Surgical excision of isolated renal-bed recurrence after radical nephrectomy for renal cell carcinoma

OBJECTIVE: To present our results on managing loco-regional recurrence of renal cell carcinoma (RCC) with surgical excision, as local recurrence at the site of a previous nephrectomy is resistant to both systemic therapy and radiotherapy. PATIENTS AND METHODS: In all, 16 patients were operated on between 1994 and 2003 for local recurrence of RCC. The median (mean, range) age at the time of local recurrence was 57.9 (57.4, 28.9-71.7) years, and the median interval from primary surgery 2.22 (3.88, 0.27-14.46) years. Before surgery eight patients had been given systemic immunotherapy, with no response of their local recurrence. RESULTS: Two patients were deemed inoperable because of direct invasion of the great vessels and the liver by tumour. The remaining 14 patients had recurrence in residual adrenal tissue (two), para-aortic nodes (three), para-caval nodes (two), retrocaval nodes (one), renal bed (six), liver, spleen and stomach (one each), and diaphragm (two). Although complete macroscopic en-bloc clearance was achieved in these patients, only eight had tumour-free margins on histological examination. The histology was consistent with RCC recurrence in all cases. All of the patients were followed with computed tomography at regular intervals. At a median follow-up of 1.0 (1.65, 0.25-6.5) years, five patients remain disease-free, four have local and distant relapse, and five developed distant metastasis only. The presence of tumour at the resection margin was a significant factor in predicting local and distant disease-free survival (P < 0.05). CONCLUSIONS: En bloc excision of isolated locally recurrent RCC is possible, and complete surgical extirpation can lead to prolonged disease-free survival.     

Patterns of intervention for renal lesions in von Hippel-Lindau disease

OBJECTIVE

To review the records of patients at our centre with von Hippel‐Lindau (VHL) disease, to determine the incidence of renal cell carcinoma (RCC) and patterns of intervention using minimally invasive therapies.

PATIENTS AND METHODS

Patients with genetically confirmed VHL were evaluated in a multidisciplinary clinical care centre established in 2003. Patients were preferentially offered percutaneous radiofrequency ablation (RFA). Cystic tumours were considered contraindications to RFA, as were larger tumours or extensive multifocality with tumours of >3 cm. These patients had either open partial nephrectomy (OPN) or, in unsalvageable cases, radical nephrectomy.

RESULTS

Of 38 patients with VHL, 16 (42%) were found to have RCC; two with small tumours are under observation. Fourteen of the 16 have had a total of 25 renal interventions, none of whom has progressed to end‐stage renal disease. OPN was performed in 15 (60%) cases, including those who had had multiple bilateral procedures; RFA was used in five (20%) cases. After median follow‐up of 41 months, local recurrence was detected in 33%; the metastasis‐free survival rate was 93.3% and overall survival 87.5%.

CONCLUSIONS

Of patients with VHL, 88% with renal involvement require interventions for their kidneys. OPN is the primary method used, and was successful both as a primary and secondary procedure in 60% of cases. In only 20% was RFA possible due to limitations of current technology. The introduction of protocol‐based targeted therapies holds the promise of reducing the number of interventions required for treating VHL.     

晚期肾癌免疫治疗新进展

肾细胞癌（RCC）是泌尿系统常见的恶性肿瘤,早期可行手术根治性切除,晚期对放化疗均不敏感。随着肿瘤生物治疗的研究,晚期RCC的免疫治疗取得了许多实质性的进展。本文综述近年晚期RCC免疫治疗的临床研究进展。     

Role of MMP-2, MMP-9 and VEGF as serum biomarker in early prognosis of renal cell carcinoma

Introduction

Renal cell carcinoma epitomizes a diversified group of tumors which contributes more than 15,000 deaths annually worldwide. In spite of tremendous efforts to identify prognostic factors apart from grade, histology and tumor size, they are not so obvious yet to fulfill the requirement. In this study, the prognostic role of serum matrix metalloproteinase (MMP)-2, 9, and vascular endothelial growth factor (VEGF) levels in patients with pre and postoperative renal cell carcinoma are evaluated to use as biomarker.

Laparoscopic Radical Nephrectomy for Renal Masses 7 Centimeters or Larger

Objective:

To report our operative experience and oncologic outcomes for the laparoscopic management of large renal tumors.

Methods:

All laparoscopic and hand-assisted laparoscopic radical nephrectomies performed at our institution were reviewed. Thirty patients with tumors ≥7cm and a pathologic diagnosis of renal cell carcinoma were included.

Results:

Mean operative time was 175.7±24.5 minutes, and mean estimated blood loss was 275.5±165.8 mL. No case required conversion to open radical nephrectomy. The mean hospital stay was 2.4±1.6 days. Four patients (13%) had minor complications. Of the 30 tumors, 18 were pathologic stage T2, 9 were stage T3a, 2 were stage T3b, and one was stage T4. At a mean follow-up of 30 months (range, 10 to 70), 22 patients (73%) were alive without evidence of recurrence, and 5 patients (17%) were alive with disease. One patient (3%) died of complications related to renal cell carcinoma, and 2 patients (7%) died from other causes. Overall survival was 90%, cancer-specific survival was 97%, and recurrence-free survival was 80%.

Conclusion:

Laparoscopic radical nephrectomy for large tumors is a technically challenging operation. However, in experienced hands, it is a reasonable therapeutic option for the management of larger RCC neoplasms.     

Invasion of renal sinus fat is not an independent predictor of survival in pT3a renal cell carcinoma

OBJECTIVE

To clarify the significance of the location of extrarenal tumour extension of renal cell carcinoma (RCC) as in the 2002 Tumour‐Nodes‐Metastasis classification. Renal cortical tumours with perirenal fat invasion (PFI) or sinus fat invasion (SFI) are consolidated within the pT3a grouping; tumours with SFI are close to the renal veins, lymphatics and the collecting system. This might carry a worse prognosis for disease‐specific survival (DSS), but reports are limited and contradictory.

PATIENTS AND METHODS

We retrospectively reviewed 1244 patients treated with nephrectomy from 1988 to 2007, to identify patients with pT3a renal tumours. They were classified as having PFI or SFI. Kaplan‐Meier analysis and Cox proportional hazards regression models were used to assess predictors of survival.

RESULTS

The 230 patients who met the inclusion criteria had a median follow‐up of 24 months. SFI was found in 63 (27.4%) patients and was associated with a worse 5‐year DSS than the 167 (72.6%) with PFI (62.5% vs 75.0%; log rank P = 0.022). On univariate analysis, diameter (hazard ratio, HR 1.1), nuclear grade (HR 4.5), margin status (HR 5.8), lymph node metastases (HR 6.4), and systemic metastases (HR 15.4) were significant for DSS. In a multivariate model, only nuclear grade (HR 3.1), margin status (HR 8.9) and systemic metastases (HR 9.8) were independent predictors.

CONCLUSION

Patients with renal tumours with SFI are more likely to die from RCC than those with PFI. However, in the present patients the presence of SFI was not an independent predictor of DSS.     

Increased preoperative serum C-reactive protein level predicts a poor prognosis in patients with localized renal cell carcinoma

OBJECTIVE: To evaluate the value of the preoperative serum C-reactive protein (CRP) level in the prognosis of patients with localized renal cell carcinoma (RCC). PATIENTS AND METHODS: The study comprised 101 patients who had a radical nephrectomy for localized RCC (pT1-3N0M0). An elevated CRP was defined as >0.5 mg/dL before surgery. Survival rates for each variant were calculated using the Kaplan-Meier method, with the difference between survival curves evaluated using the log-rank test. Multivariate analysis was by Cox proportional hazard model; for all analyses the difference was considered significant when P < 0.05. RESULTS: The median (range) follow-up was 55 (2-187) months; 26 patients (26%) had high CRP levels, and 12 (46%) of these and three (4.0%) of the remaining 75 died from disease. The 5- and 10-year disease-specific survival rates (75% and 30%, respectively) in patients with high CRP levels were significantly worse than those in patients with normal CRP levels (both 93%, P < 0.001). In other variants, preoperative haemoglobin concentration, pathological stage, grade, histological type and microvascular tumour invasion were also related to disease-specific survival. By the Cox proportional hazards model, pathological stage and an elevated CRP were the most important prognostic factors for disease-specific survival in patients with localized RCC (P = 0.008 and 0.012, respectively). CONCLUSION: The preoperative CRP level was associated with poor survival in patients with localized RCC.