Kidney cancer metastasis to the adrenal gland. Role of adrenalectomy

We analysed case records of 2507 patients with renal cell carcinoma treated in the department of onco-urology of Cancer Research Center (Moscow). 1939 of them underwent nephrectomy between 1971 and 1999. The overall incidence of adrenal metastases according to CT and histological findings was 4.7%. Synchronous metastases occurred in 90 and metachronous ones in 30 patients. Radical nephrectomy with adrenalectomy was performed in 18 out of 90 patients with synchronous metastases, palliative nephrectomy in 20 and 52 patients were not considered for surgery. Among 18 patients who underwent complete surgical resection, 12(66%) had either lymph node involvement or distant metastases. A microscopic metastasis was found on histological examination only in 1 patient with normal CT scan and macroscopically intact adrenal on intraoperative assessment. Mean survival after radical nephrectomy with adrenalectomy in 6 patients with solitary lesions was 57 months compared to the longest survival of 31 months in patients with widespread disease. Solitary metachronous ipsilateral and contralateral adrenal involvement was present in 7 patients. The average interval between nephrectomy and appearance of adrenal metastasis in this group was 73 months. One patient was lost for follow-up and one died of adrenal deficiency 4.3 months after adrenalectomy. One patient underwent a consecutive removal of brain and lung metastases 33 and 38 months following adrenalectomy while the remaining 4 were alive in 15, 16, 26 and 34 months with no evidence of the disease. Thus, ipsilateral adrenalectomy is obligatory only in patients with severe disease as shown by CT scan or at nephrectomy. About one-third of the patients will benefit from the surgery. Adrenalectomy should be performed in case of obvious adrenal involvement. The aggressive surgical approach is justified in solitary metachronous adrenal involvement because of long-term survival expected in some of such patients.     

Prognostic factors for survival after surgery for adrenal metastasis

Aim

To better define the indications for adrenalectomy for adrenal metastasis we have analysed factors predicting survival in our institutional series.

Methods

A consecutive series of 30 patients undergoing adrenalectomy for metastasis (1996–2007), excluding patients with simultaneous ipsilateral renal cell carcinoma (RCC), was studied. Metastases were regarded as synchronous (<6 mo), or metachronous (>6 mo), depending on the interval after primary surgery. Survival was calculated from time of adrenalectomy and factors influencing survival were identified.

Results

The tumour diagnoses were RCC n = 9, malignant melanoma n = 5, non-small-cell lung cancer n = 5, colorectal carcinoma n = 4, foregut carcinoid n = 2, adrenocortical carcinoma, breast cancer, hepatocellular carcinoma, urothelial carcinoma, and liposarcoma (one each); nine adrenal metastases were synchronous and 21 metachronous. Ten patients had undergone previous surgery for extra-adrenal metastases. Out of 30 adrenalectomies 10 were laparoscopic (LAdx) and 20 open (OAdx) procedures without surgical complications. The local recurrence rate was low: LAdx 1/10, OAdx 1/20, and the median survival was 23 months. Independent prognosticators of favourable survival were adrenalectomy for potential cure (p = 0.01), no previous metastasis surgery (p = 0.02), and tumour type (p = 0.043), with better prognosis for patients with adrenal metastasis from colorectal carcinoma and RCC and worse prognosis in non-small-cell lung cancer and malignant melanoma.

Conclusions

Surgery for adrenal metastasis is safe and the indication for this procedure in an individual patient can be supported by several prognostic factors. The survival benefit in patients with adrenalectomy for potential cure indicates a therapeutic value of adrenalectomy in selected patients.     

Clinical Characteristics,Molecular Phenotyping,and Management of Isolated Adrenal Metastases From Lung Cancer

IntroductionAdrenal gland metastases occur in up to 20% of patients with non–small-lung cancer. In selected cases with limited burden of disease, surgery may be offered to improve patient outcome; furthermore, tissue analysis would provide useful information on genotype of primary and secondary neoplasms.Materials and MethodsWe report our experience in the management of adrenal metastasis by retrospectively reviewing data of 21 consecutive patients treated with curative intent to the primary tumor followed by adrenalectomy in a 15-year time span. Targeted next generation sequencing was performed to compare molecular profile of primary lung cancers and adrenal metastases. Patient overall survival was assessed by Kaplan-Meier method, using adrenalectomy as time zero. Survival rates were compared by log rank test.ResultsNo surgery-related mortality or morbidity was observed. Median survival was 50 months; 5-year overall survival was 34.5% (95% confidence interval, 12%-66%). No significant survival difference was observed with respect to timing of onset (synchronous vs. metachronous) or side (homolateral vs. contralateral) of adrenal metastasis, T or N status of primary lung cancer, mutational asset, and histologic type. Mutations in TP53 genes were found in 61% and 85% of primary and metastatic tumors, respectively. In 3 of 15 cases, we found differences between molecular mutation patterns in primary lung cancer and corresponding adrenal metastasis.ConclusionsAdrenalectomy is a safe and effective approach in selected cases. Discordance between primary and secondary tumor mutational profile was found in 20% of assessable patients.     

Late adrenal metastasis in operable non-small-cell lung carcinoma

Treatment of early-stage (I, II, and some IIIA) non-small-cell lung cancer (NSCLC) is curative resection. Simultaneous isolated adrenal metastasis represents a dilemma. Although many studies addressing the management of adrenal metastasis diagnosed simultaneously with NSCLC have been published, only very few reports of late adrenal metastasis can be found in the literature. Our purpose is to discuss the management of solitary late (metachronous) adrenal metastasis from operable NSCLC based on published experience. We describe a patient with a solitary metachronous adrenal metastasis diagnosed 3 years after resection of NSCLC. Adrenalectomy was done, followed by combination chemotherapy with paclitaxel and carboplatin. MEDLINE literature on similar cases was reviewed and updated. Only 18 cases have been reported from 1965 to 2000. The median interval between the diagnosis of NSCLC and development of adrenal metastasis was 11.5 months. All patients were male. Unilateral adrenal metastases were reported in 15 patients, whereas 3 had bilateral metastases. Five patients were treated with adrenalectomy, and eight patients were treated with adrenalectomy and postoperative adjunctive chemotherapy. Chemotherapy alone was used in two patients and two patients underwent palliative radiation therapy. One patient was treated with intraarterial chemotherapy followed by radiation therapy. Solitary metachronous adrenal metastases are rare. There are no standard treatment guidelines for this group of patients. Review of the literature showed that median survival after treatment was 19 months for the group treated with adrenalectomy followed by chemotherapy; 15 months for the chemotherapy group; 14 months for the adrenalectomy group; and 8 months for the group treated with palliative radiation.     

Ipsilateral adrenalectomy is not obligatory in nephrectomy for renal cell carcinoma

To analyse the necessity of obligatory ipsilateral adrenalectomy (IA) for renal cell carcinoma (RCC), we made a study of 329 RCC patients operated from 2002 to 2007. Nephrectomy was conducted in 208 (63.2%) patients, renal resection--in 121 (36.8%), adrenalectomy--in 19 (5.8%) patients. High-contrast multislice computed tomography (HCMCT) was performed in all the patients. Preoperative HCMCT detected adrenal lesions in 62 (18.84%) patients. Adrenal adenoma was suspected in 39 (11.8%) patients: ipsilateral in 19 (48.77%), contralateral in 11 (28.23%), bilateral in 9 (23%) patients. Adrenal hyperplasy was diagnosed in 11 (3.34%) patients. It was ipsilateral in 5 (45.4%), contralateral in 4 (36.4%), bilateral in 2 (18.2%) patients. The tumor invaded the ipsilateral adrenal in 4 (1.2%) patients. A RCC metastasis into the adrenal was suspected in 8 (2.4%) patients. A synchroneous affection was seen in 5 (1.5%) patients: ipsilateral in 4 (80%) and bilateral in 1 (20%) patients. RCC invaded the ipsilateral adrenal in 1.2% patients with RCC, its adrenal metastasis was detected in 1.5% RCC patients. In preservation of the adrenal in adenoma or hyperplasy 5-year follow-up registered no changes. Neither pathological processes were diagnosed for 5 years in preservation of unaffected adrenal. Thus, adrenalectomy is not obligatory in radical nephrectomy.     

Adrenalectomy for solitary adrenal metastases from non-small cell lung cancer

BACKGROUND: The treatment of patients with adrenal metastases from lung cancer (non-small cell lung cancer, NSCLC) remains controversial. Several studies of adrenalectomy in cases of isolated adrenal metastases from NSCLC suggest that these patients could have improved survival. Our aim is to define the history of patients after resection of solitary metastases to the adrenal gland and to identify characteristics of patients who achieved prolonged survival. METHODS: Between January 1997 and July 2000, 11 patients underwent curative resection for metastatic NSCLC of the adrenal gland in our institution. In all patients who were accepted for curative adrenalectomy, the primary NSCLC had been treated by complete resection. RESULTS: Eleven patients (seven men and four women) with unilateral adrenal metastases of NSCLC entered the study. Median age was 59 years (range 47-67 years). There was no perioperative death. The overall median survival after metastasectomy was 12.6 months (CI: 9.2-16.1 months). Patients with curative resection and metachronous disease (n=6) had a median survival of 30.9 months and tended to do better than patients with synchronous adrenal metastases (n=5) (median survival: 10.3 months). CONCLUSIONS: We conclude that adrenalectomy for clinically solitary, resectable metastases can be performed safely. It appears reasonable that such selected patients should be considered surgical candidates.     

Factors related to improved clinical outcomes associated with adrenalectomy for metachronous adrenal metastases from solid primary carcinomas

Background

Surgery for metachronous adrenal metastases from solid primary carcinoma has increased with the development of technical skills. Here we analyzed the postoperative clinical outcomes of patients who underwent adrenalectomy for metachronous adrenal metastases from solid primary carcinomas.

Radical nephrectomy using a chevron incision to treat complicated renal carcinoma: a report of 15 cases

OBJECTIVE To investigate the outcome and indications for radical nephrectomy with a Chevron incision to treat complicated renal carcinoma.METHODS Large renal carcinomas were found in 15 patients during a preoperative CT and/or MRI examination. A tumor thrombus in the renal vein or inferior vena cava was found in 5 cases, and a complication of metastasis in the contralateral adrenalgl and was found in 2 patients. All of the 15 patients underwent a radical nephrectomy by a chevron incision and the postoperative pathological results noted.RESULTS Of the 15 patients who underwent a radical nephrectomy and lymphadenectomy, 5 also received a thrombectomy, and 2 a contralateral adrenalectomy. All surgical operations were safe and successful. The mean operation time was (4.45±0.83) h, and the intraoperative blood loss was (785±910) ml. All patients recovered well after the surgery. Multimodal therapy was conducted in these cases, with rigorous follow-up.CONCLUSION In determining the type of incision for surgery of renal carcinoma, a chevron incision is suitable for cases with a large tumor, local nodal metastasis, thrombus of the renal vein or inferior vena cava and complicated metastasis to the contralateral adrenal gland. The incision produces a clear operating field with less intra- and post-operative complications.     

Metastases from renal tumor to adrenals

The aim of the study was assessment of diagnosis and surgical treatment of adrenal metastases (AM) of renal carcinoma (RC). 10 cases of RC AM have been analysed. Bilateral metastases were diagnosed in 2 patients, ipsilateral in 5 patients, contralateral in 3. Three patients had synchronous metastases, seven had metachronous ones. AM were detected 8 months to 14 years after after operation on the kidney. Non-invasive dynamic control over the retroperitoneal space after nephrectomy for RC using advanced visual methods (ultrasonography, x-ray and resonance magnetic CT) not only detects AM but also determines metastatic genesis of the tumor. Thus, significant verification of RC AM, especially of metachronous origin, requires the study of the findings obtained at clinical, laboratory, ultrasonic, radiation examinations as well as comparison of histological structure of the removed kidney tumor and the adrenal. Early diagnosis and removal of a solitary adrenal metastasis of RC provides prolongation of the patient's life and survival of patients with RC late stages.     

Metastasis to gallbladder and adrenal gland of renal cell carcinoma

We studied a case of metastasis to the gallbladder and left adrenal gland of clear cell-type renal cell carcinoma (RCC) in the right kidney. A polypoid gallbladder tumor and left adrenal mass were found 2 years after surgery for clear cell-type RCC in a 50-year-old man. The gallbladder tumor and left adrenal mass showed hypervascularity on diagnostic imaging. Systemic image screening showed no other metastatic lesion. Simple cholecystectomy and left adrenalectomy were performed. A histopathological examination showed tumor cells in a gallbladder polyp. Furthermore, based on various specific and immunohistochemical studies, the patient was pathologically diagnosed to have gallbladder and right adrenal gland metastasis of clear cell-type RCC.     

Albumin-to-Alkaline Phosphatase Ratio as a Novel Prognostic Factor in Patients Undergoing Nephrectomy for Non-Metastatic Renal Cell Carcinoma: Propensity Score Matching Analysis

IntroductionTo evaluate the prognostic value of albumin-to-alkaline phosphatase ratio (AAPR) on recurrence and survival in patients with non-metastatic renal cell carcinoma (RCC) treated with radical or partial nephrectomy.Patients and MethodsBetween June 1994 and December 2018, 491 patients with RCC who underwent radical or partial nephrectomy at 2 institutions were enrolled in this study. Recurrence-free survival (RFS) and cancer-specific survival (CSS) analyses were performed to distinguish the differences in postoperative recurrence and survival between patients stratified by an optimal cut-off value of AAPR. Multivariable Cox proportional hazards regression models were established to determine the independent prognostic factors after propensity score weighting.ResultsOf the total 491 patients, 51 patients (10.4%) developed local recurrence or distant metastasis and 26 patients (5.3%) died of disease during the follow-up period. Patients with AAPR<0.41 had significantly lower rates of RFS and CSS than those of patients with AAPR≥0.41 in multivariate analysis (P < .001 and P = .027, respectively). After propensity scroe matching analyses, this difference was still remained for RFS (P < .001). However, AAPR was not an independent prognostic factor for CSS but the value was almost pregnant (HR = 2.674; 95%CI = 0.872–8.203; P = .086).ConclusionAAPR can serve as a novel and useful tool to refine prognosis in patients with non-metastatic RCC treated with partial or radical nephrectomy. These findings suggest that AAPR could be a promising prognostic factor for prediction of recurrence and survival in patients with non-metastatic RCC who undergo nephrectomy.     

Solitary Adrenal Metastasis in a Patient with Sigmoid Colon Cancer; Report of a Case

A 73-year-old man had sigmoidectomy for sigmoid colon cancer in December 2001. Although he was followed regularly with chemotherapy, his serum carcinoembryonic antigen (CEA) increased on August 2002. Abdominal computed tomography and magnetic resonance imaging showed a right adrenal mass and no other abnormality. The preoperative diagnosis was a solitary adrenal metastasis from sigmoid colon cancer; the lesion was removed in September 2002. On pathology, adrenal metastasis was confirmed. Although the patient’s serum CEA normalized soon thereafter, 12 months after adrenalectomy, the CEA again increased; the patient had local recurrence of the resected adrenal lesion and liver metastasis. Therefore, the patient was given systemic chemotherapy, but his condition deteriorated, and he died 38 months after adrenalectomy. Adrenal metastasis from colorectal cancer is not unusual; however, a solitary metastasis is rarely found and resected surgically. As surgical treatment of the metastatic lesion could improve patients’ prognosis to some extent if it is detected early, the possibility of adrenal metastasis should be kept in mind when colorectal cancer patients are followed.     

Metastatic renal cell carcinoma

Opinion statement Patients with renal cell cancer (RCC) develop metastatic spread in approximately 33% of cases. The clinical management of patients with metastatic RCC is complicated by the lack of significant efficacy from available therapies. Common sites of metastases include the lung, liver, bone, brain, and adrenal gland, with case reports detailing the capacity of RCC to appear almost anywhere in the body. More than one organ system is often involved in the metastatic process. Metastases may be found at diagnosis or at some interval after nephrectomy. Approximately 20% to 50% of patients will eventually develop metastatic disease after nephrectomy. A shorter interval between nephrectomy and the development of metastases is associated with a poorer prognosis. Patients with metastatic RCC face a dismal prognosis, with a median survival time of only 6 to 12 months and a 2-year survival rate of 10% to 20%. Recent advances in biologic response modifier therapy have brought new hope to a small percentage of patients who respond to this therapy and rekindled interest in cytoreductive nephrectomy as an integral part of the management of these patients.     

Results of a surgical resection for patients with stage IV non--small-cell lung cancer

PurposeThis study retrospectively investigated the clinical significance of surgical treatment for stage IV non–small-cell lung cancer (NSCLC).SubjectsThere were 36 patients who underwent surgical resection for stage IV NSCLC between 1999 and 2008.ResultsThe patients included 22 males and 14 females. All patients had either synchronous distant metastasis or pleural dissemination. The mean age of the patients was 65.8 years (range, 18 to 90 years). The histological types included 29 adenocarcinomas, 5 squamous-cell carcinomas and 2 large-cell carcinomas. The organs of metastasis were bone in 5 patients, brain in 4, adrenal gland in 4, axillary lymph nodes in 3, liver in 2, and 1 patient had a contralateral pulmonary metastasis. The number of metastases was one site in 13, two sites in 3, three sites in 1, and five sites in 2 patients. The patients with bone metastasis were treated with radiation, and the patients with brain metastasis underwent stereotaxic radiosurgery. The patients with either adrenal metastasis, axillary lymph node metastasis, or contralateral lung metastasis underwent surgical resection. Among the patients with distant metastasis, the 5-year survival rate was 30.1 %. There were 17 patients with pleural dissemination. The 5-year survival rate in these patients was 25.3%. The overall 5-year survival rate after surgery in the patients with stage IV disease was 26.8%.ConclusionSelected patients who can undergo surgical resection for the primary tumor and effective local therapy for metastatic lesions still have a chance to obtain long-term survival. Surgical treatment for NSCLC with oligometastatic disease can be considered as one arm of multidisciplinary treatment.     

同侧小体积肾及肾上腺肿瘤一期手术16例体会

目的 总结同侧小体积肾及肾上腺肿瘤患者一期行后腹腔镜肾部分及肾上腺部分切除术的临床经验。方法 回顾性分析2010年9月至2021年11月南京医科大学第一附属医院收治的16例同侧小体积肾及肾上腺肿瘤一期后腹腔镜手术患者的临床资料。结果 所有患者均在后腹腔镜下完成肾部分及肾上腺部分切除手术,其中机器人辅助手术3例,无中转开放手术者。肾肿瘤直径0.9～4.0(2.4±1.0) cm;肾上极肿瘤7例,肾中极4例,肾下极4例,1例多发;肾上腺肿瘤直径1.0～4.0(2.0±1.0) cm。术后病理示肾透明细胞癌12例,嫌色细胞癌1例,极性倒置的乳头状肾肿瘤1例,肾错构瘤2例;肾上腺皮质腺瘤15例,嗜铬细胞瘤1例。肾透明细胞癌合并肾上腺皮质腺瘤最常见,占比68.75%。术后随访1～90个月（中位随访时间24个月）,均无复发或转移。结论 小体积肾肿瘤合并的同侧肾上腺肿瘤多为良性,此类患者一期行后腹腔镜肾部分及肾上腺部分切除术安全有效,术后需长期随访。     

Metastatectomy for extra-cranial extra-adrenal non-small cell lung cancer solitary metastases: systematic review and analysis of reported cases

Back ground

Although patients with stage IV non-small cell lung cancer (NSCLC) have a poor prognosis, a subset of patients with solitary brain or adrenal metastasis have more favorable outcome following surgical resection. Nevertheless, the outcome and predictive factors for survival following metastatectomy for patients with other metastatic sites are not well defined.

Methods

We performed a systematic review using PUBMED database for all articles which included patients with NSCLC and solitary metastasis to sites other than the adrenal gland or the brain who had undergone resection of their metastasis and definitive treatment of the primary lung cancer. Potential prognostic factors on survival including age, sex, histology, T and N stage of the primary tumor, synchronous vs. metachronous presentation, visceral vs. non-visceral metastasis and the use of perioperative chemotherapy were analyzed using multi-variable Cox proportional hazard model.

Results

62 cases were eligible for the analysis. The 5-year survival rate was 50% for the entire cohort. Mediastinal lymph node involvement was independently predictive of inferior outcome; 5-year survival rate 0% vs. 64% in favor of no involvement, p < 0.001. Similarly, patients with intra-thoracic stage III disease had an inferior outcome compared to patients with stage II and stage I disease: 5-year survival rate 0% vs. 77% and 63%, respectively, p < 0.001. Other factors have no effect on outcome.

Conclusion

Selected patients with distant metastatic NSCLC can achieve long term survival following metastatectomy and definitive treatment of the primary tumor. Mediastinal lymph node involvement is associated with poor prognosis.     

Renal Cell Carcinoma with Simultaneous Bilateral Adrenal Metastasis: Ipsilateral Radical Nephrectomy with Contralateral Adrenal Preservation

Although renal cell carcinoma (RCC) can metastasize to almost every organ, the most common metastatic sites are the lungs, abdomen, bones and brain. We present a rare case of a 72-year-old male with a large left RCC with simultaneous bilateral adrenal metastasis. In the process of surgical treatment, he underwent left radical nephrectomy with ipsilateral adrenalectomy. Due to the poor general condition of the patient, and also to prevent adrenal insufficiency, the right adrenal mass was preserved, without imposing any hazard to the patient. Systemic immunotherapy was initiated and the patient is still alive 1 year after surgery.     

Solitary sites of metastatic disease in non-small cell lung cancer

Opinion statement Metastatic (stage IV) non-small cell lung cancer is a lethal disease, with few patients surviving longer than 5 years. Surgery is not an option, and adjuvant therapy regimens (platinum-based chemotherapy, radiation therapy, and supportive care) have been structured around palliation and maximizing the quality of life for patients. However, patients with solitary foci of metastatic disease represent a subgroup with a better prognosis. Studies have indicated that surgical resection may enhance the survival rate of patients in this setting. Patients who have resectable primary tumors and a solitary site of metastasis, based on a thorough metastatic work-up, benefit from surgical resection (primary tumor and solitary metastasis). The role of adjuvant chemotherapy and radiation depends on the individual and patient setting. There have been several case series indicating an improvement in the long-term (5-year) survival rates of patients after surgical resection of solitary metastases of the brain, adrenal gland, and other sites. Prospective trials will be required to determine the magnitude of benefit of surgical resection for patients and the role of multimodality therapy. The standard of care for patients with solitary metastases in non-small cell lung cancer should include consideration of surgical resection and ablation. Favorable criteria include control of the primary tumor, a negative metastatic survey, good performance status, and a significant metachronous interval.     

Treatment with nephrectomy only for small, stage I/favorable histology Wilms' tumor: a report from the National Wilms' Tumor Study Group.

PURPOSE: Children younger than 24 months with small (< 550 g), favorable histology (FH) Wilms tumors (WTs) were shown in a pilot study to have an excellent prognosis when treated with nephrectomy only. PATIENTS AND METHODS: A study of nephrectomy only for the treatment of selected children with FH WT was undertaken. Stringent stopping rules were designed to insure closure of the study if the true 2-year relapse-free survival rate was 90% or lower. RESULTS: Seventy-five previously untreated children younger than 24 months with stage I/FH WTs for which the surgical specimen weighed less than 550 g were treated with nephrectomy only. Three patients developed metachronous, contralateral WT 1.1, 1.4, and 2.3 years after nephrectomy, and eight patients relapsed 0.3 to 1.05 years after diagnosis (median, 0.4 years; mean, 0.51 years). The sites of relapse were lung (n = 5) and operative bed (n = 3). The 2-year disease-free (relapse and metachronous contralateral WT) survival rate was 86.5%. The 2-year survival rate is 100% with a median follow-up of 2.84 years. The 2-year disease-free survival rate (excluding metachronous contralateral WT) was 89.2%, and the 2-year cumulative risk of metachronous contralateral WT was 3.1%. CONCLUSION: Children younger than 24 months treated with nephrectomy only for a stage I/FH WT that weighed less than 550 g had a risk of relapse, including the development of metachronous contralateral WT, of 13.5% 2 years after diagnosis. All patients who experienced relapse on this trial are alive at this time. This approach will be re-evaluated in a clinical trial using a less conservative stopping rule.     

Analysis of features of recurrence after radical nephrectomy in patients with N0M0 renal cell carcinoma

Background. To reduce unnecessary tests for patients with renal cell carcinoma (RCC) at low risk of metastasis, we designed a postoperative surveillance protocol for N0M0 RCC, based on the features of recurrence. Methods. Of 462 N0M0 RCC patients who underwent radical nephrectomy, 180 patients (39%) showed recurrence. We stratified these patients according to pathologi-cal T-stage (pT-stage) with consideration given to the pathological grade of malignancy (grade). A surveillance protocol was designed based on calculated disease-free survival rates. Results. The median time until recurrence was 36 months (range, 1 to 228 months), and 78.3% of all patients, recurrence was diagnosed within 5 years. The rate of recurrence increased in accordance with increased pT-stage: pT1a, 9.9% (10/101); pT1b, 29.8% (39/131); pT2, 41.7% (20/48); pT3a, 58.8% (60/102); pT3b, 60.9% (42/69); pT3c, 71.4% (5/7); pT4, 100% (4/4). Significant differences in disease-free survival rates were observed among the patients at all pT-stages, except for pT1b vs pT2, pT2 vs pT3a, pT3a vs pT3b, and pT3c vs pT4. Basically, a 5-year follow-up was conducted, except for the patients with pT1b (grade 1 + 2), pT2 (grade 1 + 2), pT3a (grade 1, 3), and pT3b (grade 1 + 2), who showed recurrence more than 5 years postoperatively. Conclusion. We conclude that our surveillance protocol for N0M0 RCC after nephrectomy, based on pT-stage and grade, is to some extent a reasonable guideline. However, a further survey of prognostic factors for RCC is necessary, because of the difficulty in predicting recurrence in patients with a low pT-stage and because of the presence of patients with late recurrence. Received: December 21, 1999 / Accepted: May 29, 2000