The prognostic value of the site of invasion in T3aN0M0 clear cell renal cell carcinoma

Background

The 7th Tumor-Node-Metastasis system for clear cell renal cell carcinoma (ccRCC) classified renal sinus fat invasion (SFI), perirenal fat invasion (PFI), or renal vein invasion (RVI) as stage pT3a. However, their close interactions and prognostic value of them remain controversial. The goal of this study is to further analyze their prognostic values for patients with T3aN0M0 ccRCC.

Prognostic factors in T3b renal cell carcinoma

Objectives  We reviewed our patients with pathologic T3b renal cell carcinoma (RCC) to determine which factors influenced survival in this high risk patient group. Methods  From April 1988 to August 2006, 722 patients underwent nephrectomy for RCC at Vanderbilt University. 128 patients (17%) had T3b disease by 2002 AJCC TNM staging criteria. 31 (24%) of these patients had known metastases at the time of nephrectomy. Patient demographics, clinical, and pathological characteristics were collected. Results  There were 95 men (74%) and 33 women (26%) whose median age was 64 years (range 35–87). Median follow-up was 25.2 months (0–124). Median follow-up among those still alive at last follow up was 45.8 months (2.4–114). For overall survival (OS), disease specific survival (DSS), and recurrence free survival (RFS), non-clear cell histology, grade, presence of sarcomatoid features, LN positive disease, presence of necrosis, positive margins, and metastasis present at the time of nephrectomy were all associated with worse outcomes. Race, gender, ASA class, age, and inferior vena cava (IVC) involvement were not associated with outcome. On multivariate analysis, metastasis at the time of nephrectomy, margin involvement, and the presence of necrosis were independently associated with decreased OS and DSS. The presence of necrosis and lymph node involvement were independent predictors of worse RFS. Conclusions  Our data suggests that in patients with T3b RCC, the presence or absence of macroscopic necrosis should be included as part of the pathology report to help guide prognosis in this high risk patient group.     

Prognostic significance of indeterminate lung nodules in renal cell carcinoma

ObjectivesMany patients with renal cell carcinoma (RCC) are found to have lung nodules at the time of diagnosis. The significance of these nodules is unclear. This study sought to determine whether the presence of indeterminate lung nodules affects survival for patients with early-stage RCC.Methods and materialsA retrospective review was performed of patients with stages I to III RCC at an academic hospital who underwent nephrectomy between 2001 and 2006 and had baseline imaging available for review. Presence of lung nodule(s) was determined, along with patient and disease characteristics. The time from diagnosis to last known follow-up, metastasis, and death were determined. The study follow-up period extended to July 2012. Univariate and multivariate Cox proportional hazards models assessed disease-free and overall survival.ResultsOf 548 patients, 240 met the inclusion criteria. Lung nodules were absent in 148 and present in 92 cases. Disease-free survival was associated with the presence of nodules (hazard ratio [HR] = 1.90; 95% CI: 1.04–3.46; P = 0.0362), tumor stage (stage II—HR = 5.61; 95% CI: 2.69–11.72; P<0.001 and stage III—HR = 2.49; 95% CI: 1.21–5.10; P = 0.0129) and tumor grade (HR = 2.43 for grades 3 or 4; 95% CI: 1.31–4.53; P = 0.005). The number and size of nodules were not associated with survival. Overall survival was associated with Charlson comorbidity score (HR = 1.30; 95% CI: 1.15–1.47; P<0.0001) and primary tumor size (HR = 1.29; 95% CI: 1.14–1.46; P<0.0001) but not the presence of lung nodules (HR = 1.73; 95% CI: 0.83–3.60; P = 0.1454).ConclusionsThe presence of indeterminate lung nodules had a negative effect on disease-free survival. Stage and grade were also significant. These findings underscore the importance of baseline imaging and vigilant surveillance of patients in whom nodules are identified.     

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.     

The necessity of chemotherapy in T3N0M0 colon cancer without risk factors

Background

For patients with T3N0M0 colon cancer without known risk factors, the necessity of chemotherapy has no definite consensus.

Methods

From 1994 to 2004, we retrospectively analyzed 247 patients who had pathologically confirmed T3N0M0 colon cancer without risk factors.

Results

Among the 247 patients, 198 (80.2%) received chemotherapy and 49 (19.8%) underwent surgery alone. The 5-year survival rate was 92.8% for patients with T3N0M0 colon cancer without risk factors. Only chemotherapy increased survival (P = .032) by multivariate analysis. The 5-year survival rates were 85.4% in the surgery-only group and 94.2% in the group that received surgery with chemotherapy. There was no difference in the therapeutic efficacy of 5-fluorouracil, capecitabine, and uracil/tegafur (P = .424) for survival.

Conclusion

The results of this study showed that chemotherapy improved the survival of patients with T3N0M0 colon cancer without risk factors.     

NNMT在肾透明细胞癌的表达及对肾癌细胞侵袭能力的影响

目的:研究NNMT在肾透明细胞癌中的表达情况及对肾癌细胞侵袭能力的影响。方法:采用RT-PCR和Western blot方法检测正常肾小管上皮细胞株HKC、肾癌细胞株786-O及30例肾透明细胞癌组织、相应癌旁组织中NNMT的mRNA和蛋白的表达水平,并分析NNMT的mRNA水平与临床病理参数的关系。化学合成针对NNMT特异的siRNA序列,应用脂质体Lipofectamine 2000将其转染进786-O细胞中,利用RT-PCR和Western blot法检测NNMT在786-O细胞中的表达水平,用Transwell小室法检测肾癌细胞786-O侵袭能力的变化。结果:NNMT在肾癌细胞786-O中的mRNA和蛋白表达水平显著高于正常肾小管上皮细胞株HKC(P<0.001);肾透明细胞癌组织和对应的癌旁组织中NNMT的mRNA相对表达量分别为(1.582±0.2145)、(0.1269±0.04279),两组比较P<0.001。NNMT的mRNA水平与肿瘤大小、临床分期有关(P<0.05);Tran-swell法检测结果显示降低NNMT的表达后786-O细胞的侵袭能力明显下降。结论:NNMT在肾透明细胞癌组织和细胞中表达升高,可能在肾癌发生、发展过程中发挥重要作用。     

Prognostic significance of lymphovascular invasion in surgically cured rectal carcinoma

BACKGROUND: Surgery is considered curative in Dukes' B rectal cancer; however, many patients present with early relapse. To identify additional staging information, venous and lymphatic invasion were evaluated as potential prognostic factors. METHODS: Patients with Dukes' B or C rectal disease treated between 1976 and 2001 at a single institution were compared. Patient and treatment characteristics and vascular invasion were documented. The impact of vessel invasion was determined using Cox proportional hazards model. RESULTS: There were 256 Dukes' B patients and 74 Dukes' C cases without vascular invasion. Five-year survival was 76.5% for Dukes' B and 57.1% for Dukes' C patients. Vessel involvement increased the risk of recurrence (hazard ratio [HR] = 3.27, P = .0003) and death (HR = 3.11, P = .002) in B2 patients. The magnitude of these associations were comparable to that of C1 patients for recurrence (HR = 2.81, P = .004) and death (HR = 3.05, P = .005), as well as C2 patients for recurrence (HR = 3.45, P = .0008) and death (HR = 3.87, P = .0005). CONCLUSION: Vascular invasion may be useful in characterizing patients with aggressive Dukes' B disease, who might benefit the most from adjuvant systemic therapy.     

Analysis of renal cell carcinoma with subdiaphragmatic macroscopic venous invasion (T3b)

OBJECTIVE

To review our institutional experience of surgery for renal cell carcinoma (RCC) with subdiaphragmatic macroscopic venous invasion (T3b) and to assess variables associated with cancer‐specific survival (CSS), as the stratification of RCC with venous involvement (T3b and T3c) is subject to debate.

PATIENTS AND METHODS

We retrospectively reviewed the hospital records of patients who underwent a radical nephrectomy with resection of subdiaphragmatic tumour thrombus (T T) between October 1990 and May 2006. The log‐rank and Cox uni‐ and multivariate regression analysis were used to evaluate predictive factors for CSS.

RESULTS

In all, 101 cases were identified. In the N0M0 group, univariate Cox regression analysis confirmed that ipsilateral adrenal gland invasion, Mayo Clinic level of T T, histological subtype and fat invasion were significantly associated with worse CSS. In multivariate Cox regression analysis, only Mayo Clinic level of T T was an independent predictor for CSS. In the subgroup with renal vein involvement only, the median CSS was not reached. In the subgroups with level I, II and III T T involvement, the median CSS was 69, 26 and 21 months, respectively. In the N+ and/or M+ group, only tumour size and type were independent predictors of CSS, while the level of T T was not. Radical nephrectomy yielded poor results with a median CSS of 13 months.

CONCLUSION

The Mayo Clinic level of T T is an independent prognostic predictor for CSS in non‐metastatic T3b RCC. We strongly support the need for re‐classification of the currently applied 2002 Tumour‐Node‐Metastasis staging system, which in its present form does not discriminate between levels of subdiaphragmatic venous invasion.     

进展期肾细胞癌的治疗进展

进展期肾细胞癌(RCC)的临床预后欠佳,由于其对于传统的放化疗的低敏感性,使得临床工作中缺乏较为有效的治疗手段.多个因素影响进展期肾癌的临床预后.目前免疫治疗可使部分进展期肾癌得到部分程度的缓解,新兴的靶向治疗在前期的临床实验中取得了令人满意的效果,使部分患者的肿瘤进展得以延迟,RCC靶向治疗制剂多针对RCC细胞增生、血管形成等多个靶向途径,包括Sorafenib,Sunitinib,Temsirolimus和Bevacizumab等.而联合免疫治疗,将对进展期肾癌的预后产生更为有效的改善.     

肾细胞癌原癌基因mdm2产物的定量分析

目的探讨肾细胞癌原癌基因mdm2产物表达量与细胞DNA含量及临床病理参数的关系。方法采用流式免疫荧光技术对50例肾细胞癌DNA含量及mdrm2蛋白表达进行定量分析。结果23例mdm2蛋白阳性表达，mdm2表达量与DNA含量有关，与瘤体大小、分级、分期、预后无关。结论mdm2蛋白表达与肾细胞癌的发生、发展有关，但尚不足以作为衡量预后的指标。     

Chromophobe renal cell carcinoma in an 18-year-old female

Renal cell carcinoma (RCC) in young adults is uncommon. Whether they have different clinicopathologic characteristics and outcomes from those in older patients is still a conflicting matter. In this article we present an uncommon subtype of RCC which is chromophobe RCC (chRCC) in a female aged less than 20 years.     

Metastatic renal cell carcinoma extending to the left atrium through the inferior pulmonary vein

Metastatic renal cell carcinoma with involvement through the pulmonary veins to the left atrium is very rare. We report the case of a 70-year-old male with metastatic renal cell carcinoma to the right lower lobe of the lung abutting the inferior pulmonary vein with extension to the left atrium without pre-operative evidence. Surgical resection was achieved through a posterolateral thoracotomy. Lung masses that abut the pulmonary veins should prompt further investigation with a pre-operative transoesophageal echocardiogram to minimize unexpected intraoperative findings.     

肾透明细胞癌组织中B7-H3的表达及意义

目的 评价B7-H3在肾透明细胞癌组织中的表达及其与预后的关系.方法 采用免疫组化方法 检测154例肾透明细胞癌患者肿瘤标本中B7-H3的表达,分析其与患者临床病理因素以及术后生存时间之间的关系.结果 154例患者中,B7-H3阳性28例(18.18%),其中无瘤生存6例,复发7例,死亡15例,至最后随访日期,总生存期(OS)为(19.71±20.32)个月;B7-H3阴性126例(81.82%),其中无瘤生存119例,复发3例,死亡4例,OS为(33.47±18.32)个月,两者比较差异有统计学意义(P＜0.05).单因素分析表明,B7-H3阳性表达患者在肿瘤大小、原发肿瘤分期、区域淋巴结转移、远处转移、临床分期等方面较阴性表达患者有明显差异,B7-H3阳性表达患者术后生存时间较阴性表达患者明显缩短.结论 B7-H3的表达可能与肾透明细胞癌的转移和进展有关,可以作为肾透明细胞癌的一个独立预后因素.     

Nephron‐sparing surgery for pathological stage T3b renal cell carcinoma confined to the renal vein

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

OBJECTIVE

To report the functional and oncological outcome of nephron‐sparing surgery (NSS) for pathological stage pT3bNxMx (2002 Tumour‐Node‐Metastasis staging) renal cell carcinoma (RCC) with tumour thrombus confined to the renal vein.

PATIENTS AND METHODS

Of the 305 patients who underwent NSS at our institute from October 2004 to July 2009, seven (2%) were found to have stage T3bNxMx RCC on final pathology. Their charts were reviewed to identify demographic, operative and pathology details of these patients, in addition to obtaining functional and oncological outcome data.

RESULTS

All seven patients had centrally located endophytic tumours. There were absolute indications for NSS in six patients (solitary kidney in five, renal insufficiency in one). The clinical stage was T1a in five and T3b in two patients; in those with cT1a, thrombus was first identified with intraoperative ultrasonography in two and by palpation of the renal vein or during the NSS in the remaining three. Renal surface hypothermia was applied in four cases (mean 77 min) and warm ischaemia in three (mean 38 min). The mean (range) tumour size was 3.9 (2.5–6) cm and all the tumours were clear cell RCC on histology, and all had negative surgical margins. The mean estimated glomerular filtration rate (eGFR) decreased by 24% after surgery. One patient developed new‐onset renal failure (eGFR <30 mL/min/1.73 m²). Postoperative urine leak occurred in one patient successfully managed with a JJ stent. One patient developed a local recurrence with level III inferior vena caval (IVC) tumour thrombus 9 months after NSS and was managed with radical excision and IVC thrombectomy followed by postoperative dialysis. Six other patients were free of recurrence with no need for dialysis at a mean follow‐up of 30 months.

CONCLUSIONS

In selected patients with pathological stage T3b RCC and tumour thrombus confined to the renal vein, NSS is a feasible treatment option with acceptable oncological and renal functional outcomes.     

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

Background

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