2.5 times (all P < 0.001) for stages T1, T2 and T3, respectively.

CONCLUSIONS

From the prognostic perspective, staging lymphadenectomy appears of most value in patients with T1‐2 RCC, but the low prevalence of eNM questions the practical applicability of nodal staging in those patients. Conversely, in patients with T3 RCC, the prevalence and the prognostic impact of eNM might make a staging lymphadenectomy worthwhile.     

Transurethral endoscopic treatment of patients with upper tract urothelial carcinomas using neodymium‐YAG and/or holmium‐YAG laser ablation

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

To report our experience of treating patients with original and recurrent upper tract urothelial carcinomas (UC) using endoscopic lasers, with holmium‐YAG and/or neodymium‐YAG laser ablation, and for whom tumour stage and grade were obtained by endoscopic biopsy.

PATIENTS AND METHODS

From March 2003 to March 2007, 15 patients with upper tract UC were treated with endoscopic laser ablation as the primary management. Patients were followed up by intravenous urography, computed tomography, urine cytology and/or ureteroscopic surveillance at 3‐ to 12‐month intervals. The median (range) follow‐up was 25.5 (13–51) months.

RESULTS

Of the 15 patients, five had an upper tract recurrence during the follow‐up. Three of these were treated with total nephroureterectomy and two had a progression in tumour stage or grade. Three patients had residual tumours; they were treated with repeated endoscopic laser treatments and had no recurrence over a median (range) of 24 (13–26) months. The renal preservation rate was 12/15 and the local recurrence rate was six/15 after the initial endoscopy. The median operative duration and tumour size were 60 min and 10 mm, respectively.

CONCLUSION

Patients with low‐grade and ‐stage disease and normal contralateral kidneys also benefit from this approach, if there is an adequate endoscopic biopsy. As the operative duration tended to be associated with the maximum tumour size, this treatment is potentially available for a maximum tumour size of <4 cm; if the tumour is <4 cm surgery will require <120 min.     

Is surveillance of small renal masses safe in the elderly?

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

To determine if preoperative variables, including gender, age and tumour size, influence the decision for active surveillance of renal masses, as due to the increasing detection of incidental renal masses within the ageing population there is a need to identify reliable means of selecting patients who require therapy.

PATIENTS AND METHODS

We retrospectively identified all renal masses resected at our institution between 1 December 1999, and 1 October 2005. The size of tumour, patient age and gender were compared between those with and without malignancy on final pathology. The influence of these variables in predicting malignancy, high grade, and high stage were assessed by univariate and multivariate analysis using logistic regression models, with a significance level of P < 0.05. Subsets were analysed for the groups of patients with tumours of ≤3 or >3 cm and those aged ≤75 or >75 years.

RESULTS

Among 466 of 501 patients with evaluable data, univariate analysis showed that both male gender and increasing size positively predicted malignancy (odds ratio 1.13 and 1.40, respectively), but age, treated as a continuous variable, did not. On multivariate analysis both remained independent predictors of malignancy (odds ratio 1.13 and 1.40, respectively). Size was the only independent predictor of high‐stage and high‐grade disease on both univariate and multivariate analysis. Among 156 patients with tumours of ≤3 cm, on multivariate analysis, male gender was only weakly associated with the risk of malignancy, whereas size remained strongly predictive (odds ratio 1.98, P = 0.076; and 2.16, P = 0.015, respectively). Neither male gender, size nor age increased the risk of high‐stage or high‐grade disease in this cohort. Patients who were aged >75 years had a greater risk of high‐stage disease than those aged <75 years (odds ratio 2.64, P = 0.008). On multivariate analysis, age >75 years remained an independent predictor of malignancy and high‐stage, along with size (odds ratio 2.75, P = 0.014; and 1.35, P < 0.001).

CONCLUSIONS

Increased size of tumour increases the risk of malignancy and the likelihood of high‐stage and high‐grade disease. Among patients aged >75 years there was a higher risk of malignancy and high‐stage disease than in those aged ≤75 years. As such, the decision for observation should not be based upon age alone, and should be approached with caution in patients aged >75 years, particularly for larger lesions.     

Independent prognostic value of tumour diameter and tumour necrosis in upper urinary tract urothelial carcinoma

OBJECTIVE

To identify significant prognostic indicators of upper urinary tract (UUT) urothelial carcinoma (UC) and to assess a risk stratification of patients.

PATIENTS AND METHODS

We retrospectively analysed data from 162 patients with non‐metastatic UC primarily occurring in UUT treated with open nephroureterectomy. Variables assessed included age, gender, pT, tumour grade, tumour necrosis extension, pN, tumour location, multifocal location, tumour diameter, and subsequent development of a bladder tumour. Tumour necrosis was measured using commercial software (Eureka interface system, version 4.0.22, HESP technology, Menarini Diagnostics, Italy) and was classified as none, focal (<10% of tumour area) or extensive, ≥10% of tumour area). The prognostic significance of each variable on metastasis‐free survival (MFS) and disease‐free survival (DFS) was tested in univariable analysis with the log‐rank test. Variables with significance levels of P < 0.05 according to the univariable analyses were entered into a multivariable forward‐stepwise Cox regression model.

RESULTS

At a mean follow‐up of 66 months, 20 cancer‐related deaths (12.3%) were censored. In multivariable analysis, tumour diameter, pT stage and tumour necrosis were independent predictors of MFS and DFS. All events occurred in patients with extensive tumour necrosis and a tumour diameter of ≥3 cm. The median survival of patients with advanced‐stage tumours, extensive necrosis and a tumour diameter of ≥3 cm were significantly impaired by increasing pT stage(P < 0.001).

CONCLUSION

Tumour necrosis and tumour diameter are compelling prognostic factors that deserve further study in a prospective setting to determine if their use in combination with more traditional variables, such as pT stage, might better determine prognosis and guide the follow‐up and treatment of patients.     

Living‐donor renal transplantation of grafts with incidental renal masses after ex‐vivo partial nephrectomy

OBJECTIVES

To assess transplantation of high‐risk kidneys with incidental renal masses (found occasionally during the routine evaluation of a living kidney donor) into recipients with limited life‐expectancy on haemodialysis, as this offers a potential solution to the current organ deficit.

PATIENTS AND METHODS

We detected five small (<2.3 cm), incidental, enhancing renal masses during donor evaluation. All patients had a standard metastatic evaluation. After laparoscopic donor nephrectomy a back‐table partial nephrectomy was performed and frozen‐section analysis was used to confirm both the diagnosis and negative surgical margins before transplantation.

RESULTS

Renal cell carcinoma was found in three of the five masses (one each cystic, clear cell and papillary; Fuhrman grades II, II and III, respectively) and the other two patients had angiomyolipoma. There were no long‐term complications in the transplanted kidneys. One patient developed delayed acute humoral rejection after transplantation and was treated appropriately. Both donor and recipient were followed with periodic imaging. At a median (range) last follow‐up of 15 (1–41) months, four patients were alive and one had died from complications after a fall. The cancer‐specific survival was 100%. There was no evidence of local recurrence in any patient at the last follow‐up.

CONCLUSION

Live donor kidneys with incidental small renal masses might be acceptable for transplantation in high‐risk recipients after careful back‐table partial nephrectomy.     

Lymphovascular invasion predicts poor outcome of urothelial carcinoma of renal pelvis after nephroureterectomy

OBJECTIVE

To evaluate the significance of lymphovascular invasion (LVI) to predict cancer‐specific survival (CSS) in patients with renal pelvic urothelial carcinoma (UC).

PATIENTS AND METHODS

In all, 76 patients with primary renal pelvic UC were treated by nephroureterectomy (NU). Inclusion criteria included nonmetastatic renal pelvic UC with no previous history of bladder cancer, concomitant ureteric lesion, or neoadjuvant chemotherapy. Age, gender, adrenalectomized or not, pathological T stage, grade, and LVI were examined by univariate and multivariate analyses to determine which were independent risk factors.

RESULTS

In all, 38 men and 38 women were included with a mean (range) age of 66 (41–93) years. The median (range) follow‐up was 48 (15–88) months. At follow‐up, eight cancer‐related deaths (10.5%) were censored, and 66 patients (85.9%) were alive and disease‐free. LVI was the only significant predictor of CSS in the univariate and multivariate analyses.

CONCLUSIONS

Adrenal metastases from primary renal pelvic UCs were rare. The present results suggest that ipsilateral adrenalectomy is not necessary during radical NU for treating patients with renal pelvic UCs. LVI appears to be a better prognostic factor for predicting poor outcome of renal pelvic UC than pT stage or tumour grade when using the current tumour‐nodes‐metastases staging system.     

The influence of body mass index on the long-term survival of patients with renal cell carcinoma after tumour nephrectomy

OBJECTIVE

To assess whether under‐ or overweight at the time of surgery has any effect on the survival of the patients with renal cell carcinoma (RCC), as obesity increases the risk of developing RCC.

PATIENTS AND METHODS

We prospectively evaluated 780 patients who had nephrectomy for RCC between 1990 and 2005. We used uni‐ and multivariate Cox proportional hazards models to assess the effect of body mass index (BMI), tumour stage, Fuhrman grade, age, sex, histological type and performance status on cancer‐specific survival (CSS). Patients were grouped according to BMI (in kg/m²), as underweight (<18.5), normal (18.5–<25), overweight (25–<30) and obese (≥30).

RESULTS

The median (range) follow‐up was 5.3 (0.5–15.4) years, the patients being followed until June 2006; 254 patients died during the follow‐up. Multivariate analyses of all patients showed that tumour stage, Fuhrman grade, Karnofsky performance status, age, sex and BMI were independent prognostic factors for CSS. While underweight patients had a significantly worse prognosis than those of normal weight, overweight or obese patients had a similar outcome to that of patients of normal weight. In a subgroup analyses including patients with localized RCC only, there was a strong tendency to less aggressive disease in the overweight group (P = 0.081).

CONCLUSIONS

Being underweight is an unfavourable and new risk factor for CSS in patients with RCC treated by nephrectomy. Although not significant, there seems to be a limited favourable prognostic effect of overweight on CSS in patients with localized RCC.