SHOULD DIRECT IPSILATERAL ADRENAL INVASION FROM RENAL CELL CARCINOMA BE CLASSIFIED AS pT3a?

PURPOSE: The 2002 American Joint Committee on Cancer primary tumor classification for renal cell carcinoma (RCC) defines a tumor as pT3a if it invades the perinephric or renal sinus fat or directly invades the ipsilateral adrenal gland. In the current study we evaluated the association of direct ipsilateral adrenal invasion with outcome to determine if reclassification of these tumors as pT4 would improve the accuracy of the current tumor classification. MATERIALS AND METHODS: We studied 424 patients who underwent nephrectomy and adrenalectomy for unilateral, sporadic, pT3 or pT4 RCC between 1970 and 2000 at the Mayo Clinic. Cancer specific survival was estimated using the Kaplan-Meier method. RESULTS: Cancer specific survival for the 22 patients with pT3a or pT3b tumors that directly invaded the ipsilateral adrenal gland was significantly worse compared with that of patients with pT3a (p <0.001) or pT3b (p = 0.011) disease that did not invade the adrenal gland. There was no significant difference in the 5-year cancer specific survival between the patients with pT3a or pT3b tumors that directly invaded the ipsilateral adrenal gland and patients with pT4 tumors (cancer specific survival rates of 20% and 14%, respectively, p = 0.490). CONCLUSIONS: Although rare, RCC with direct ipsilateral adrenal invasion behaves more aggressively than tumors involving perinephric or renal sinus fat. We believe that RCC tumors with direct adrenal invasion should be classified as pT4.     

CANCER SPECIFIC SURVIVAL FOR PATIENTS WITH pT3 RENAL CELL CARCINOMA—CAN THE 2002 PRIMARY TUMOR CLASSIFICATION BE IMPROVED?

PURPOSE: The 2002 primary tumor classification for renal cell carcinoma (RCC) does not distinguish between patients with tumor thrombus involving the renal vein only and those with inferior vena cava tumor thrombus below the diaphragm. We evaluated the association of tumor thrombus level and fat invasion with outcome to determine if further subclassification would improve the prognostic accuracy of the current classification. MATERIALS AND METHODS: We studied 675 patients treated with radical nephrectomy or nephron sparing surgery for pT3a (206, 30.5%), pT3b (422, 62.5%), pT3c (19, 2.8%) or pT4 (28, 4.2%) RCC at the Mayo Clinic between 1970 and 2000. Associations with outcome were evaluated using Cox proportional hazards regression. RESULTS: There were 531 deaths from RCC at a median of 1.5 years following nephrectomy. Patients with pT3b RCC and level I, II or III tumor thrombus were significantly more likely to die of RCC compared to patients with pT3b RCC and level 0 tumor thrombus (risk ratio 1.62, p <0.001). Patients with peripheral perinephric or renal sinus fat invasion were also more likely to die of RCC compared to patients without fat invasion (risk ratio 1.87, p <0.001). Therefore, patients with pT3 RCC were reclassified into 4 groups as thrombus level 0 without fat invasion, fat invasion only, thrombus level 0 with fat invasion or thrombus level I, II or III without fat invasion, and thrombus level I, II or III with fat invasion or thrombus level IV. This reclassification significantly improved prediction of death from RCC compared with the current classification (c indexes of 0.61 versus 0.55, respectively). CONCLUSIONS: Further subclassification of the primary tumor classification for patients with pT3 RCC improved prognostic accuracy.     

pT1 substaging in renal cell carcinoma: validation of the 2002 TNM staging modification of malignant renal epithelial tumors

PURPOSE: Tumor size has been used as one of the criteria to stratify renal cell carcinoma (RCC) into different pathological stages (pT). The recent 2002 UICC/TNM classification of malignant epithelial renal tumors is modified to substratify pT1 RCC into pT1a (less than 4.0 cm) and pT1b (greater than 4.0 but less than 7.0 cm). In this study we ascertained if this stage modification has prognostic relevance. MATERIALS AND METHODS: A total of 259 consecutive radical nephrectomy specimens of organ confined RCC from 1970 to 1997 at 1 institution, including 153 of conventional RCC (CRCC), 71 of papillary RCC, 28 of chromophobe RCC, 1 of collecting duct carcinoma and 6 of RCC not otherwise specified, with a mean clinical followup of 7.5 years (median 6.4) were included in the study. RESULTS: There were 115 pT1a (44.4%), 95 pT1b (36.7%) and 49 pT2 tumors (18.9%). Disease recurrences (DR) and disease specific death occurred in 2 (1.7%) and 0 cases (0%) of pT1a, 7 (7.3%) and 5 (5.3%) of pT1b, and 16 (32.6%) and 12 (24.5%) of pT2. DR for pT1b was higher compared with pT1a (all histological subtypes RR 3.68), although this difference was not statistically significant (p = 0.106). If only CRCCs were analyzed, DR in the pT1b group was statistically higher compared with pT1a (RR 8.54, p = 0.047). Disease specific survival in pT1a could not be evaluated because no deaths occurred in this subgroup. DR and disease specific survival were significantly different between pT1b and pT2 tumors for all histological subtypes (RR 5.51, p = 0.001 and 5.49, p = 0.001) and for the CRCC subtype (RR 5.50, p = 0.001 and 5.18, p = 0.005, respectively). Using size as a continuous variable the logarithmic change in tumor size was a significant predictor of DR (RR 8.82, p = 0.001). All statistical analyses were adjusted for age and sex. CONCLUSIONS: Substaging RCC into pT1a and pT1b yields prognostically important information, validating the 2002 TNM modification for malignant renal epithelial malignancies. The substratification of pT1 is particularly useful in tumors with CRCC histology.     

Does stage T3a renal cell carcinoma embrace a homogeneous group of patients?

PURPOSE: Renal cell carcinoma invading the perinephric fat is classified as a stage T3a tumor in the 2002 TNM version. Based on long-term followup we examined the prognostic significance of this definition. MATERIALS AND METHODS: We evaluated the outcome in 237 consecutive patients with localized renal cell carcinoma operated on between January 1985 and December 1997. Median followup was 8 years. Disease-free survival was analyzed using univariate and multivariate analyses. Based on this we proposed and tested a new TNM system against the 2002 TNM version. RESULTS: Tumor recurrence was diagnosed in 48 patients (20.2%) at a median of 21.5 months. Diameter based analysis of stage T3a revealed that this was an inhomogeneous group that included patients with small tumors and an excellent prognosis along with patients with large tumors and a poor prognosis. Based on this information we initiated a modified TNM staging system that ignores perinephric fat invasion. In the proposed staging system stage T1a includes tumors 4 cm or less and stage T1b includes tumors more than 4 but 7 cm or less. Stage T2 is divided into T2a-tumors greater than 7 but 10 cm or less and T2b-tumors greater than 10 cm. Stage T3a is reserved for renal vein tumor invasion. The proposed TNM performed better than the 2002 version using the Nagelkerke R(2) test (0.439 vs 0.359), and the Hosmer and Lemeshow test (0.335 vs 0.191). CONCLUSIONS: The current definition of stage T3a renal cell carcinoma embraces an inhomogeneous group of patients with marked differences in prognosis. We believe that tumor invasion into the perinephric fat does not necessarily predict aggressive biological behavior.     

Prognostic impact of tumor size on pT2 renal cell carcinoma: an international multicenter experience

PURPOSE: The current tumor classification for renal cell carcinoma classifies pT2 tumors as larger than 7 cm in greatest dimension and limited to the kidney. We examined the current pT2 tumor classification of renal cell carcinoma and determined whether a tumor size cutoff exists that would improve prognostic accuracy. MATERIALS AND METHODS: We studied 706 patients with pT2 renal cell carcinoma treated with surgical extirpation at 9 international academic centers. Data collected from each patient included age at diagnosis, gender, 2002 TNM (tumor, node, metastasis) stage, tumor size, nuclear grade, performance status, histological subtype and disease specific survival. Disease specific survival was evaluated with univariate and multivariate analysis. RESULTS: Median followup was 52 months. Univariate Cox regression analysis showed a significant association of tumor size with disease specific survival (HR 1.11, p<0.001). An ideal tumor size cutoff of 11 cm was identified, which led to the stratification of 2 groups with respect to disease specific survival (p<0.0001) with 5 and 10-year survival rates of 73% and 65% for pT2 11 cm or less, and 57% and 49% for pT2 larger than 11 cm, respectively. The incidence of metastases was significantly greater in the larger than 11 cm group, while Eastern Cooperative Oncology Group performance status, Fuhrman grade and histological subtype were similar. Multivariate Cox regression analysis retained tumor size as an independent prognostic factor and as the strongest prognostic factor for patients with pT2N0M0 disease. CONCLUSIONS: Our data suggest that the current pT2 classification can be improved by subclassification into pT2a and pT2b based on a tumor size cutoff of 11 cm. Patients in the proposed pT2bN0M0 group are at higher risk for death from renal cell carcinoma and should be considered for adjuvant therapies. External validation is warranted before suggesting change to the TNM classification.     

Independent validation of the 2002 American Joint Committee on cancer primary tumor classification for renal cell carcinoma using a large, single institution cohort

PURPOSE: The primary tumor classification for renal cell carcinoma (RCC) was updated by the American Joint Committee on Cancer in 2002. To date the new classification has not been validated using an independent group of patients and, therefore, its accuracy for predicting patient outcome is unknown. In the current study we evaluated the 2002 primary tumor classification and compared its predictive ability with that of the 1997 classification. MATERIALS AND METHODS: We studied 2,746 patients treated with radical nephrectomy or nephron sparing surgery for unilateral, sporadic RCC between 1970 and 2000. Cancer specific survival was estimated using the Kaplan-Meier method. The predictive abilities of the 1997 and 2002 classifications were compared using the concordance index. RESULTS: There were 812 deaths from RCC a mean of 3.3 years following nephrectomy. Median followup in patients still alive at last followup was 9 years. Estimated 5-year cancer specific survival rates by the 2002 tumor classification were 97%, 87%, 71%, 53%, 44%, 37% and 20% in patients with pT1a, pT1b, pT2, pT3a, pT3b, pT3c and pT4 RCC, respectively. The concordance index for the association between the 2002 classification and death from RCC was 0.752 compared with 0.737 for the 1997 classification, indicating that the 2002 version contained more predictive ability. CONCLUSIONS: Our data suggest that the 2002 primary tumor classification with pT1 cancers subclassified into pT1a and pT1b provides excellent stratification of patients according to cancer specific survival and it has a predictive ability that is superior to that of the 1997 classification.     

Small renal tumors: correlation of clinical and pathological features with tumor size

PURPOSE: We analyzed the association between tumor diameter and pathological stage, histological subtype, tumor grade and the incidence of metastases in renal cell carcinoma with a diameter of up to 4 cm (clinical stage T1a). MATERIALS AND METHODS: We analyzed a consecutive series of 663 patients with renal tumors 4 cm or less who underwent surgery at our institution between 1990 and 2006. After excluding 115 patients (17.3%) with benign tumors 548 with renal cell carcinoma were included in the study. Tumor size on preoperative imaging was correlated with pathological stage, tumor grade, histological subtype and incidence of metastases at diagnosis. For data analysis tumors were stratified by tumor diameter into 3 groups, including 2 cm--99 patients with tumors up to 2 cm, 3 cm--234 with tumors between 2.1 and 3.0 cm, and 4 cm--215 with tumors between 3.1 and 4.0 cm in diameter. RESULTS: Median clinical diameter of renal cell carcinoma in the whole series was 2.93 cm (range 0.8 to 4.0). Tumor stage was pT1a, pT1b and pT3 in 84.5%, 8.0% and 7.5% of cases, respectively. Tumor grade was 1 to 3 in 24.5%, 65.0% and 10.6% of cases, respectively. The renal cell carcinoma histological subtype was clear cell carcinoma in 77.9% of patients, papillary carcinoma in 15.3% and chromophobe carcinoma in 6.8%. Advanced tumor stage (pT3) was found in 3.0%, 5.1% and 12.1% of the patients in the 2, 3 and 4 cm groups, respectively (p <0.05). Grade 3 was found in 7.1%, 9.0% and 14.0% of the patients in the 2, 3 and 4 cm groups, respectively (p <0.05). Metastases at diagnosis were found in 3.0%, 2.6% and 6.0% of the patients in the 2, 3 and 4 cm groups, respectively. CONCLUSIONS: Negative prognostic features increase with tumor diameter and they are associated with even small tumors. However, above a tumor size of 3.0 cm there is a sharp increase in the incidence of negative prognostic parameters. New diagnostic tests are warranted to better stratify patients with respect to treatment aggressiveness for small incidental renal tumors.     

Renal cell carcinoma: vena caval invasion and prognostic factors

Ninety-one consecutive patients with renal cell carcinoma stages pT1-4/N0-3/V0-2/M0 were analyzed for survival rates. The overall 5-year survival was 57%. Factors which made an impact on 5-year survival rates were: (1) grade of anaplasia (GI: 72%, GII: 42%, GIII: 22%; p = 0.0001); (2) pathological stage (pT1-2: 86%, pT3: 30%; p = 0.0000); (3) perinephric fat invasion (pT1-2: 86%, pT3a: 61%; p = 0.01); (4) nodal involvement (N0: 69%, N1: 11%; p = 0.0000), and (5) venous invasion (V0: 72%, V1-2: 30%; p less than 0.01). There were no differences in survival rates between V1 and V2 tumors (p greater than 0.05). Using multivariate statistical analysis we found that grade of anaplasia and venous invasion contained dire prognostic information (p = 0.0000). Among patients with stage pT3b, those without perinephric fat invasion or nodal involvement had a better survival rate than those with capsular infiltration (p less than 0.01) and a significantly better rate than those with perinephric fat invasion and nodal involvement (p less than 0.01). Moreover, there were no differences between stages pT3b with venous invasion only and stages pT1-2 (p greater than 0.05). Patients with venous invasion developed distant metastases with a significantly higher frequency than those without (p = 0.01). The prognostic impact of venous invasion is unclear yet, but is probably related to perinephric fat invasion and nodal involvement. Until further data are collected, the radical approach with complete removal of the thrombus remains the treatment of choice for localized renal cell carcinoma with vena caval extension.(ABSTRACT TRUNCATED AT 250 WORDS)     

TNM T3a renal cell carcinoma: adrenal gland involvement is not the same as renal fat invasion

PURPOSE: Upper pole tumors with direct extension into the adrenal gland are currently staged as pT3a tumors in the 1997 TNM staging system. To determine whether the clinical behavior of pT3a adrenal tumors differs from that of tumors with perinephric fat invasion (also stage pT3a) a retrospective analysis was performed. MATERIALS AND METHODS: Of 1,087 patients who underwent nephrectomy 27 were identified with direct adrenal involvement and 187 were identified with perinephric fat or renal sinus involvement. Variables and outcomes analyzed in each group included the percent of patients with metastatic disease at presentation, lymph node involvement, Eastern Cooperative Oncology Group score, response to immunotherapy, and median and overall survival using Kaplan-Meier curves. RESULTS: Median survival for patients with pT3a disease and perinephric or renal sinus fat involvement was 36 months with a 36% 5-year cancer specific survival rate. In contrast, patients with adrenal gland invasion had significantly worse survival at a median of 12.5 months and a 0% 5-year cancer specific survival rate (p <0.001), which was similar to median survival of those with stage pT4 disease (11 months). CONCLUSIONS: Upper pole tumors with direct extension into the adrenal gland predict significantly worse survival than similarly staged tumors with fat invasion and they have a prognosis similar to that of stage pT4 disease. While these data await external validation, consideration should be given to re-categorizing tumors with direct adrenal gland involvement as stage pT4 or in a subcategory such as pT4a.     

Significance of TNM staging,Demographic and Histologic Features in Predicting the Prognosis of Renal Cell Carcinoma

Background : The aim of this study was to evaluate the prognostic significance of clinical, demographic and detailed histopathological parameters in renal cell carcinoma (RCC).

Methods : A total of 102 patients who underwent partial or radical nephrectomy for a renal mass between 2008 and 2013 were evaluated retrospectively. Fuhrman grade, TNM stage, macroscopic satellite tumor nodule formation, histopatho-logical subtype, renal vein invasion (RVI), necrosis, microvessel invasion (MVI), sarcomatoid differentiation and overall survival (OS) were evaluated to determine prognostic factors.

Results : The 102 patients consisted of 73 with clear cell tumor, 15 with papillary tumor, 12 with chromophobe tumor and 2 collecting duct RCC cases. A statistically negative relationship was observed between increasing age and OS when the patients were grouped as above and under 40 years of age. There was no statistical relationship between OS and his-topathological subtype, adrenal gland invasion, and lymph node metastasis. The risk of death was 10-fold increased in patients with stage 4 tumor compared to patients with stage 1 tumor. Statistically significant macroscopical parameters for OS were satellite tumor nodule presence, Fuhrman grade, tumor size, renal sinus and perinephric fat invasion, distant metastasis, and RVI. The risk of death was 13-fold higher in cases with sarcomatoid differentiation. There was a strong correlation between the presence of a satellite tumor nodule, necrosis, sarcomatoid differentiation and the tumor stage. A statistically negative correlation was observed between OS and the MVI, sarcomatoid differentiation, and necrosis. Conclusion : We found the Fuhrman grade, tumor size, renal sinus and perinephric fat invasion, distant metastasis, RVI, MVI, sarcomatoid differentiation, necrosis and satellite tumor nodule to be all statistically significant parameters for OS. The addition of other variables to the TNM stage and grade may improve the prediction of outcomes for RCC patients.     

A new staging system for locally advanced (pT3-4) renal cell carcinoma: a multicenter European study including 2,000 patients

PURPOSE: We provide an adequate prognostic stratification for locally advanced renal cell carcinoma and propose a new TNM classification. MATERIALS AND METHODS: We analyzed clinical and pathological data on a large series of patients undergoing radical nephrectomy for pT3-4 renal cell carcinoma at 12 European centers. Cancer specific survivals were estimated using the Kaplan-Meier method. The log rank test was used for comparing survival curves and for univariate analysis. The Cox proportional hazards regression model was used for multivariate analysis. RESULTS: The analysis included 1,969 patients. Median survivor followup was 49 months. Five-year cancer specific survival was 60% for pT3a, 46.2% for pT3b, 10% for pT3c and 12% for pT4 tumors (p <0.0001). According to median survival we identified 3 prognostic groups, including 1--patients with renal vein thrombosis (117 months), fat invasion (98 months) or infradiaphragmatic vena caval thrombosis (67 months), 2--patients with adrenal invasion alone (24 months), renal vein thrombosis plus fat invasion (24 months) or infradiaphragmatic vena cava plus fat invasion (24 months) and 3--patients with renal or infradiaphragmatic caval thrombosis plus adrenal involvement (11 months), supradiaphragmatic vena caval thrombosis (12 months) or Gerota's fascia invasion (12 months). Five-year cancer specific survival rates in groups 1 to 3 were 61%, 35% and 12.9%, respectively (p <0.0001). On multivariate analysis the proposed classification had an independent prognostic value. CONCLUSIONS: Our results suggest the necessity of reclassifying locally advanced renal cell carcinoma according to the 3 described prognostic categories.     

pT2 classification for renal cell carcinoma. Can its accuracy be improved?

PURPOSE: The 2002 tumor classification for renal cell carcinoma (RCC) classifies pT2 tumors as more than 7 cm in greatest dimension, limited to the kidney. In this study we determined whether a size cutoff point exists within pT2 tumors and whether such subclassification would further improve the accuracy of the current tumor classification. MATERIALS AND METHODS: We studied 544 patients with unilateral, sporadic pT2 RCC treated with radical nephrectomy or nephron sparing surgery between 1970 and 2000. The association of tumor size with death from RCC was examined using martingale residuals from a Cox proportional hazards regression model to determine the optimal size cutoff point. RESULTS: There were 204 deaths from RCC a median of 3.8 years following nephrectomy. Univariately tumor size was significantly associated with death from RCC (risk ratio 1.08, 95% CI 1.04 to 1.13, p <0.001). A scatterplot of tumor size vs expected risk of death per patient suggested that a cutoff point between 9 and 10 cm was appropriate. When adjusted for regional lymph node involvement and distant metastases, the 10 cm cutoff point performed better than the 9 cm point (risk ratio 1.42, 95% CI 1.07 to 1.90, p = 0.017 vs 1.22, 95% 0.86 to 1.72, p = 0.268). Therefore, we propose using a 10 cm cutoff point to subclassify patients into pT2a and pT2b. CONCLUSIONS: Our data suggest that the prognostic accuracy of the 2002 pT2 tumor classification can be further improved by subclassifying patients with tumors greater than 7 and less than 10 cm into a pT2a category, and those with tumors 10 cm or greater into a pT2b category.     

Patients with pT1 renal cell carcinoma who die from disease after nephrectomy may have unrecognized renal sinus fat invasion

Prior studies suggest that the renal sinus permits early tumor spread in otherwise localized renal cell carcinoma (RCC) tumors. We hypothesized that renal sinus fat invasion may be unrecognized in pT1 patients who subsequently die from RCC. Between 1985 and 2002, we identified 577 patients who underwent radical nephrectomy for localized pT1 clear cell RCC as reviewed by a single urologic pathologist (J.C.C.). Among these patients, 49 died from RCC including 33 who had their original nephrectomy specimen stored in formalin. These specimens were then resectioned with thin cuts of the renal sinus and reviewed by the same pathologist. For comparison, 33 patients who did not die from RCC (controls) also had their original nephrectomy specimen resectioned. Among the 33 patients who died from seemingly localized RCC, 14 (42%) had previously unrecognized renal sinus fat invasion compared with 2 (6%) of the controls (P<0.001). In addition, 19 (58%) patients who died from RCC had renal sinus small vein (microscopic venous) invasion, a pathologic feature not currently incorporated into the TNM staging system for RCC. This feature was present in 7 (21%) of the controls (P=0.003). In total, 22 (67%) patients who died from RCC had unrecognized renal sinus fat or small vein invasion compared with 7 (21%) of the controls (P<0.001). We conclude that renal sinus fat invasion is an important adverse pathologic feature that is clearly underreported in the literature. Appropriate assessment of nephrectomy specimens should include proper sampling of the renal sinus even for seemingly localized tumors.     

Microscopic venous invasion: a prognostic factor in renal cell carcinoma

OBJECTIVE: Microscopic venous invasion (MVI) is characterized by local destruction of the endothelium by a tumor. The prognostic value of MVI in renal cell carcinoma (RCC) is not well established. MATERIALS AND METHODS: From 1980 until 1990, 255 patients (169 men and 86 women), aged 16-87 (mean 60) years were treated by radical nephrectomy for N0M0 RCC. There were 9 pT1, 163 pT2, 30 pT3a, 34 pT3b, and 19 pT3ab (TNM 1992). The median follow-up time was 74 months. MVI was determined by a double-blind histological study with immunohistochemical staining. RESULTS: MVI was noted in 74 patients (29%). MVI significantly increased metastatic progression (p = 0.003). Only stage and Fuhrman's grade were significant factors for metastatic progression in a multivariate analysis. MVI decreased the actuarial survival rates at 1 year (p = 0.01), but not significantly at 5 and 10 years. MVI and non-MVI survival curves were statistically different with the Peto/Wilcoxon (p = 0.04) and Gehan/Wilcoxon (p = 0.03) tests, but not with the log rank test (p = 0.06). MVI decreased survival in cases with a tumor size of 10 cm or more, capsular invasion, macroscopic venous invasion, stage pT3ab, sarcomatoid cell carcinoma and Fuhrman's grade IV. Only the stage was a significant factor for survival in a multivariate analysis. CONCLUSION: In RCC, MVI is related to cancer progression and survival, but probably not as an independent prognostic factor.     

Histopathologic analysis of tumor bed and peritumoral pseudocapsule after in vitro tumor enucleation on radical nephrectomy specimen for clinical T1b renal cell carcinoma

Purpose

This study was designed to assess the feasibility and histopathologic safety of tumor enucleation for renal cell carcinoma, through histopathologic analysis of the tumor bed and peritumoral pseudocapsule (PC) after in vitro tumor enucleation.

Association between renal mass biopsy and upstaging to perinephric fat involvement in a contemporary cohort of patients with clinical T1a renal cell carcinoma

Background

Although tumor tract seeding from renal mass biopsy (RMB) is exceedingly rare, the possibility of tumor capsule violation from RMB leading to perinephric fat invasion has not been quantified. We evaluated the association between RMB and perinephric fat invasion in patients with clinical T1a renal cell carcinoma who underwent partial or radical nephrectomy.

Simple enucleation for the treatment of renal cell carcinoma between 4 and 7 cm in greatest dimension: progression and long-term survival

PURPOSE: We present our findings in a series of patients treated with simple enucleation for RCC 4 to 7 cm in greatest dimension. We specifically report the incidence of local and systemic recurrence, and the disease specific survival rate. MATERIALS AND METHODS: We retrospectively reviewed clinical and pathological data on 71 patients who underwent nephron sparing surgery by simple enucleation between 1986 and 2004 for sporadic, unilateral, pathologically confirmed, 4 to 7 cm RCC. Patients with a solitary kidney due to previous RCC treated with radical nephrectomy were excluded from study. None of the patients had preoperative or intraoperative suspicion of positive nodes. All patients were free of distant metastases before surgery (M0). Patient status was last evaluated in May 2005. Mean followup was 74 months (median 51, range 12 to 225). RESULTS: Pathological review according to the 2002 TNM classification showed that 42% of the tumors (30 of 71) were pT1a, 44% (31 of 71) were pT1b and 14% (10 of 71) were pT3a. Mean tumor greatest dimension +/- SD was 4.7 +/- 0.81 cm (median 4.5, range 4.0 to 7.0) cm. None of the patients died within the first 30 days of surgery. There were no major complications requiring open reoperation, such as bleeding and urinary leakage/urinoma. Five and 8-year cancer specific survival was 85.1% and 81.6%, respectively. Five-year cancer specific survival in patients with pT1a (4 cm), pT1b and pT3a disease was 95.7%, 83.3% and 58.3%, respectively (pT1a vs pT1b p = 0.254, pT1a vs pT3a p = 0.006 and pT1b vs pT3a p = 0.143). Overall 10 patients experienced progressive disease (14.9%), of whom 3 had local recurrence (4.5%) alone or local recurrence associated with distant metastases. CONCLUSIONS: Simple tumor enucleation is a useful and acceptable approach to nephron sparing surgery for 4 to 7 cm RCC. It provides long-term cancer specific survival rates similar to those of radical nephrectomy and is not associated with a greater risk of local recurrence than partial nephrectomy for RCC less than 4 cm in greatest dimension.     

Current TNM classification of renal cell carcinoma evaluated: revising stage T3a

PURPOSE:: Recent studies of rare cases of pT3a renal cell carcinoma extending directly into the adrenal gland showed worse survival than in other pT3a cases and recategorization as stage pT4 was suggested. We assessed the prognostic validity of a stage pT3a diagnosis based on perirenal fat infiltration. MATERIALS AND METHODS:: The records of 1,794 patients with renal cell carcinoma who underwent surgical resection between 1975 and 2000 at our institution were analyzed retrospectively. Focusing on pT3a tumors, as defined by perirenal fat infiltration, numerous clinical and histopathological parameters were investigated by univariate and multivariate statistical methods with cancer specific survival as the primary end point. RESULTS:: We identified 237 of 1,794 patients with perirenal fat infiltration, classified as having pT3a disease. In patients with pT3a tumors tumor size was a significant parameter predicting survival. The most significant cutoff value for tumor size in pT3a disease was 7 cm. Patients with distant metastasis had a worse prognosis independent of T classification. Therefore, to assess the prognostic value of the current T classification in regard to T3a tumors we excluded patients with tumor stage cM+ for further subgroup analysis. Survival comparison of pT1 pNall, cM0 (744 of 1,794 cases) and pT3a pNall, cM0 7 cm or less (100 of 237) as well as pT2 pNall, cM0 (265 of 1,794) and pT3a pNall, cM0 greater than 7 cm (93 of 237) yielded similar results. After splitting pT3a into a modified T1/T2 classification a significant difference in 5-year survival analysis for a modified T1/T2 stage was found (pT1 plus pT3a less than 7 cm 90% vs pT2 plus pT3a greater than 7 cm 73%, p <0.001). Subsequently multivariate analysis in all 1,794 patients showed that modified T stage was an independent significant predictor of cancer specific survival. CONCLUSIONS:: We suggest revising the current pT3a classification based on perirenal fat infiltration but rendering a modified pT1/pT2 classification, which resolves pT3a cases without the loss of prognostic validity. Perirenal fat infiltration should not be used to assign T category. Tumors directly infiltrating the adrenal gland should be reclassified as T4.     

Re: prognostic relevance of capsular involvement and collecting system invasion in stage I and II renal cell carcinoma

Klatte and coworkers examined the prognostic relevance of capsular involvement with no invasion of the perinephric fat and collecting system invasion in a series of 519 patients with intracapsular renal cell carcinoma (RCC) treated with partial or radical nephrectomy and followed for a median of 49 mo (range: 1-199 mo).Capsular involvement and collecting system invasion were reported in 21.6% and 7.5% of patients, respectively. Capsular involvement was significantly associated with a higher nuclear grade and larger tumors, whereas collecting system invasion was significantly associated only with microvascular invasion. In addition, capsular involvement and collecting system invasion were not associated with each other, but had a significant impact on recurrence-free survival (p = 0.007 and p < 0.001, respectively). Interestingly, patients with capsular involvement had the same recurrence-free survival as patients diagnosed as having pT3a N0 M0 RCC. In multivariate analysis, both capsular involvement and collecting system invasion were independent predictors of recurrence-free survival with a reported risk ratio of 1.84 and 3.78, respectively.