肝移植治疗肝细胞癌合并门静脉癌栓的疗效评价

目的 评价肝移植治疗肝细胞癌合并门静脉癌栓患者的临床应用价值.方法 回顾性分析2002年1月至2006年12月146例行肝移植术治疗肝细胞癌合并门静脉癌栓患者的临床资料,其中10例患者曾行肝切除术,8例患者围手术期死亡,予以排除.对其余128例患者进行了随访,分析影响患者存活率的相关因素.结果 128例肝移植患者术后中位存活时间为13.0个月,术后6个月、1年、2年累积存活率分别为78.1%、51.6%和29.7%.单因素分析表明,癌栓分级、肿瘤大体类型、肿瘤数目是影响患者预后的主要危险因素;多因素分析显示,癌栓分级和肿瘤数目与患者术后累积存活率具有显著的相关性.结论 现阶段肝细胞癌合并门静脉癌栓的患者行肝移植术远期疗效尚不满意,在供者资源严重短缺的条件下应限制应用.     

Myxoid\Round Cell Liposarcoma (MRCLS) Revisited: An Analysis of 418 Primarily Managed Cases

Background

Objectives of this study were to evaluate oncologic outcomes and to provide guidelines for the management of primary myxoid (MLS) and round cell liposarcoma (RCLS).

Methods

A multicenter, retrospective study of 418 cases of MRCLS primarily managed by Canadian multidisciplinary sarcoma teams.

Results

Study included 418 cases (MLS: 311 patients and RCLS: 107; > 5% round cell) with a median age of 45 years and a median follow-up of 5.2 years. Median tumor size was 10 cm, and 81% were deep and 90% were in lower limb. The majority of patients underwent surgical resection and radiotherapy, with a small percentage (6%) receiving chemotherapy. The overall 10-year local control rate was 93% with no differences between MLS and RCLS. Radiotherapy was significant in preventing local relapse and reducing tumor diameter (median = 18%) and improving microscopic margin status, but did not impact survival. Radiotherapy and the margin status were independent predictors of local recurrence. The 5- and 10-year metastatic-free survivals were 84 and 77% respectively for MLS and 69 and 46% for RCLS. The initial site of metastasis was found in multiple locations (34%) and bone involvement was frequent (40%) with predilection for spine (79%). Round cell percent (> 5%) and tumor diameter (> 10 cm) correlated with increased risk for metastasis and death.

Conclusions

MLS and RCLS showed different metastatic risk but equally good local control. Radiotherapy was effective in preventing local recurrence and should be delivered as neoadjuvant. New staging strategies are to be defined to account for the unusual metastatic pattern.     

Linac radiosurgery for brain metastasis of melanoma

PURPOSE: To evaluate the efficacy and toxicity of stereotactic radiotherapy in the treatment of brain metastases of melanoma. PATIENTS AND METHODS: From 1994 to 2001, 25 patients presenting with 61 metastases of cutaneous melanoma were treated with radiosurgery. Median age was 47 years (range: 25-73 years) and median Karnofski performance status 80 (range: 50-100). Twenty patients had one radiosurgery, 5 had two or three. Median metastasis diameter was 21 mm (range: 6-54.4 mm), and median metastasis volume was 1.7 cm(3) (range: 0.4-25.6 cm(3)). Irradiation was delivered by a linear accelerator. Median minimal dose was 14.1 Gy (range: 10-19.4 Gy), and median maximal dose was 20.5 Gy (range: 16-48 Gy). RESULTS: Mean follow-up was 12.6 months (range: 1-85 months). Five metastases progressed (9.8%), 2-12 months after radiosurgery. Three-, 6- and 12-month local control rates were 95 +/- 3, 90 +/- 5 and 84 +/- 7%, respectively. By univariate analysis, only absence of extracranial tumor was a prognostic factor of local control. Three-, 6- and 12-month brain-disease-free survival rates were 75 +/- 9, 68 +/- 11 and 38 +/- 13%, respectively. According to univariate analysis, only the Score Index for Radiosurgery in brain metastases (SIR) was a prognostic factor of brain-event-free survival (p = 0.03). Median survival was 8 months. Three-, 6- and 12-month overall survival rates were 75 +/- 9, 53 +/- 10, and 29 +/- 10%, respectively. According to univariate analysis, extracranial controlled disease status (p = 0.03), and SIR (p = 0.04) were prognostic factors for overall survival. According to multivariate analysis, none was an independent prognosticator for overall survival. Complications were minimal. CONCLUSION: Radiosurgical treatment of brain metastases of melanoma is effective and accurate. The use of radiosurgery alone is an appropriate management strategy for many patients with brain metastases of melanoma.     

Prognostic value of sarcomatoid histology and volume-weighted mean nuclear volume in renal cell carcinoma

OBJECTIVE: To determine the prognostic value of two histopathological factors, sarcomatoid histology and volume-weighted mean nuclear volume (MNV) in renal cell carcinoma (RCC). PATIENTS AND METHODS: The study included 106 patients (72 men and 34 women, mean age 63 years, range 32-83) with RCC, all of whom were surgically treated between 1985 and 1995. The presence of any sarcomatoid component was determined and MNV estimated using a stereological method in histological slides of tumour specimens from these patients. The prognostic significance of the two variables was evaluated by univariate and multivariate analyses in comparison with other histopathological variables (T, N and M categories, nuclear grade, tumour size, tumour type), using the cause-specific and progression-free survival of the patients as the endpoints. RESULTS: Among the 106 RCC cases examined, a sarcomatoid component was detected in 34 (32%); the MNV was 90-627 micro3 (mean 225). By univariate and multivariate analysis, both variables were significant prognostic factors for cause-specific survival in all patients. In addition, multivariate analysis of the 74 patients with localized RCCs (T1-3, N0 M0) showed that sarcomatoid histology was a significant prognostic factor for disease progression. CONCLUSION: The presence of sarcomatoid histology and the MNV, both of which can be examined with no specialized laboratory procedures, seem to be useful tumour-related prognostic factors in RCC.     

Prognostic factors for first recurrence in patients with retroperitoneal sarcoma

BACKGROUND: Retroperitoneal sarcomas are characterized by a high local recurrence rate despite optimal surgical treatment. The definition of prognostic factors for recurrence could help offer high-risk patients a closer follow-up and a multidisciplinary therapeutic approach. PATIENTS AND METHODS: A cohort of 40 patients treated for a primary retroperitoneal sarcoma was retrospectively analyzed. Median follow-up was 24 months. Patient (sex and age), tumor (maximal size, histologic type, tumor localization, and histologic grade), and treatment (complete vs. incomplete surgery) characteristics were included in univariate and multivariate prognostic factor analyses. RESULTS: After a median follow-up of 24 months (range 3-121), the overall recurrence rate was 65%. Median time between initial surgery and recurrence was 15 months (range 11.5-29.5). In univariate analysis, surgical positive margins (P = 0.011), bilateral tumors (P = 0.0034), nonliposarcoma histologic subtypes (P = 0.043), and a high histologic grade (P = 0.0072) were associated with an increased recurrence rate. All these factors except the histologic subtypes retained an independent prognostic value in the multivariate analysis. Death was strongly related to recurrence (P = 0.0033). CONCLUSION: The optimal treatment of patients with primary retroperitoneal sarcoma should be based on radical surgery, with en bloc organ resection if necessary, to minimize the risk of positive margins. In high-risk patients, close follow-up is mandatory to offer optimal subsequent surgical procedures. The impact of a multidisciplinary therapeutic approach remains to be proved.     

Predictors and patterns of recurrence after resection of hepatocellular carcinoma

BACKGROUND: The majority of patients with hepatocellular carcinoma (HCC) who undergo complete tumor resection subsequently develop tumor recurrence. The objectives of this study were to determine the risk factors for recurrence of HCC after hepatectomy and to examine the outcomes once tumor recurrence occurs. STUDY DESIGN: From February 1990 to May 2001 a total of 164 patients underwent liver resection for HCC at our institution and were prospectively followed. Time to recurrence and survival after recurrence were determined by Kaplan-Meier analysis. Patient, tumor, and treatment characteristics were tested for their prognostic significance by univariate and multivariate analysis using the logrank test and the Cox proportional hazards model, respectively. RESULTS: The median patient age was 64 years (range 21 to 87 years) and 106 patients (65%) were male. After a median followup of 26 months, 90 patients (55%) have developed recurrent cancer. Among them, 75 patients (83%) had tumor detectable in the liver, which was the only site of disease in 67 (74%). In all, 15 patients (20%) had extrahepatic disease (7 lung, 4 peritoneum, 2 pancreas, 1 bone, and 1 brain). The median time to recurrence was 24 months (range 1 to 274 months). Predictors of recurrence on univariate analysis were tumor size greater than 5 cm, more than one tumor, cirrhosis, vascular invasion (microscopic or macroscopic), and tumor satellites. On multivariate analysis only tumor size greater than 5 cm (p = 0.04) and vascular invasion (p = 0.01) predicted recurrence. The median survival after recurrence was 11 months (range 0 to 60 months). Of the 90 patients who developed tumor recurrence 49 (67%) were able to undergo additional ablative or surgical therapy (33 embolization, 9 ethanol injection, and 14 re-resection). On multivariate analysis vascular invasion in the original tumor predicted poor survival after recurrence (p = 0.009). CONCLUSIONS: The liver is the predominant site of first recurrence after resection of hepatocellular carcinoma, and once recurrence occurs survival is limited. The current study underscores the need for effective adjuvant therapy for patients with HCC treated with partial hepatectomy.     

Permanent iodine-125 interstitial radiation therapy in the treatment of non-glioblastoma multiforme high-grade gliomas

BACKGROUND: This study evaluates prognostic factors influencing survival outcomes for 60 patients with permanent iodine-125 implants in the primary treatment of non-glioblastoma multiforme (GBM) high-grade gliomas. METHODS: Stereotactic treatment planning aimed to encompass the contrast-enhancing rim of the tumor visualized by CT, with an initial dose rate of 0.05 Gy/h with 125I, delivering 100 Gy at 1 year and 103.68 Gy at infinity. Survival was evaluated using the Kaplan-Meier method for univariate analysis and the Cox regressional method for multivariate analysis. In addition to the implant, 34 patients received external radiation therapy (5,000-6,000 cGy) before the implant; 13 patients were implanted without additional external beam radiation, and 13 patients underwent external radiation therapy before implant placement. RESULTS: With a mean follow-up of 77.6 months (range 3.5-164 months), 1-, 3-, 5- and 10-year survival were 86.7% (+/-0.05%), 60% (+/-0.07%), 50% (+/-0.07%) and 45.7% (+/-0.7%), respectively. The median survival time was 57 months. Second surgery was performed following the implant in 19 patients. Findings were tumor recurrence in 11 patients (22.5%), radiation necrosis in 7 patients (14.3%) and brain abscess in 1 patient (2%). Age, sex, tumor location, side of brain, tumor volume, Karnofsky score and neurological status were correlated with survival outcome. Favorable prognostic factors were age younger than 45 years, superficial tumor location and preoperative Karnofsky score greater than 70. RPA classification was used to define this group of patients. In RPA classes I and II (n = 43), 1-year survival was 93%, while 3-, 5- and 10-year survival was 67.4, 60.5 and 55.5%, respectively, and median survival time was 91 months. In RPA class III (n = 7), 1-year survival was 71.4%, while 3- and 5-year survival was 42.9 and 28.6%, respectively, and median survival time was 47 months. In RPA class IV (n = 10), 1-year survival was 60%, while 3-, 5- and 10-year survival was 50, 22.2 and 11.1%, respectively, and median survival time was 37 months. CONCLUSION: Brachytherapy with permanent implant of 125I appears promising in the treatment of primary non-GBM malignant gliomas. It improved survival time and reduced the incidence of complications and provided good quality of life. In order to further confirm these results, multicenter randomized prospective studies are needed. RPA analysis is a valid tool to define prognostically distinct survival groups. In this study, 2-year survival and median survival time were improved in all prognostic classes. This would suggest that selection bias alone does not account for the survival benefit seen with 125I implants. Further randomized studies with effective stratification are needed.     

Malignant pleural mesothelioma: clinicopathologic and survival characteristics in a consecutive series of 394 patients.

OBJECTIVE: Treatment of malignant pleural mesothelioma (MPM) remains disappointing, although recent reports suggest that multimodality therapy including surgery may provide a significant survival benefit. The aims of this single institution study were: to investigate clinicopathologic characteristics and potential prognostic factors in MPM patients, and to ascertain whether surgery followed by adjuvant therapy had an independent prognostic role. METHODS: Retrospective review of a prospectively compiled computerized database of all patients with MPM evaluated between 1989 and 2003. Kaplan-Meier method, log-rank test, and Cox model were used in the statistical analysis. RESULTS: There were 394 patients: 270 men (68.5%), 124 women, median age 64 (range 28-93). Twenty-seven patients (6.8%) underwent surgical resection (extrapleural pneumonectomy 15, pleurectomy/decortication 12), followed by adjuvant therapy. As of March 2006, 381 patients (96.7%) had died (median survival, 11.7 months; range 0.03-117.9). Median follow-up of 13 surviving patients (3.3%) was 45.2 months (range 28.7-126.5). Overall survival at 2 years was 18.8%. Multimodality therapy including surgery yielded a median survival of 14.5 months and a 2-year survival rate of 29.6%. Using univariate analysis, age (p=0.009), chest pain (p=0.01), weight loss (p=0.001), performance status (p=0.0001), platelet count (p=0.008), histology (p=0.0001), macroscopic appearance of pleural surface (non-specific inflammation, tumor-like thickening, or nodules; p=0.0001), visceral pleura involvement (p=0.0001), degree of involvement of pleural cavity (less than or more than one third of the cavity; p=0.0001), and multimodality therapy (p<0.01) were found to be significant prognostic factors. At multivariate analysis, performance status, platelet count, histology, and degree of involvement of pleural cavity remained independently associated with survival, whereas multimodality therapy failed to enter the model. CONCLUSIONS: Significant predictors of survival include performance status, platelet count, histology, and degree of involvement of pleural cavity. Within the confines of this retrospective study and the small number of patients undergoing multimodality therapy, the role of surgery in the treatment of MPM remains unclear. Further investigation is warranted to determine the optimal treatment strategy in this disease.     

Prognostic factors influencing survival in gastrointestinal leiomyosarcomas. Implications for surgical management and staging.

The appropriate surgical therapeutic options for either localized or more advanced disease in patients with gastrointestinal leiomyosarcomas remain unclear. A staging classification for this disease has not been adopted nor risk factors identifying patients at risk for recurrence defined. To address these issues, this study evaluated the influence of various clinicopathologic variables on overall and disease-free survival. In an univariate analysis of overall survival involving 191 patients, the Cox proportional hazards model identified four factors that were associated with a significantly better outcome: complete resection without tumor rupture (p less than 0.001), localized lesions (p less than 0.001), low grade of tumor (p = 0.02), and tumors smaller than 5 cm (p = 0.03). When interactive effects of these factors were taken into account, however, type of resection of the tumor was selected as the only significant prognostic factor in a multivariate analysis. Complete resection without tumor rupture improved overall survival of patients with localized disease (median, 46 months) as well as those with contiguous organ invasion (median, 36 months) or peritoneal implants (median, 36 months). In contrast, patients with incomplete resections survived for a median of 21 months. Patients with tumor rupture, despite removal of all gross disease, behaved similarly to those with incomplete resections; median survival was only 17 months. For disease-free survival, important determinants selected from a multivariate analysis were tumor rupture (p = 0.002), contiguous organ invasion (p = 0.02) and high tumor grade (p = 0.02). A staging classification incorporating these prognostic factors of significance was evaluated using a TGM system: T1 (less than 5 cm), T2 (greater than or equal to 5 cm), T3 (contiguous organ invasion or peritoneal implants), T4 (tumor rupture); G: G1 (low grade), G2 (high grade); M: M0 (no metastases), M1 (metastases present). The corresponding 5-year overall survivals for stages I, II, III, IVA, and IVB were 75%, 52%, 28%, 12%, and 7%. Disease-free survival at 2 years after surgery was 89%, 57%, and 47% for stages I, II, and III, respectively. In conclusion, surgery remains the primary modality of treatment for patients with gastrointestinal leiomyosarcomas, and complete resection of all disease without tumor rupture, even of locally advanced disease, improves overall and disease-free survival. A staging classification appears feasible and is recommended to determine outcome in patients with leiomyosarcomas arising from the gastrointestinal tract.     

The role of cyberknife radiosurgery/radiotherapy for brain metastases of multiple or large-size tumors.

OBJECTIVE: Focused, highly targeted radiosurgery and fractionated radiotherapy using the Cyberknife are useful treatments for multiple or large metastases. Here we present our results of Cyberknife radiosurgery for 71 patients with 148 metastatic brain lesions. METHODS: There were 32 women and 39 men with a median age of 63 (range: 30-88) years. Radiographic follow-up was available for 60 patients with 104 lesions. The mean and median initial volumes of the tumor per lesion were 6.6 and 2.9 cm(3) (range: 0.1-53.2 cm(3)), respectively, at the time of the initial Cyberknife treatment. Forty patients (56%) had a single lesion, and 31 (44%) had multiple lesions (range: 2-7) at initial treatment. The number of fractions ranged from 1 to 3, and forty (27%) of 148 lesions were treated by a fractionated course of Cyberknife therapy. The mean marginal dose was 20.2 Gy (range 7.8-30.1 Gy, median: 20.7 Gy). RESULTS: At 44 weeks of median follow-up, there were no permanent symptoms resulting from radiation necrosis. Overall 6-month and 1-year survival rates were 74% and 47%, respectively, and the median survival time was 56 weeks. The Karnofsky performance score and extracranial metastasis were significant prognostic factors at 6 months and 1 year, respectively, in both univariate and multivariate analyses. Age or multiple metastases did not influence prognosis at 6 months and 1 year. Local control was achieved in 83% (86 lesions). After additional radiosurgical or surgical salvage, no patient died as a result of intracranial disease. Twenty-five patients developed 92 new metastases (range 1-13) outside of the treated lesions with 22.4 weeks of median follow-up. Among them, 21 patients (84 lesions) were treated by salvage Cyberknife. CONCLUSION: Despite the inclusion of an unfavorable group of patients with large tumors, our results for survival and tumor control rates are comparable to those of published series. The Cyberknife provides the advantage of allowing for fractionated treatment to multiple or large-size tumors.     

"Functional" Surgery in Subungual Melanoma

BACKGROUND: Subungual melanomas represent approximately 2% to 3% of cutaneous melanomas in White populations. Complete or partial amputation proximal to the distal interphalangeal joint of the digits has been suggested. Recently, we introduced for acral melanomas, similar to lentigo maligna melanoma, limited excision and complete histology of excisional margins (three-dimensional histology). OBJECTIVE: To evaluate the prognostic relevance of clinical parameters and different surgical management in patients with subungual melanoma. STUDY DESIGN: From 1980 to 1999, subungual melanoma was diagnosed in 62 of 3,960 stage I and II melanoma patients (1.6%) of the melanoma registry of the Department of Dermatology (University of Tuebingen). A retrospective comparative analysis of two treatment groups was performed: Thirty-one patients had an amputation in or proximal to the distal interphalangeal joint (median follow-up of 55 months), and 31 patients had "functional" surgery with local excision of the tumor and only partial resection of the distal phalanx (median follow-up of 54 months). RESULTS: In the univariate analysis, the level of invasion (P=0.0059), ulceration (P=0.0024), and tumor thickness (P=0.0004) were significant prognostic factors for recurrence-free survival but not for survival. In a multivariate analysis, only lower tumor thickness and a reduced level of amputation were independent significant prognostic parameters for recurrence-free survival (P=0.035 and P=0.0069). Patients with an amputation in or proximal to the distal interphalangeal joint did not fare better than patients with less radical "functional" surgery. CONCLUSION: Limited excision with partial resection of the distal phalanx only and three-dimensional histology to assure tumor-free resection margins give better cosmetic and functional results and do not negatively affect the prognosis of patients with subungual melanoma.     

Repeat resection of pulmonary metastases in patients with soft-tissue sarcoma

BACKGROUND: Even after an apparent complete resection of sarcomatous pulmonary metastases, 40% to 80% of patients will re-recur in the lung. The benefit of subsequent re-resection is poorly defined. This study examines patient survival after repeat pulmonary exploration for re-recurrent metastatic sarcoma at a single institution. STUDY DESIGN: Between July 1982 and December 1997, data on 3,149 adult in-patients with soft tissue sarcoma were prospectively gathered. Of these, pulmonary metastases were present or developed in 719 patients and 248 underwent at least one resection. Of the patients relapsing in the lung after an apparently complete resection, 86 underwent reexploration. Disease-specific survival (DSS) after re-resection was the end point of the study. Time to death was modeled using the method of Kaplan and Meier. The association of factors to time-to-event end points was analyzed using the log-rank test for univariate analysis and the Cox proportional hazards model for multivariate analysis. Clinicopathologic factors were analyzed with the Pearson chi-square or Fisher's exact test when appropriate. RESULTS: The median DSS after re-resection for all patients undergoing at least two pulmonary resections was 42.8 months with an estimated 5-year survival of 36%. The median DSS in patients with complete reresection was 51 months (n = 68) compared with 6 months in patients with an incomplete re-resection (n = 16, p<0.0001). Patients with one or two nodules at re-resection (n = 39) had a median DSS of 51 months compared with 20 months in patients with three or more nodules (n = 40, p = 0.003). Patients in whom the largest metastasis re-resected was less than or equal to 2 cm (n = 33) had a median DSS of 44 months compared with 20 months in patients with metastasis greater than 2 cm (n = 43, p = 0.033). Patients with primary tumor high-grade histology (n = 75) had a median DSS of 32 months and patients with low-grade histology (n = 11) had a median DSS that was not reached (p = 0.041). Three independent prognostic factors associated with poor outcomes may be determined preoperatively: > or =3 nodules, largest metastases > 2 cm, and high-grade primary tumor histology. Patients with either zero or one poor prognostic factor had a median DSS > 65 months and patients with three poor prognostic factors had a median DSS of 10 months. CONCLUSIONS: Reexploration for recurrent sarcomatous pulmonary metastases appears beneficial for patients who can be completely re-resected. Outcomes are described by factors that may be determined preoperatively, including metastasis size, metastasis number, and primary tumor histologic grade. Patients who cannot be completely re-resected or those with numerous, large metastasis and high-grade primary tumor pathology have poor outcomes and should be considered for investigational therapy.     

肌层浸润性膀胱癌保留膀胱术后复发与进展的相关因素分析

目的 探讨影响肌层浸润性膀胱癌保留膀胱术后复发与进展的相关因素,为临床选择肌层浸润性膀胱癌患者行保留膀胱手术提供依据.方法 回顾性分析获得系统随访的38例行保留膀胱手术的肌层浸润性膀胱癌患者的资料,对性别、年龄、肿瘤数目、肿瘤大小、病理分级、既往复发、手术方式、即刻灌注、静脉化疗等因素进行生存分析,定义复发或进展为终点事件.生存分析运用Kaplan-Meier法,单因素与多因素分析运用Cox回归,采用Log-rank法进行显著性检验.结果 随访3~36个月,25例复发(复发率65.8%),17例进展(进展率44.7%).复发时间(11.6±0.8)个月,中位复发时间11个月,未复发生存时间(19.9±1.5)个月,中位生存时间19个月.进展时间(11.2±1.2)个月,中位进展时间10个月.Cox单因素分析发现,肿瘤数目、肿瘤大小、病理分级、既往复发、静脉化疗均是影响肿瘤复发与进展的因素;Cox多因素分析发现,肿瘤数目(RR=2.968,P=0.004)、病理分级(RR=2.128,P=0.027)是影响肿瘤复发的独立危险因素,肿瘤数目(RR=4.519,P=0.003)、病理分级(RR=3.137,P=0.014)同样是影响肿瘤进展的独立危险因素. 结论 肿瘤数目、病理分级是影响肌层浸润性膀胱癌保留膀胱术后复发与进展的独立危险因素,临床上尽可能选择肿瘤数目较少、病理分级较低的肌层浸润性膀胱癌患者行保留膀胱手术.     

Surgical management of renal cell carcinoma associated with complex inferior vena caval thrombi

The operative morbidity and mortality of radical nephrectomy are considerably higher when the vena cava is involved by the tumor. The prognostic significance of vena caval extension in this setting remains controversial. We reviewed our experience of vena caval thrombectomy specifically addressing prognostic factors. We retrospectively studied 96 patients treated at our institution between 1985 and 2001. The study population included 28 women and 68 men; (37 left- and 59 right-sided tumors). Twenty-seven patients had metastatic disease at presentation. Prognostic features (age, sex, race, side of tumor, embolization, tumor grade, tumor confinement by renal capsule, cephalic extent of thrombus, nodal status, and presence of distant metastasis) were evaluated using a Cox proportional hazards model (univariate and multivariate). These prognostic features were analyzed in the group as a whole and in the subgroup of patients who did not have metastatic disease at presentation and did not die perioperatively. There were 5 perioperative deaths. Extracapsular tumor extension and regional node involvement were present in 64% and 17% of the patients, respectively. Level of tumor thrombus were as follows: level I (41%), II (29%), III (7%), IV (15%). Fuhrman's grade was 2 in 17%, 3 in 45%, and 4 in 30% of the patients. For all 96 patients, median overall survival (OS) was 35 months. Five-year OS was 35%. The presence of distant metastasis at presentation did not significantly alter median OS (20 months with metastasis vs. 38 months without, P = 0.3), although this finding may have been confounded by selection. The presence of nodal metastasis was associated with decreased OS by multivariate analysis (P < 0.01). After exclusion of patients dying perioperatively and patients with metastasis at presentation, median OS and progression-free survival were 40 and 18 months, respectively (5-year OS was 40%). In the multivariate model, none of the factors examined were associated with OS, but age <58 years, and the presence of extracapsular tumor extension were associated with an increased risk of recurrence. In patients with renal tumors and extension of tumor thrombus into the vena cava, the level of propagation of the thrombus does not predict for OS. Selected patients with metastatic renal cancer may benefit from aggressive surgical resection of the primary tumor and associated tumor thrombus.     

Synovial sarcoma: the importance of size and location for survival

A retrospective analysis was done on 135 consecutive patients with extremity and truncal synovial sarcomas seen at our institutions between 1961 and 1996. Ninety-nine patients (73%) presented with a newly diagnosed localized primary sarcoma, nine patients (7%) presented with a locally recurrent sarcoma previously treated at another institution, and 27 patients (20%) presented with metastatic disease. The median followup for surviving patients was 78 months (range, 20-420 months). The overall survival for patients with localized primary and locally recurrent synovial sarcoma was 51% at 10 years. Patients with localized synovial sarcomas less than 5 cm in longest diameter had a survival at 10 years of 88% compared with a 10-year survival of 38% and 8% for patients with sarcomas 5 to 10 cm and greater than 10 cm in longest diameter, respectively. Distal location (hands and feet) and histologic grade also were statistically significant predictors of patient survival for localized synovial sarcoma on univariate analysis. On multivariate analysis size greater than 10 cm and size 5 to 10 cm were associated with an 18-fold and a 3.1-fold increased risk of death compared with tumors smaller than 5 cm. Grade and location were not found to be independent predictors of survival on multivariate analysis. Primary tumor size and initial status at presentation were prognostic for survival and patients with synovial sarcomas larger than 5 cm or locally recurrent at presentation should be considered for more aggressive surgical and adjunctive radiotherapy or chemotherapy.     

Impact of clinicopathological parameters in patients treated for renal cell carcinoma

PURPOSE: We determined the impact of clinical and pathological factors in the outcome of patients with renal cell carcinoma treated surgically. MATERIALS AND METHODS: We retrospectively reviewed the records of 230 consecutive patients after radical or partial nephrectomy. We analyzed clinical (incidental or symptomatic disease) and pathological (tumor size, histological type, Fuhrman nuclear grade, microvascular invasion and lymph node involvement) parameters. Disease-free and cancer specific survival curves were individualized for each parameter and on multivariate analysis. RESULTS: Median postoperative followup was 34.3 months, median time to recurrence was 22 months and mean overall survival was 130 months. A total of 40 patients (17.3%) presented with local and/or metastatic recurrence and 32 (13.9%) died of the disease. Five-year disease-free and cancer specific survival rates on univariate analysis were 56.7% and 64% for symptomatic tumors, 76.6% and 68% for clear cell carcinoma, 26.9% and 39% for sarcomatoid tumors, 34.7% and 47.5% for high grade tumors, 26.7% and 39.7% for microvascular invasion, 37.5% and 49.1% for tumors larger than 7 cm, and 11% and 32% for lymph node involvement, respectively. On univariate analysis patients with lymph node involvement and microvascular invasion had a poor prognosis. Multivariate analysis showed that the single independent prognostic factor was microvascular invasion. CONCLUSIONS: This study points out different clinical and pathological prognostic factors of survival in patients treated for renal cell carcinoma. Microvascular invasion was the only independent prognostic factor on multivariate analysis.     

Cytoreductive nephrectomy for pT3b–T4 M1 renal cell carcinoma in 39 patients: Single center analysis

We reviewed cytoreductive nephrectomy for pT3b–T4 renal cell carcinoma with metastasis and evaluated the prognostic factors for cancer‐specific survival. A total of 39 patients who underwent cytoreductive nephrectomy for renal cell carcinoma with pathological T3b–T4 (2009 Union for International Cancer Control consensus) from 1986 to 2011 in our hospital were the participants in this study. Prognostic factors for cancer‐specific survival were analyzed. The median patient age was 64 years (range 31–84). Pathological T3b, T3c and T4 were found in 24 (61%), one (3%) and 14 (36%) patients, respectively. The distribution of the histological type was clear cell type in 34 (87%), papillary type in two (5%) and any type of renal cell carcinoma with a sarcomatoid component in three patients (8%). The median overall and cancer‐specific survival was 7.5 and 7.6 months, respectively. Low‐grade performance status, regional lymph node metastasis, higher pT stage and histological type were prognostic factors for cancer‐specific survival on univariate analysis. On multivariate analysis, lymph node metastasis, higher pT stage and histological type (non‐clear cell or sarcomatoid component) were significant predictors for cancer‐specific survival. With cytoreductive nephrectomy for patients with pT4, lymph node metastasis and non‐clear cell histology, we have to be particularly careful in terms of cancer control.     

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

OBJECTIVE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Microvascular tumor invasion, tumor size and Fuhrman grade: a pathological triad for prognostic evaluation of renal cell carcinoma

PURPOSE: The biological behavior and clinical outcome of renal cell carcinoma are difficult to predict. We investigated the prognostic impact of clinicopathological variables to establish a risk stratification model to predict recurrence and survival rates. MATERIALS AND METHODS: We studied 230 patients with renal cell carcinoma (stages T(1-4) N(x) M(0)) who underwent radical nephrectomy and/or nephron sparing surgery, and were followed for a median of 48 months (range 3 to 140). Univariate and multivariate analyses were performed, and the influence of clinical presentation, histological tumor size, tumor grade, lymph node involvement and microvascular tumor invasion on disease-free and cancer specific survival curves was determined. A composition model based on independent prognostic variables was then created to stratify tumors into low, intermediate and high risk of progression. RESULTS: The tumor recurrence rate was 17% (39 of 230) and the cancer specific mortality rate was 13% (31 of 230). Multivariate analyses determined that microvascular tumor invasion, tumor grade and tumor size were the only independent prognostic factors. Disease-free survival rates for low, intermediate and high risk tumors were 94.7%, 56.8% and 13.1%, respectively. Cancer specific survival rates were 94.7%, 61.7% and 32.0%, respectively. CONCLUSIONS: Tumor size, Fuhrman grade and microvascular tumor invasion are strong and independent predictors of survival of patients with renal cell carcinoma. Risk assessment and stratification based on this triad of pathological features may allow better individualization of followup schedules and trials of adjuvant treatment for patients with renal cell carcinoma.     

Oligodendrogliomas in the CT/MR-Era

BACKGROUND: The aim of this study was to investigate survival times and 4 prognostic factors of oligodendrogliomas in the CT/MR-era, since most previous studies result from the pre-CT-era, where modern histopathological classification, diagnostic and therapeutic tools were not used. Thus, in the past mixed gliomas were included, and survival times and prognostic factors were not corrected for grades. METHOD: We present a retrospective study of 19 pure low grade (LO) and 21 pure anaplastic (AO) oligodendrogliomas (according to WHO) treated in the CT/MR-era 1987 to 1999. Survival times and rates were calculated in each grade according to the Kaplan-Meier-method. Following factors were analyzed for influence on survival in each grade using uni- and multivariate analysis: KI (karnofski index) equal or greater than 80 at time of diagnosis, contrast medium enhancement and calcification in preoperative CT or MRI, radiation therapy. FINDINGS: In LO median survival time was 114 months and 5 and 10-year survival rates were 78.9 and 44.1%, respectively. For AO median survival time was 21 months and 5- and 10-year survival rates were 23.8% and 0.05%, respectively. This difference reached statistical difference (p=0.0002). In LO none of the factors were statistically associated with better survival. Patients with AO had a significantly better outcome, when presenting with a KI of 80 or higher (uni- and multivariate analysis), than had tumours without contrast medium uptake (univariate) and for those with radiation therapy (univariate and multivariate). INTERPRETATION: In the CT/MR-era we did not observe a longer survival time or rate for patients with pure oligodendrogliomas compared to historical data. Prognostic factors should be evaluated separately in each grade, since grading according to WHO is strongly associated with survival. Patients with AO had a statistically longer survival when presenting with higher KI, without contrast enhancement and after postoperative radiation therapy.