Collecting duct renal cell carcinoma: a matched analysis of 41 cases

OBJECTIVES: Collecting duct renal cell carcinoma (CDRCC) is a rare but reportedly aggressive histologic subtype. We assessed the stage and histologic features of patients with CDRCC and compared cancer-specific mortality in CDRCC and matched patients with clear-cell renal cell carcinoma (CRCC). METHODS: Forty-one (0.6%) patients with CDRCC and 5246 CRCC patients were identified within a cohort of 6608 patients treated with either radical or partial nephrectomy for renal cancer. Within the 5246 CRCC cases, 105 were matched with CDRCC cases for grade, tumour size, and T, N, and M stages. Kaplan-Meier and life table analyses addressed RCC-specific survival. RESULTS: Of all CDRCC patients, 76% had pT3 disease at nephrectomy versus 37% for those with CRCC. The predominant Fuhrman grades were III (56%) and IV (22%) in CDRCC versus II (42%) and III (28%) for CRCC. Moreover, 49% of CDRCC patients were pN1-2 versus 8% for CRCC. Of CDRCC patients 19% had distant metastases at nephrectomy versus 14% for CRCC. Finally, 73% of CDRCC patients had either local or systemic symptoms versus 56% for CRCC. After matching, the RCC-specific mortality of CDRCC patients was no different from that for CRCC patients (RR=1.1; p=0.8). One- and 5-yr CDRCC-specific survival rates were 86% and 48%, respectively, versus 86% and 57% for matched CRCC controls. CONCLUSIONS: CDRCC patients present with more advanced stage and with more aggressive disease compared with CRCC patients. After nephrectomy, when CDRCC cases were matched with CRCC, the same cause-specific survival was seen.     

Cyst-associated renal cell carcinoma: Clinicopathologic characteristics and evaluation of prognosis in 27 cases

BACKGROUND: No consistent clinicopathologic characteristics of cyst-associated renal cell carcinoma (CRCC) have previously been determined. METHODS: In total, 768 patients with renal cell carcinoma (RCC) underwent radical or partial nephrectomy. Renal cell carcinoma was classified as CRCC in 27 of these patients (3.5%, subdivided into RCC originating in a cyst and cystic RCC), clear-cell RCC in 662 patients (86.2%), chromophobe cell renal carcinoma in 36 patients (4.7%) and papillary RCC in 43 patients (5.6%) according to the criteria of the World Health Organization. RESULTS: The pathologic stage and nuclear grade were usually lower in those with CRCC (low stage/low grade; 89%/96%) or chromophobe cell renal carcinoma (low stage/low grade; 89%/80%) than in those with clear-cell RCC (low stage/low grade; 59%/65%) or papillary RCC (low stage/low grade; 53%/69%). Of the 27 CRCC patients, only 19 (70%) could be diagnosed through preoperative imaging studies. Patients with CRCC showed a favorable prognosis (survival rate: 95% at 1 year, 89.7% at 3 years and 84.4% thereafter) and, especially among the patients with RCC originating in a cyst, no cancer-related death was observed. Comparing the survival among four types of RCC, a favorable outcome was observed in cases of CRCC or chromophobe cell renal carcinoma compared with clear-cell RCC or papillary RCC (clear vs chromophobe: P = 0.002; chromophobe vs papillary: P = 0.019; clear vs cyst-associated: P = 0.001; papillary vs cyst-associated: P = 0.00079). CONCLUSIONS: In cases of CRCC, the disease was usually detected at lower stages and grades and therefore the prognosis was better than in cases of other types of RCC. Preoperative diagnosis of this disease was very difficult, especially in cases of RCC originating in a cyst.     

Nephrectomy improves the survival of patients with locally advanced renal cell carcinoma

OBJECTIVES

To examine the cancer‐specific survival of patients treated with nephrectomy and compared it to that of patients managed without surgery.

PATIENTS AND METHODS

Of 43 143 patients with renal cell carcinoma (RCC) identified in the 1988–2004 Surveillance, Epidemiology and End Results database, 7068 had locally advanced RCC and with no distant metastasis. These patients had a nephrectomy (6786, 96.0%) or no surgical therapy (282, 4.0%). Multivariable Cox regression models, and matched and unmatched Kaplan‐Meier survival analyses, were used to compare the effect of nephrectomy vs non‐surgical therapy on cancer‐specific survival. Also, competing‐risks regression models adjusted for the effect of other‐cause mortality. Covariates and matching variables consisted of age, gender, tumour size and year of diagnosis.

RESULTS

The 1‐, 2‐, 5‐ and 10‐year cancer‐specific survival of patients who had nephrectomy was 88.9%, 88.1%, 68.6% and 57.5%, vs 44.8%, 30.6%, 14.5% and 10.6% for non‐surgical therapy. In multivariable analyses, relative to nephrectomy, non‐surgical therapy was associated with a 5.8‐fold higher rate of cancer‐specific mortality (P < 0.001). Non‐surgical therapy was also associated with a 5.1‐fold higher rate of cancer‐specific mortality in matched analyses (P < 0.001). Finally, competing‐risks regression confirmed the statistical significance of the variable defining treatment type (nephrectomy vs non‐surgical therapy) in multivariable and matched analyses (P < 0.001).

CONCLUSION

Relative to non‐surgical treatment, nephrectomy improves the cancer‐specific survival of patients with locally advanced RCC; our findings await prospective confirmation.     

Expression of matrix metalloproteinase-10 in renal cell carcinoma and its prognostic role

OBJECTIVES: Matrix metalloproteinase (MMP)-10 is associated with malignant aggressiveness in various cancers, but its importance has not been investigated in conventional renal cell carcinoma (CRCC). The purpose of this study was to determine the clinical significance and malignant potential of MMP-10 in human CRCC tissues. PATIENTS AND METHODS: Specimens were obtained from 103 CRCC patients who underwent radical surgery and were examined by immunohistochemistry for MMP-10 expression. The proportions of Ki-67-stained cells (proliferation index: PI) and densities of CD34-positive vessels (microvessel density: MVD) were measured by a computer-aided image analysis system. The relationships between MMP-10 expression and clinicopathologic features and various parameters including tumour size, PI, MVD, and survival were investigated by univariate and multivariate analyses. RESULTS: MMP-10 expression was mainly detected in cancer cell cytoplasm, and 45 (43.7%) CRCCs were considered MMP-10-positive. MMP-10 expression correlated with grade (p=0.006) and pT stage (p<0.001), and it was a significant and independent factor for high pT stage in multivariate analysis model. MMP-10 expression was associated with MVD (p = 0.022) but not tumour size or PI. MMP-10 expression in CRCC was a significant predictor of poor outcome by log-rank test (p = 0.013) but not by multivariate analysis. CONCLUSIONS: MMP-10 seems to play an important role in renal cancer cell invasion and is a potentially useful therapeutic target to prevent CRCC tumour progression.     

Outcome after cytoreductive nephrectomy for metastatic renal cell carcinoma is predicted by fractional percentage of tumour volume removed

OBJECTIVE: To determine if the fractional percentage of tumour volume (FPTV) removed at cytoreductive nephrectomy predicts disease-specific survival (DSS), as metastatic renal cell carcinoma ((M+)RCC) is associated with poor overall survival with only a 10-20% patient survival at 2 years. PATIENTS AND METHODS: The Columbia Urologic Oncology Database was reviewed; 1016 patients had renal surgery from 1988 to 2005, 78 patients with (M+)RCC underwent nephrectomy. The FPTV removed was determined using pathological and imaging reports. The patients were stratified as having a > or <90% FPTV. Kaplan-Meier analysis with log-rank test was used to determine survival advantage between groups. A Cox proportional hazard model was used for FPTV in both univariate and multivariate analyses. Secondary analyses were conducted to determine if the size of the primary tumour or volume of metastases affected outcome and if the FPTV affected hospitalization time. RESULTS: In all, 55 patients had their FPTV calculated exactly; 45 had a >90% FPTV. The median DSS times were 11.6 and 2.9 months for patients with >90% and <90% FPTV removed (P = 0.002). The hazard ratio for death was 0.24 for patients with a >90% FPTV in a univariate model (P = 0.016) and 0.29 in multivariate analysis (P = 0.02). Patients with a <90% FPTV spent a greater percentage of time hospitalized before death, 21.2% vs 6.5% (P = 0.03). CONCLUSION: For patients with (M+)RCC, overall survival is limited, but can be extended by cytoreductive nephrectomy. The FPTV expected to be removed is a simple and available method to counsel patients regarding the benefits of surgical intervention.     

Prediction of lymph node status by analysis of prognostic factors and possible indications for elective axillary dissection in T1 breast cancers.

OBJECTIVE: To identify those patients with T1 breast cancers with lower risk of nodal metastases who can safely be spared axillary dissection. DESIGN: Retrospective study. SETTING: University hospital, Italy. SUBJECTS: Review of clinical records and histopathological slides of 547 patients with T1 breast cancer, operated on between 1984 and 1997. MAIN OUTCOME MEASURES: Incidence of axillary metastases in relation to age, menopausal status, diameter and grade of tumour, vascular invasion, DNA ploidy, S-phase fraction and hormone receptor state, by univariate and multivariate analysis. RESULTS: Axillary metastases were present in 159 patients (29%). On univariate analysis, diameter of tumour 10 mm or less (pT1a/pT1b cancers), no vascular invasion, and grade 1 tumour were significantly correlated with a lower risk of nodal metastases, but only vascular invasion (p = 0.0001, odds ratio = 3.1) and diameter of tumour (p = 0.04, odds ratio = 1.6) were independent predictors on multivariate analysis. Among 34 pT1a/pT1b cancers, with low grade of tumour and no vascular invasion, only 2 (6%) had axillary metastases. When only one favourable predictive factor was associated with diameter of tumour of 10 mm or less, the incidence of axillary metastases ranged from 12% for 43 patients with grade 1 cancers to 13% for 76 patients with no vascular invasion. CONCLUSIONS: Axillary dissection may be avoided in pT1a and pT1b breast cancers (< or = 10 mm), with low grade of tumour or no vascular invasion. T1 breast cancers 10 mm or less in diameter should be treated by a two-step approach, first wide excision of the tumour and then axillary dissection or not depending on pathological examination of the primary tumour.     

Collecting system invasion in renal cell carcinoma: impact on prognosis and future staging strategies

PURPOSE: To define further the prognostic impact of urothelial invasion in renal cell carcinoma (RCC) we examined the outcome in patients presenting to our institution with kidney cancer treated with nephrectomy. MATERIALS AND METHODS: We reviewed the medical records of 895 patients with RCC who were treated with nephrectomy between 1989 and 1999. Median followup was 31 months. Kaplan-Meier survival curves were constructed with respect to 1997 TNM stage, Fuhrman grade and University of California-Los Angeles Integrated Staging System stage, comparing patients with and without collecting system invasion. Univariate and multivariate analyses were performed. Overall survival was defined as time from nephrectomy to time of death or last followup. RESULTS: Of the 895 patients 124 (14%) demonstrated collecting system invasion. Patients with collecting system invasion were more likely to be symptomatic and have associated metastases and/or positive nodes at diagnosis. Urothelial invasion was evident in 21 of 329 T1, 12 of 131 T2, 84 of 388 T3 and 7 of 47 T4 tumors. Three-year overall survival for patients with vs without collecting system invasion by stage was 67% vs 81% for T1, 60% vs 69% for T2, 31% vs 46% for T3 and 29% vs 12% for T4 disease. Patients with urothelial invasion incurred a significant increase in the likelihood of death and were at 1.4 times greater risk of death compared with patients without collecting system invasion. CONCLUSIONS: Our findings suggest that collecting system invasion in RCC cases is associated with specific clinical findings as well as poor prognostic variables and it has a profound impact on prognosis in low stage tumors.     

A population‐based comparison of survival after nephrectomy vs nonsurgical management for small renal masses

OBJECTIVE

To examine population‐based rates of cancer‐specific and other‐cause mortality after either non‐surgical management (NSM) or nephrectomy, in patients with small renal masses, as several reports from selected institutions support the applicability of surveillance in patients with small renal masses, but there are no population‐based studies confirming the general applicability of this therapy.

PATIENTS AND METHODS

Of 43 143 patients with renal cell carcinoma identified in the 1988–2004 Surveillance, Epidemiology and End Results database, 10 291 had localized small renal masses (≤4 cm) and were offered NSM (433, 4.2%) or nephrectomy (9858, 95.8%). Univariable matched and multivariable unmatched competing‐risks regression models were used in the analyses.

RESULTS

Cumulative incidence plots based on unmatched data, where the effect of other‐cause mortality was controlled for, showed a 5.2%, 6.5% and 9.4% survival benefit for nephrectomy vs NSM at 1, 2 and 5 years after nephrectomy or diagnosis, respectively. The same magnitude of the benefit (4.5%, 5.6% and 8.0%) persisted in analyses matched for age, tumour size and year of diagnosis or of nephrectomy. Finally, in multivariable analyses, treatment type, age, tumour size and year of diagnosis or of nephrectomy were independent predictors.

CONCLUSION

Relative to nephrectomy, NSM appears to undermine the overall and cancer‐specific survival of patients with small renal masses by as much as 9.4%, at 5 years.     

Factors of importance for prediction of survival in patients with metastatic renal cell carcinoma, treated with or without nephrectomy

OBJECTIVE: The indications for nephrectomy in patients with metastatic renal cell carcinoma remain controversial. A number of variables were analysed to identify factors that might predict the survival time, and these factors were used to obtain guidance as to which patients might benefit from palliative nephrectomy. MATERIAL AND METHODS: We reviewed the medical records for 106 consecutive patients with primary metastatic renal cell carcinoma, including clinicopathological factors, routine laboratory data and metastatic spread. The association of the different factors to survival time was evaluated by univariate and multivariate analysis. RESULTS: A number of factors correlated to survival time in univariate analysis, including solitary versus multiple metastases, serum albumin and DNA ploidy, but after Cox multivariate analysis their significance was lost. The remaining independent prognostic factors were performance status, number of metastatic sites, erythrocyte sedimentation rate (ESR), calcium in serum and vein invasion with tumour thrombus formation. The factors with no association to survival time were the metastatic sites, tumour size and nuclear grade. Patients treated with nephrectomy had a significantly longer survival time than those who did not undergo nephrectomy (p < 0.001). None of the 28 patients who did not undergo nephrectomy survived for 2 years, compared with 38 of the 78 patients who were nephrectomized. CONCLUSIONS: Patients who can be expected to survive longer, and who might be recommended for nephrectomy despite metastatic disease, would have the following independent factors: a good performance status, metastases limited to one organ, low ESR, normal calcium in serum and no tumour thrombus formation.     

Metastatic renal cell carcinoma (RCC): Spontaneous regression,long-term survival and late recurrence

We report 4 cases of metastatic renal cell carcinoma (RCC) with long-term survival either following radical nephrectomy alone or in combination with radio- or hormonal therapy. Two patients with lymph node metastases showed a long-term survival of 12 or more years following radical tumour nephrectomy (with lymphadenectomy) and radiotherapy. One of them exhibited a histologically proven tumour recurrence nearly 12 years after primary surgical treatment and died shortly later; the other one is still without any evidence of metastatic disease. Two other patients exhibited spontaneous regression of pulmonary metastases: one regression occurred after radical tumour nephrectomy alone, the other one after successful primary hormonal treatment and subsequent radical tumour nephrectomy. The following important aspects are emphasized: 1. Renal cell carcinoma is a very unpredictable tumour. Once the diagnosis of renal cell carcinoma is proved, a patient can never be considered cured. 2. Although adjuvant palliative nephrectomy has produced contradictory results in several reports, radical tumour nephrectomy either alone or in combination with other adjuvant therapies such as radiotherapy, hormonal or immunological treatment, can be worthwhile. Cases with long-term survival and spontaneous regression of distant metastases are proof of this. Besides, if carefully selected, the mortality rate of different adjuvant therapies is not significantly higher in patients with metastatic disease than in patients without metastases. The world literature on this subject is reviewed.     

A preoperative prognostic model for patients treated with nephrectomy for renal cell carcinoma

Background

Currently two pretreatment prognostic models with limited accuracy (65–67%) can be used to predict survival in patients with localized renal cell carcinoma (RCC).

Objective

We set out to develop a more accurate pretreatment model for predicting RCC-specific mortality after nephrectomy for all stages of RCC.

Design, setting, and participants

The data originated from a series of prospectively recorded contemporary cases of patients treated with radical or partial nephrectomy between 1984 and 2006. Model development was performed using data from 2474 patients from five centers and external validation was performed using data from 1972 patients from seven centers.

Measurements

The probability of RCC-specific mortality was modeled using Cox regression. The significance of the predictors was confirmed using competing risks analyses, which account for mortality from other causes.

Results and limitations

Median follow-up in patients who did not die of RCC-specific causes was 4.2 yr and 3.5 yr in the development and validation cohorts, respectively. The freedom from cancer-specific mortality rates in the nomogram development cohort were 75.4% at 5 yr after nephrectomy and 68.3% at 10 yr after nephrectomy. All variables except gender achieved independent predictor status. In the external validation cohort the nomogram predictions were 88.1% accurate at 1 yr, 86.8% accurate at 2 yr, 86.8% accurate at 5 yr, and 84.2% accurate at 10 yr.

Conclusions

Our model substantially exceeds the accuracy of the existing pretreatment models. Consequently, the proposed nomogram-based predictions may be used as benchmark data for pretreatment decision making in patients with various stages of RCC.     

Comparison of complications after radical and partial nephrectomy: results from the National Veterans Administration Surgical Quality Improvement Program

OBJECTIVE: To determine whether radical nephrectomy causes less morbidity, less mortality and is associated with a shorter hospital stay than is partial nephrectomy. PATIENTS AND METHODS: A total of 1885 nephrectomies (1373 radical and 512 partial) conducted between 1991 and 1998 in the Department of Veterans Affairs (VA) National Surgical Quality Improvement Program were evaluated. Using multivariate analyses, outcomes were risk-adjusted based on 45 preoperative variables to compare mortality and morbidity rates. RESULTS: The unadjusted 30-day mortality was 2.0% for radical and 1.6% for partial nephrectomy (P = 0.58). Risk-adjusting the two groups did not result in a statistically significant difference in mortality. The 30-day overall morbidity rate was 15% for radical and 16.2% for partial nephrectomy (P = 0.52); risk-adjusted morbidity rates were not statistically different. There were no statistically significant differences in the rates of postoperative progressive renal failure, acute renal failure, urinary tract infection, prolonged ileus, transfusion requirement, deep wound infection, or extended length of stay. CONCLUSIONS: Partial nephrectomy carried out in the VA program has low morbidity and mortality rates, comparable with the complication rates after radical nephrectomy.     

Surgery for renal cell cancer extending into the inferior vena cava - evaluation of survival and perioperative complications using a standardized classification system

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Patients should undergo surgery, although in the recent past some case series reported thrombus shrinkage with target therapies. Operations can be performed safely. The study adds the use of a standardized classification system for perioperative complications and reports less positive results with neoadjuvant target therapies.

OBJECTIVE

? To present a single‐centre experience of surgery for kidney cancer involving vena cava thrombus with surgical technique, complications and outcome using a standardized classification system for perioperative complications.

PATIENTS AND METHODS

? Sixty‐eight consecutive cases were retrospectively analysed. Thrombus extension was at level I (but inside the vena cava) in 10 cases, level II in 28 cases, level III in 18 cases and level IV in 12 cases; 18 patients had distant metastases. ? Radical tumour nephrectomy was performed in all cases. Complete liver mobilization was carried out in 23 cases and cardiovascular bypass with circulatory arrest was performed in five cases. ? Follow‐up was available for 66 patients. Median follow‐up was 29 months (interquartile range 30.75).

RESULTS

? The 28‐day mortality was 0%. ? According to the Clavien–Dindo classification there were two grade 1, 54 grade 2, two grade 3a, two grade 3b and two grade 4a perioperative complications. ? The factors pN, grading and metastases at presentation predicted overall survival in univariate analyses. In a multivariate model none of the factors age, metastases at presentation, pN, WHO‐grading, American Society of Anesthesiologists score, tumour size and thrombus level significantly predicted survival. ? Immediate target therapy with neoadjuvant intention in three patients did not result in surgical therapy.

CONCLUSIONS

? Aggressive surgical treatment causes no perioperative mortality and leads to a low rate of grade 3 and grade 4 complications (8.8%). ? A median overall survival of 47 months shows that surgical treatment has favourable results in these patients.     

Effect of resection and outcome in patients with retroperitoneal sarcoma

BACKGROUND: A consecutive series of 47 patients with retroperitoneal sarcoma (RPS) were resected and prospectively followed. METHOD: Between July 1994 and March 2005, 47 patients (24 men, 23 women; mean age, 56 years; range, 17-82 years) were evaluated. RESULTS: A total of 23 patients had primary RPS and 24 patients had recurrent RPS. A total of 30 out of 47 patients (64%) underwent removal of contiguous intra-abdominal organs. The peroperative mortality was nil and significant preoperative complications occurred in eight cases only (17%). High tumour grade and incomplete resection were significant variables for a worse survival in all 47 patients, both in the univariate and multivariate analyses (P = 0.008 and P = 0.016, respectively). Among 28 radically resected patients, only histological grade affected overall survival (90% 5-year survival for low-grade tumour vs 26% 5-year survival for high-grade tumour; P = 0.006) with a similar effect noted for disease-free survival. CONCLUSIONS: Histological grade was the only factor that affected overall and disease-free survival for RPS tumours. An aggressive surgical approach in both primary and recurrent RPS is associated with long-term survival.     

Lymph node metastases in non-muscle invasive bladder cancer are correlated with the number of transurethral resections and tumour upstaging at radical cystectomy

The first paper in this section, from Mainz, attempts to identify the clinical variables associated with the prevalence of lymph node metastases in non-muscle invasive bladder cancer. The authors found that delay in cystectomy in this potentially dangerous type of tumour is to be avoided, with a higher incidence of lymph node metastases as the number of transurethral resections increases. A paper from Austria shows that in renal carcinoma the pT1 subdivision is associated with differences in conventional histopathology and expression of biomarkers. OBJECTIVE: To identify clinical variables associated with the prevalence of lymph node metastases (LNMs) in patients with non-muscle invasive transitional cell carcinoma (TCC) of the bladder treated with radical cystectomy. PATIENTS AND METHODS: Of 866 patients treated by radical cystectomy and pelvic lymphadenectomy between 1989 and 2002, 219 had non-muscle invasive TCC of the bladder. A retrospective evaluation of these patients included univariate and multivariate analyses of sex, age, number of transurethral resections of the bladder tumour (TURBTs), interval between first TURBT and cystectomy, adjuvant therapy, maximum histopathological tumour stage and grade at TURBT, and tumour upstaging in the cystectomy specimen. RESULTS: LNMs were diagnosed in 33 patients (15%). After multivariate analysis modelling, the number of TURBTs and tumour upstaging in the cystectomy specimen were correlated with the prevalence of LNMs at cystectomy. The number of TURBTs increased the prevalence of LNMs from 8% in patients with one TURBT to 24% in those with two to four TURBTs. Tumour upstaging in the cystectomy specimen increased the prevalence of LNMs from 4% to 36%. CONCLUSION: Inappropriate delay and inadequate staging of high-grade non-muscle invasive TCC of the bladder are to be avoided. The present multivariate analysis showed that the number of TURBTs and tumour upstaging in the cystectomy specimen correlated with an increased prevalence of LNMs.     

Platelet count and preoperative haemoglobin do not significantly increase the performance of established predictors of renal cell carcinoma-specific mortality

OBJECTIVE: Anaemia and/or thrombocytosis were identified as independent predictors of poor survival in renal cell carcinoma (RCC). We tested the extent to which these markers worsen the prognosis in these patients. METHODS: Analyses targeted 1828 patients with renal cell carcinoma. Univariable, multivariable, and predictive accuracy analyses addressed RCC-specific mortality (RCC-SM). RESULTS: In univariable and multivariable analyses, both platelet count and preoperative haemoglobin level were statistically significant predictors of RCC-SM. However, neither platelet count nor preoperative haemoglobin level increased the combined multivariable accuracy of established RCC-SM (predictive accuracy gain=0.3%) predictors. CONCLUSIONS: Patients who present with severe anaemia or elevated platelets are at no higher risk of RCC-SM than that related to their stage, grade, histologic subtype, and Eastern Cooperative Oncology Group-Performance Status.     

Population-based analysis of factors associated with survival in patients undergoing cytoreductive nephrectomy in the targeted therapy era

ObjectivesDespite level 1 evidence demonstrating a survival benefit of cytoreductive nephrectomy (CN) in well-selected patients with metastatic renal cell carcinoma (mRCC) in the cytokine era, its role in the contemporary period of targeted therapy remains understudied. To help facilitate improved patient selection for CN and clinical trial design in the targeted therapy era, this study sought to identify factors associated with RCC-specific survival in patients diagnosed with mRCC and undergoing CN between 2005 and 2010 using a large population-based cohort.Materials and methodsPatients diagnosed with mRCC and undergoing CN between 2005 and 2010 were identified from the Surveillance Epidemiology and End Results cancer database. Kaplan-Meier methods were used to calculate disease-specific survival. Stepwise multivariable Cox proportional hazards regression analysis was used to identify factors independently associated with risk of RCC-specific death.ResultsA total of 2,478 patients were identified who were eligible for analysis with a median disease-specific survival of 21 months (95% CI: 19, 22). Factors independently associated with an increased risk of RCC-specific death included age at diagnosis≥60 years, African American race, higher American Joint Committee on Cancer T stage (≥T₃), high Fuhrman nuclear grade (3 or 4), primary tumor size≥7 cm, regional lymphadenopathy, both distant lymph node and visceral metastases, and sarcomatoid histology. A higher number of adverse factors correlated with an increased risk of RCC-specific death (P<0.001).ConclusionsFactors associated with RCC-specific survival identified in this large population-based study can be used to better stratify patients suitable for CN and to help with future clinical trial design and interpretation.     

Contribution of grade,vascular invasion and age to outcome in clinically localized renal cell carcinoma

OBJECTIVE: To determine the relative prognostic importance of microvascular invasion in apparently localized renal cell carcinoma (RCC). PATIENTS AND METHODS: A retrospective clinical and pathological review was conducted of 176 consecutive patients identified from pathology records who had a nephrectomy for RCC with a median follow-up of 44 months. Vascular invasion was recorded and categorized by the level of microvascular invasion (MVI), renal vein invasion (RVI) and inferior vena cava invasion (IVCI). Tumour type, grade and size were also assessed. These variables were assessed by univariate and multivariate analysis to determine their effect on disease-free survival. RESULTS: In the univariate analysis tumour size, grade, vascular invasion and young age each predicted reduced disease-free survival. On multivariate analysis for all 176 patients, grade, vascular invasion and young age were the significant independent predictors of reduced disease-free survival. In a subgroup of 149 patients from whom those with very high risk determinants were excluded (those with grade 4 tumours and/or IVCI) most of the risk of metastasis could be accounted for by vascular invasion and young age alone (MVI vs no vascular invasion, hazard ratio 3.18, 95% confidence interval 1.29-7.84; RVI vs no vascular invasion 2.41, 0.989-5.89; and age per year 0.963, 0.94-0.992). CONCLUSIONS: Grade, vascular invasion and young age are the main independent predictors of relapse in clinically localized RCC after nephrectomy. For most patients, who do not have very high risk indicators, the main adverse predictors are vascular invasion and young age. These findings are important when selecting patients for trials of adjuvant therapy and have implications for pathological staging.     

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.     

The need for routine adrenalectomy during surgical treatment for renal cell cancer: the Hannover experience

OBJECTIVES: To further clarify the need for routine adrenalectomy during the surgical treatment of renal cell cancer, as in the absence of clinically overt metastatic disease, tumorous lesions within the adrenal gland are found in only 2-10% of patients, with most being over-treated by adrenalectomy. PATIENTS AND METHODS: The medical records of 819 patients undergoing adrenalectomy combined with nephrectomy, irrespective of the local extension of the primary tumour or the clinical stage at first diagnosis, were reviewed to determine the reliability of currently available imaging methods in predicting adrenal gland metastases. Several patient and tumour characteristics were correlated with the presence of intra-adrenal metastases, and their possible independent prognostic value was determined by a multivariate logistic regression model. RESULTS: There was metastatic spread into the adrenal gland in 27 of 819 (3.3%) patients. In only three of eight patients in whom the adrenal was identified as the only metastatic site were preoperative abdominal computed tomography scans interpreted as false-negative. On multivariate statistical analysis only the presence of distant metastases, vascular invasion within the primary tumour and multifocal growth of renal cell cancer within the tumour-bearing kidney were identified as independent predictors of the presence of intra-adrenal metastases. CONCLUSIONS: None of the patient or tumour characteristics evaluated reliably predicted the likelihood of adrenal metastases in patients with no evidence of disseminated metastatic spread. However, previously published data indicate that the frequency of metachronous metastases within the contralateral kidney (1.8-3.8%) is significantly higher than the risk of a preoperatively undetected isolated intra-adrenal metastatic lesion when currently available imaging modalities are applied. Therefore, routine adrenalectomy should not be recommended if the preoperative radiological examinations are normal.