Progression and long-term survival after simple enucleation for the elective treatment of renal cell carcinoma: experience in 107 patients

PURPOSE: We present our findings in a series of T1a renal cell carcinoma treated with elective simple enucleation, specifically reporting the incidence of local recurrence, and progression-free and disease specific survival rates. MATERIALS AND METHODS: A total of 107 patients who underwent elective nephron sparing surgery performed with simple enucleation from January 1989 to December 2000 were studied retrospectively. None of the patients had preoperative or intraoperative suspicion of positive nodes. All patients were free from distant metastases before surgery (M0). Patient status was last evaluated in July 2004. Mean (median, range) followup was 88.3 (84, 44 to 175) months. RESULTS: Pathological review according to the 2002 TNM classification showed that 95% (102 of 107) of tumors were pT1a, 4% (4 of 107) pT1b and 1% (1 of 107) pT3a. Mean (SD, median, range) tumor greatest dimension was 2.7 (0.93, 2.5, 0.6 to 5) cm. None of the patients died in the immediate postoperative period (within the first 30 days). There were no major complications such as bleeding and urinary leakage/urinoma requiring reoperation. The 5 and 10-year cancer specific survival was 99% and 97.8%, respectively. The 5 and 10-year progression-free survival was 98.1% and 94.7%, respectively. Overall 3 patients had disease progression (2.8%) of whom 2 (1.9%) were local recurrence, 1 alone and 1 associated with distant metastases diagnosed 12 months earlier. CONCLUSIONS: Simple tumor enucleation is a safe and acceptable approach for elective nephron sparing surgery. It provides excellent long-term progression-free and cancer specific survival rates, and is not associated with an increased risk of local recurrence compared with partial nephrectomy.     

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.     

Simple enucleation for the treatment of PT1a renal cell carcinoma: our 20-year experience

OBJECTIVES: To evaluate the safety and efficacy of simple enucleation as a conservative treatment for pT1a RCC, and to report on the incidence of major complications, local recurrence, and progression-free and disease-specific survival rates. METHODS: We retrospectively reviewed the data of 232 patients who had nephron-sparing surgery (NSS) by simple enucleation between 1986 and 2004 for sporadic, unilateral, pathologically confirmed pT1a RCC. The patients' status was evaluated last in September 2005. The mean (median, range) follow-up was 76 (61, 12-225) months. RESULTS: The mean (SD, median, range) tumor greatest dimension was 2.8 (0.78, 2.85, 0.6-4) cm. The histopathologic review according to the International Union Against Cancer and American Joint Commission for Cancer (1997) classification revealed 198 clear cell (85.3%), 18 papillary (7.8%), 15 chromophobe (6.5%) and one (0.4%) collecting duct RCCs. There were no major complications, such as prolonged acute tubular necrosis/chronic renal insufficiency and bleeding requiring open reoperation. One patient developed postoperative late retroperitoneal fluid collection consistent with urinoma, which required aspiration, drainage position and JJ stenting for 3 weeks. The 5- and 10-year cancer-specific survival were 96.7% and 94.7%, respectively. The 5- and 10-year progression-free survival were 96% and 94%, respectively. Overall, 13 (6.4%) patients had disease progression, three of whom had local recurrences alone (1.5%) elsewhere in the kidney; none had local recurrence at the level of the enucleation bed. CONCLUSIONS: Simple tumor enucleation is a safe and acceptable nephron-sparing treatment that provides excellent long-term local control and cancer-specific survival rates.     

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.     

Simple Enucleation for the Treatment of PT1a Renal Cell Carcinoma: Our 20-Year Experience

Objectives

To evaluate the safety and efficacy of simple enucleation as a conservative treatment for pT1a RCC, and to report on the incidence of major complications, local recurrence, and progression-free and disease-specific survival rates.

Methods

We retrospectively reviewed the data of 232 patients who had nephron-sparing surgery (NSS) by simple enucleation between 1986 and 2004 for sporadic, unilateral, pathologically confirmed pT1a RCC. The patients’ status was evaluated last in September 2005. The mean (median, range) follow-up was 76 (61, 12–225) months.

Results

The mean (SD, median, range) tumor greatest dimension was 2.8 (0.78, 2.85, 0.6–4) cm. The histopathologic review according to the International Union Against Cancer and American Joint Commission for Cancer (1997) classification revealed 198 clear cell (85.3%), 18 papillary (7.8%), 15 chromophobe (6.5%) and one (0.4%) collecting duct RCCs. There were no major complications, such as prolonged acute tubular necrosis/chronic renal insufficiency and bleeding requiring open reoperation. One patient developed postoperative late retroperitoneal fluid collection consistent with urinoma, which required aspiration, drainage position and JJ stenting for 3 weeks. The 5- and 10-year cancer-specific survival were 96.7% and 94.7%, respectively. The 5- and 10-year progression-free survival were 96% and 94%, respectively. Overall, 13 (6.4%) patients had disease progression, three of whom had local recurrences alone (1.5%) elsewhere in the kidney; none had local recurrence at the level of the enucleation bed.

Conclusions

Simple tumor enucleation is a safe and acceptable nephron-sparing treatment that provides excellent long-term local control and cancer-specific survival rates.     

Impact of tumor size on the predictive ability of the pT3a primary tumor classification for renal cell carcinoma

PURPOSE: The accuracy of the pT3a primary tumor classification for renal cell carcinoma has been questioned recently. We investigated the association of perinephric and renal sinus fat invasion with death from renal cell carcinoma independent of tumor size. MATERIALS AND METHODS: We identified 2,165 patients treated with open radical nephrectomy or nephron sparing surgery for clinically localized, sporadic pT1a, pT1b, pT2 or pT3a renal cell carcinoma between 1970 and 2002. Patients with pT3a disease were then subdivided into 3 groups according to tumor size to match the size definitions for the pT1a, pT1b and pT2 tumor classifications. RESULTS: There were 834 patients with pT1a RCC, 674 with pT1b, 494 with pT2 and 163 with pT3a RCC. At last followup 317 patients died of RCC at a median of 3.8 years following surgery. The median followup among the 1,087 patients still alive at last followup was 7.8 years (range 0 to 34). The risk ratios (95% CI) for the association between fat invasion and death from RCC among patients with tumors 4 cm or smaller, 4 to 7 cm and more than 7 cm were 6.15 (1.84-20.50, p = 0.003), 4.12 (2.50-6.78, p <0.001) and 2.13 (1.53-2.97, p <0.001), respectively. These associations remained statistically significant in a multivariate analysis that included nuclear grade and histological coagulative tumor necrosis. CONCLUSIONS: Peripheral perinephric and renal sinus fat invasion was associated with death from RCC independent of tumor size. Our data contradict reports suggesting that pT3a tumors should be reclassified according to tumor size only.     

Clinicopathological factors predicting recurrence of N0M0 renal cell carcinoma: A case series analysis of one facility

BACKGROUND: Although many factors have been reported as predictors of the recurrence of renal cell carcinoma (RCC), none of the factors are consistent among different studies. In the study presented here, the potential clinicopathological predictors of the recurrence of N0M0 RCC were examined. METHODS: A total of 201 patients who underwent nephrectomy for N0M0 RCC were examined to determine the pathological tumor stage (pT stage), pathological tumor grade of malignancy (tumor grade), symptoms, and tumor size. RESULTS: RCC recurred in 29 patients (14.4%), 50% of whom developed new tumors within 24 months after nephrectomy. The disease-free 3- and 10-year survival rates declined as the pT stage and tumor grade increased: these rates were, respectively, 98.6% and 86.5% for pT1a; 93.7% and 87.9% for pT1b; 100% and 100% for pT2; 78.6% and 58.0% for pT3a; and 88.9% and 16.7% for pT3b. Significant differences in the recurrence rate were noted between pT3 and pT1 or pT2, as well as between grade 3 disease and grade 1 or grade 2 tumors. Multivariate analysis showed that a combination of the pT stage, grade, and presence of symptoms was useful for predicting the recurrence of RCC. CONCLUSION: The present study showed that patients undergoing nephrectomy for N0M0 RCC should be followed-up carefully for 2 years postoperatively with special attention to high pT stage, high grade, and the development of symptoms.     

Nephron-sparing surgery versus radical nephrectomy in the treatment of intracapsular renal cell carcinoma up to 7cm

OBJECTIVE: To compare the oncologic outcomes of nephron-sparing surgery versus radical nephrectomy in intracapsular renal cell carcinoma (RCC) up to 7 cm by reviewing surgical experience retrospectively. METHODS: Data from 1290 consecutive patients who had surgery for RCC have been stored in a dedicated database since 1983. We selected and reviewed those related to disease-free patients who had been treated for unilateral pT1a/pT1b pN0/Nx M0 carcinomas up to 7 cm and later followed for a minimum of 12 mo. RESULTS: A total of 642 patients with mean follow-up of 72.9 mo were selected; 313 had been treated for tumours <4 cm in diameter (176 nephron-sparing surgery, 137 nephrectomy), whereas 329 had been treated for tumours measuring > or =4 cm (52 nephron-sparing surgery, 277 nephrectomy). The comparison between tumours <4 cm or > or =4 cm in diameter showed worse progression and disease-free survival rates for the latter, but the type of surgery (nephron-sparing or radical) seemed to have no significant impact. CONCLUSIONS: Conservative management can be cautiously suggested for RCC up to 7 cm because the worsening of prognosis as diameter increases shows no statistical differences for either nephron-sparing or radical surgery. The agreement of our results with those of similar studies available in the literature may suggest designing a prospective study to compare conservative and more radical surgery in the management of RCC up to 7 cm.     

肾癌肾部分切除术的临床价值及合适的手术切缘的探讨

目的：探讨肾癌肾部分切除术(保留肾单位手术)的临床价值及合适的手术切缘。方法：回顾性分析15例行肾部分切除术的肾癌患者临床资料．其中双侧异时性肾癌且一侧为多发肿瘤2例，单发肿瘤13例。肿瘤直径2～6cm．均为T1期(1997年TNM分期标准)。对15例肾癌患者行肾部分切除术．手术切缘位于肿瘤外1cm。另取肾癌根治性手术标本21例．于体外沿假包膜行肾肿瘤剜除术．并随机切取肿瘤边缘0．3cm、0．5cm及1cm处肾实质及肾蒂处淋巴脂肪组织行病理检查。结果：15冽患者随访12～72个月．平均41个月．未见并发症及残肾内肿瘤复发。21例标本于体外行肿瘤剜除后肉眼下均无肿瘤组织残留，送检组织均无肿瘤细胞浸润。结论：肾部分切除术能安全有效地治疗局限的早期肾癌患者．而手术切缘为肿瘤边缘1cm处较为合适。     

Age at diagnosis as a powerful predictor for disease recurrence after radical nephrectomy in Japanese patients with pT1 renal cell carcinoma

Objectives: To review clinical outcomes and to identify clinicopathological variables as predictors of disease recurrence in a cohort of Japanese patients undergoing radical nephrectomy for renal cell carcinoma (RCC). Methods: The present study included a total of 710 consecutive Japanese patients who underwent radical nephrectomy and were diagnosed as having localized pT1 RCC. The significance of several clinicopathological factors in predicting postoperative disease recurrence was assessed by univariable and multivariable analyses. Results: Median age was 66 years (range 32–90 years). Open and laparoscopic radical nephrectomies were carried out for 436 (61.4%) and 274 (38.6%) patients, respectively. Tumor size was 4 cm or less in 461 (64.9%) patients and greater than 4 cm and 249 (35.1%) patients. During the observation period (median 36 months; range 3–111 months), postoperative disease recurrence developed in 37 patients (5.2%), of whom 10 (1.4%) died of disease progression. The 1‐, 3‐ and 5‐year recurrence‐free survival rates were 98.3%, 95.0% and 92.7%, respectively. Age at diagnosis and tumor size were found to be significantly associated with recurrence‐free survival at both univariable and multivariable analysis. Furthermore, there were significant differences in the recurrence‐free survival with respect to both independent predictors. Conclusions: Age at diagnosis in addition to tumor size appears to be independently related to disease recurrence in Japanese patients with pT1 RCC. Thus, an intensive follow up for older patients seems to be advisable.     

Renal cell carcinoma in the solitary kidney: an analysis of complications and outcome after nephron sparing surgery

PURPOSE: We evaluated surgical techniques, pathological features and extended outcomes in patients with renal cell carcinoma in a solitary kidney treated with surgical excision. MATERIALS AND METHODS: Between 1970 and 1998, 76 patients underwent nephron sparing surgery for sporadic renal cell carcinoma in a solitary kidney, including 63 with tissue specimens available for pathological review who comprised the cohort. Six (9.5%) patients had a congenitally absent kidney and 57 (90.5%) had previously undergone contralateral nephrectomy for renal cell carcinoma. The clinical and pathological features examined were patient age at nephron sparing surgery, sex, type of nephron sparing surgery (enucleation, partial nephrectomy or ex vivo resection), tumor size, nuclear grade, histological subtype and 1997 tumor stage. Overall cancer specific, local recurrence-free and metastasis-free survival as well as early (within 30 days of nephron sparing surgery) and late (30 days to 1 year after nephron sparing surgery) complications were assessed. Univariate and multivariate analyses were done to test for the associations of clinical and pathological features with outcome. RESULTS: Most patients were treated with enucleation (36.5%), standard partial nephrectomy (38.1%) or the 2 procedures (11.1%) and in 8 (12.7%) ex vivo tumor resection was done. The renal cell carcinoma histological subtypes were clear cell in 82.5% of cases, papillary in 15.9% and chromophobe in 1.6%. Grade was 1 to 3 in 10 (15.9%), 42 (66.7%) and 10 (15.9%) tumors, respectively. At 5 and 10 years the overall survival rate was 74.7% and 45.8%, the cancer specific survival rate was 80.7% and 63.7%, the local recurrence-free survival rate was 89.2% and 80.3%, and the metastasis-free survival rate was 69% and 50.4%, respectively. Tumor stage and nuclear grade were significantly associated with death from any cause, death from renal cell carcinoma and distant metastases on multivariate analysis. Notably no patient with papillary or chromophobe renal cell carcinoma died of renal cell carcinoma, or had recurrence or metastasis. The type of nephron sparing surgery was not significantly associated with outcome, although there were too few patients with recurrence to assess the association of the type of nephron sparing surgery with local recurrence. The most common early complication was acute renal failure in 12.7% of cases, while the most common late complications were proteinuria in 15.9% and renal insufficiency in 12.7%. CONCLUSIONS: The 1997 tumor stage and nuclear grade were significant predictors of death from any cause, death from renal cell carcinoma and distant metastases in patients treated with nephron sparing surgery for renal cell carcinoma involving a solitary kidney. Nephron sparing surgery in a solitary kidney can be performed safely and with minimal morbidity.     

Follow-up guidelines for nonmetastatic renal cell carcinoma based on the occurrence of metastases after radical nephrectomy.

OBJECTIVE: To define guidelines for the follow-up management of nonmetastatic renal cell carcinoma (RCC), by assessing tumour recurrences and the clinical course in patients who had undergone radical nephrectomy. PATIENTS AND METHODS: The records of 187 patients with pT1-3, N0-X, M0 RCC who underwent radical nephrectomy between 1982 and 1997 were reviewed prospectively. Clinicopathological variables were compared with the time of first recurrence, site of metastasis and reason for diagnosis. RESULTS: Metastases were diagnosed in 98 sites in 56 of the 187 patients (30%). The risk for developing metastases increased with stage; 80% of the patients had their metastases diagnosed within 3 years (median 14.5 months) after nephrectomy. The time to first diagnosis was longer for patients with pT1 tumours and for those with skeletal metastases. The cause-specific 5-year survival rate for pT1 tumours was 95%, for pT2 87% and for pT3 tumours 37%. All patients with diploid pT1-2 RCC survived, having a survival advantage over those with aneuploid pT1-2 tumours (P=0.018). Also, pT1-2 tumours of < 5 cm were associated with better survival rates. Among 74 patients with pT3 tumours, 45 got metastases; DNA ploidy in these tumours did not influence survival. Of 30 patients with lung metastases, 28 were diagnosed during follow-up, while 25 of 26 other metastatic sites were diagnosed because of symptoms. CONCLUSIONS: The risk for tumour progression depends mainly on stage; these results indicate no need for follow-up in patients with diploid pT1-2 tumours or with aneuploid pT1 tumours of < 5 cm. For patients with aneuploid pT1-2 tumours of > 5 cm and pT3 tumours, follow-up is indicated.     

肾肿瘤剜除和改良肾部分切除术21例临床效果观察

目的评估单纯肿瘤剜除术和改良肾部分切除术治疗早期肾癌的临床效果。方法回顾性分析2006年2月至2009年4月间21例早期肾癌患者的临床资料,其中14例接受单纯肿瘤剜除术,7例改良肾部分切除术。结杲所有手术顺利完成,无1例出现严重并发症。平均热缺血时间（21土2）（17～28）min。所有切除标本都有完整的包膜,2例肿瘤〉4cm者包膜有灶状浸润,但未穿透包膜,切除的肿瘤周围肾实质内未见癌细胞。平均随访2．7年,所有患者存活,无局部复发和远处转移。1例出现肿瘤复发,但非原来手术部位,其余均无肿瘤复发。结论单纯肿瘤剜除术和改良肾部分切除术是治疗早期肾癌的安全、有效方法,能够有效保留肾单位和功能,防止肾功不全。     

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.     

Long term results of excision of small renal cancer surrounded by a minimal layer of grossly normal parenchyma: review of 94 cases

OBJECTIVE: To assess safety and effectiveness of excision of small renal cancer. METHODS: We reviewed the records of 94 patients, who underwent, from 1992 to 2001, excision of renal tumor leaving around it a thin layer of grossly normal parenchyma and adjacent perinephric fat. This technique has been called enucleoresection, as it is not a simple enucleation but neither a conventional partial nephrectomy. Patients were followed up mean routine blood examination, ultrasound and computed tomography scan every 6 months for 2 years and annually thereafter. RESULTS: Median age was 63 years (35-76). Median tumour size was 2.1cm (1.1-4.5). Clamping of renal pedicle was performed in 54 cases. Major complications included 4 cases of haemorrhage; only 1 patient required surgical exploration. Pathological stage was pT1a in 87, pT1b in 4 and pT3a in 3 patients. Surgical margins were always negative. Median follow-up was 59 months (range 10-128). Eight patients died without evidence of tumour recurrence. One pT3a patient developed distant metastases and died 2 years after surgery. Five years survival rate was 95.7% (90/94 patients), cancer specific survival rate 98.9% (93/94) and disease free survival rate 98.9% (93/94). CONCLUSIONS: Enucleoresection of small renal tumors surrounded by a minimal layer of grossly normal renal parenchyma reproduces the results of partial and radical nephrectomy with minimal morbidity.     

Reassessment of T classification system cutoff value for renal cell carcinoma

PURPOSE: The 1997 T staging classification for renal cell carcinoma (RCC) defined T1 as tumors measuring up to 7 cm in size and T1 is subdivided into T1a and T1b with a 4 cm cutoff value in the 2002 TMN classification. We evaluated the validity of these cutoff values by assessing the cancer-specific survival of patients with non-metastatic RCC according to a series of alternative size cutoff values. In addition, we calculated how these size cutoffs affected the disease specific survival rates. MATERIALS AND METHODS: A database containing the records of 200 patients with RCC who underwent open radical nephrectomy for N0M0 disease between 1985 January and 2004 January was evaluated. Tumors were stratified by cutoff values ranging from 3 to 9 cm with the 1 cm increments in order to evaluate whether the 7 cm cutoff value is appropriate. Next, T1 RCC were stratified by cutoff values ranging from 3 to 6 cm with the 1 cm increment in order to verify whether the 4 cm cutoff is appropriate. Lastly, tumors over 7 cm diameter were stratified by cutoff values ranging from 9 to 14 cm with the 1 cm increments in order to verify whether the present T2-3a categories could be divided according to tumor size. RESULTS: As for the T1-2 classification, a cutoff value at 7 cm or 8 cm shared the greatest prognostic power. Although there was no significant difference in T1a/T1b subclassification, a 4 cm or 5 cm cutoff value resulted in a greatest separation of survival curves for T1a and T1b. As for tumors from 9-14 cm in diameter, only a 13 cm cutoff value provided a significant difference in survival. CONCLUSIONS: Our results indicate that the present 7 cm cutoff value in the TMN system is valid in terms of prognostic value. The 4 cm cutoff value may not reflect the survival when total nephrectomy is considered, thus indicating that tumors at 4 cm cutoff value may be valid when nephron sparing surgery is considered. The 13 cm cutoff value seems to be most appropriate in N0M0 tumors with over 7 cm in diameter.     

Local recurrence after tumour enucleation for renal cell carcinoma with no ablation of the tumour bed: results of a prospective single-centre study

Study Type – Therapy (individual cohort)
Level of Evidence 2b What’s known on the subject? and What does the study add? Tumour enucleation was demonstrated to be an oncologically safe conservative treatment for small renal masses in agreement with the EAU guidelines. Nevertheless, the theoretical increased risk of positive surgical margins and local recurrence, led some authors to hypothesize a possible key role of laser or diathermy ablation of the tumour bed to free the kidney parenchyma from any tumour cells that extended in the kidney parenchyma. Our pathological and clinical results showed that tumour enucleation with no ablation of the tumour bed (e.g. diathermy, argon beam or Nd‐YAG laser) can ensure negative surgical margins and it is not associated with an increased risk of local recurrence.

OBJECTIVE

• ? To prospectively evaluate the risk of positive surgical margins and local recurrence after blunt tumour enucleation (TE) with no ablation of the tumour bed.

PATIENTS AND METHODS

• ? Between 2005 and 2007, data were gathered prospectively from 201 consecutive patients who had open TE with no ablation of the tumour bed.
• ? Overall, 164 consecutive patients had TE for single sporadic renal cell carcinoma (RCC).
• ? All patients had an abdominal computed tomography (CT) at the last follow‐up visit.

RESULTS

• ? The pathological review showed that 70.2% of tumours were pT1a, 18.9% were pT1b, 1.8% were pT2 and 9.1% were pT3a.
• ? The mean (range, interquartile range) tumour greatest dimension was 3.5 (0.5–12.5, 2.4–4.1) cm.
• ? Although no deliberate attempt to resect normal parenchyma was performed, the pathological analysis showed the presence of a thin layer of parenchyma with a mean (range) thickness of 0.97 (0.31–1.60) mm, around the tumour. None of the patients had positive surgical margins.
• ? At a mean (median, range) follow up of 40 (38, 25–62) months, three (1.8%) patients had local recurrence, of whom one (0.6%) had a true local recurrence at the enucleation site detected 35 months after surgery, while two had kidney recurrence elsewhere associated with concurrent systemic metastases diagnosed 16 and 13 months after surgery.

CONCLUSIONS

• ? TE with no ablation of the tumour bed is a safe technique with a local recurrence rate of 0.6%.
• ? The histopathological analysis showed the presence of a minimal tumour‐free surgical margin, although no deliberate attempt to resect normal parenchyma is performed.

     

Is There a Need to Further Subclassify pT2 Renal Cell Cancers as Implemented by the Revised 7th TNM Version?

Background

The recently modified TNM classification of renal cell carcinoma (RCC) (7th edition) has implemented a subdivision of pT2 tumours into stage pT2a (>7 or ≤10 cm) versus pT2b disease (>10 cm).

Objective

Our aim was to evaluate whether this subdivision of pT2 RCC is justified due to a clinical prognosis divergence between the two groups (pT2a vs pT2b)

Design, setting, and participants

In total, 5122 patients were subjected to either radical nephrectomy or nephron-sparing surgery at three centres in Germany (University Hospitals of Hannover, Homburg/Saar, and Marburg). Patients were reclassified into stage pT2a and pT2b according to the maximum tumour diameter as suggested by the 7th revised version of the TNM classification system.

Measurements

The t test and Fisher exact test were applied to evaluate the comparability of the two groups (pT2a vs pT2b) regarding several additional patients’ and tumour-specific characteristics of known prognostic relevance for RCC. Univariable (Kaplan-Meier analysis) and multivariable statistical analyses (Cox proportional hazards regression model) were applied to identify a possible difference between the two groups (pT2a vs pT2b) regarding cancer-specific survival (CSS).

Results and limitations

Applying the new TNM classification, 579 previously pT2-staged patients were divided into 445 (76.9%) with pT2a and 134 (23.1%) with pT2b tumours. Kaplan-Meier curves revealed no significant difference in CSS between pT2a and pT2b patients; 5-yr CSS was 79.0% and 74.1%, respectively (p = 0.38). When applying multivariable analysis, unlike tumour grade and N/M status, pT2 subclassification failed to independently predict survival in RCC patients.

Conclusions

The new subclassification of pT2 RCC into two different subgroups as suggested by the latest modification of the TNM system does not yield additional/prognostic information.     

Prognostic value of multifocality on progression and survival in localized renal cell carcinoma

OBJECTIVE: Incidence of multifocality in Renal Cell Carcinoma (RCC) is estimated at between 5 and 25%. Multifocality has been largely studied because of the growing interest in conservative surgery which is a risk of local recurrence. The aim of this study is to evaluate the relationship between multifocality and other prognostic parameters and whether it is an independent prognostic factor. MATERIAL AND METHODS: From 1980 to 1990, 255 patients (median age: 60.9 years) were treated by radical nephrectomy for pT1 to pT3b N0M0 RCC. The median follow-up time was 183 months. Multifocality was defined as the existence of at least one other tumoral localization, macroscopically and microscopically diagnosed as renal cell carcinoma, in the same kidney. Studied parameters were: age, sex, side, size, stage, Fuhrman's grade, capsular invasion, renal vein involvement and microvascular invasion. Survival was assessed with Kaplan-Meier and Cox models. RESULTS: 37 cases of multifocal RCC were diagnosed (14.5%). There was only a significant correlation with stage (p=0.002) and with capsular invasion (p=0.002). No other factor was correlated with multifocality. It had no influence on the risk of metastatic progression, overall or specific survival. CONCLUSION: There is a significant correlation between capsular invasion and multifocality that has to be considered before proposing conservative surgery for a localized RCC. Multifocality has no influence on survival or metastatic progression in case of radical nephrectomy.     

Oncologic outcome of 132 cases of laparoscopic radical nephrectomy with intact specimen removal for T1-2N0M0 renal cell carcinoma

We present the short and long-term oncologic outcome of 132 patients with pathologically confirmed T1–T2, N0M0 renal cell carcinoma (RCC), who underwent laparoscopic radical nephrectomy with intact specimen removal at our institution. Beginning January 1998, we prospectively collected data of 132 patients undergoing laparoscopic radical nephrectomy, whose final pathologic stage was T1 or T2, N0M0, RCC. The clinical data of three groups categorized as group (pT1a)—36 patients, group (pT1b)—51 patients and group (pT2)—45 patients were analyzed statistically to assess oncological outcome. The specimens were removed intact without morcellation in all patients in a homemade plastic bag. The total median follow-up was 56 months (range 3–80 months) and there were no local or port-site recurrences or hernia. Patients with pT2 tumors had significantly greater operating time, blood loss and analgesic requirements than pT1a/pT1b tumor patients. The distant metastases were found in 1, 4 and 5 patients in group pT1a, pT1b and pT2, respectively. The 5-year cancer-specific survival was 97.2, 86.3 and 82.2%, respectively, in pT1a, pT1b and pT2 tumor patients (significantly lower in pT2 than pT1a, P = 0.008). The 5-year recurrence-free survival was 97.2, 84.3 and 82.2%, respectively, in pT1a, pT1b and pT2 tumor patients (significantly lower in pT2 than pT1a, P = 0.02). Laparoscopic radical nephrectomy (retroperitoneal and transperitoneal route) with intact specimen removal for localized renal cell carcinoma (T1-2N0M0) provides satisfactory short and long-term oncologic efficacy.