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Ramaswamy A, Proudfoot JA, Ross AE, Davicioni E, Schaeffer EM, Hu JC. Prostate Cancer Tumor Volume and Genomic Risk. EUR UROL SUPPL 2023; 48:90-97. [PMID: 36743402 PMCID: PMC9895765 DOI: 10.1016/j.euros.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2022] [Indexed: 01/09/2023] Open
Abstract
Background Despite the historic association of higher prostate cancer volume with worse oncologic outcomes, little is known about the impact of tumor volume on cancer biology. Objective To characterize the relationship between tumor volume (measured by percent positive cores [PPC]) and cancer biology (measured by Decipher genomic risk classifier [GC]) in men who underwent prostate biopsy. Design setting and participants Prostate biopsies from 52 272 men profiled with Decipher captured in a population-based prospective tumor registry were collected from 2016 to 2021. Outcome measurements and statistical analysis The degree of distribution and correlation of PPC with a GC score across grade group (GG) strata were examined using the Mann-Whitney U test, Pearson correlation coefficient, and multivariable linear regression controlled for clinicopathologic characteristics. Results and limitations A total of 38 921 (74%) biopsies passed quality control (14 331 GG1, 16 159 GG2, 5661 GG3, 1775 GG4, and 995 GG5). Median PPC and GC increased with sequentially higher GG. There was an increasingly positive correlation (r) between PPC and GC in GG2-5 prostate cancer (r [95% confidence interval {CI}]: 0.07 [0.5, 0.8] in GG2, 0.15 [0.12, 0.17] in GG3, 0.20 [0.15, 0.24] in GG4, and 0.25 [0.19, 0.31] in GG5), with no correlation in GG1 disease (r = 0.01, 95% CI [-0.001, 0.03]). In multivariable linear regression, GC was significantly associated with higher PPC for GG2-5 (all p < 0.05) but was not significantly associated with PPC for GG1. Limitations include retrospective design and a lack of final pathology from radical prostatectomy specimens. Conclusions Higher tumor volume was associated with worse GC for GG2-5 prostate cancer, whereas tumor volume was not associated with worse GC for GG1 disease. The finding that tumor volume is not associated with worse cancer biology in GG1 disease encourages active surveillance for most patients irrespective of tumor volume. Patient summary We studied the relationship between prostate cancer tumor volume and cancer biology, as measured by the Decipher genomic risk score, in men who underwent prostate biopsy. We found that tumor volume was not associated with worse cancer biology for low-grade prostate cancer. Our findings reassuringly support recent guidelines to recommend active surveillance for grade group 1 prostate cancer in most patients, irrespective of tumor volume.
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Affiliation(s)
- Ashwin Ramaswamy
- Department of Urology, Weill Cornell Medicine, New York, NY, USA
| | | | - Ashley E. Ross
- Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | | | - Edward M. Schaeffer
- Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jim C. Hu
- Department of Urology, Weill Cornell Medicine, New York, NY, USA,Corresponding author. 525 East 68th Street Starr 946, New York, NY 10065, USA. Tel. +1 (646) 962-9600; Fax: +1 (646) 962-0715.
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Nguyen HH, Do TT, Hoang L, Do NS, Van TC, Nguyen DM. Retroperitoneal Laparoscopic Radical Nephrectomy for Renal Cell Carcinoma: Indications and Long-term Outcome of a Cohort Study in Vietnam. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.9925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE: Laparoscopic radical nephrectomy (LRN) has been suggested as the standard care for cancer patients in the T1-2 stage. However, whether this advanced technique is most indicated suitable for renal tumors higher than T3a and N1 is unclear, especially in different regions and countries, such as the difference between European and Asia.
METHODS: From 2013 to 2021, the data of pathologically diagnosed renal cell carcinoma (RCC) patients who received laparoscopic retroperitoneal radical nephrectomy was subjected to the present study.
RESULTS: Overall, all the registered Vietnamese patients were eligible for the study. The average operative time was 86.8 ± 21.2 min and the percentage number of patients in stages 1, 2, and 3 were 134 (70.2%), 30 (15.7%), and 27 (14.1%), respectively. Patients in the 3rd stage had a significantly longer operative time than stages 1–2 (p = 0.0001). No Lymph-node dissection (LND) was recorded in 10 patients (5.2%), limited LND in 163 patients (85.3%), regional LND in 13 patients (6.8%), extended LND (eLND) in 5 patients (2.6%). eLND showed only prolongation of operative time (p = 0.000), however, did not increase intraoperative complications as well as prolonged the duration of analgesia and hospital stay when compared with the other 2 groups (p = 0.82, 0.85, 0.91). Mean follow-up time: 42.3 ± 24.7 months. The 5-year recurrent free survival and 5-year overall survival of the stage 1, 2, 3 were: 98.3%, 100%, 87.8%, and 98.9%, 100%, and 91.3%, respectively. (p = 0.0011, p = 0.0082).
CONCLUSION: Retroperitoneal LRN could be an important technique in improving long-term oncological outcomes for Vietnamese patients, especially in the stage of T1-3N0-1M0 tumors. Radical retroperitoneal nephrectomy is safe and technically feasible as well as providing favorable long-term oncological outcomes for stage T1-2-3aN1M0 RCC.
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3
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Li W, Wang B, Dong S, Xu C, Song Y, Qiao X, Xu X, Huang M, Yin C. A Novel Nomogram for Prediction and Evaluation of Lymphatic Metastasis in Patients With Renal Cell Carcinoma. Front Oncol 2022; 12:851552. [PMID: 35480102 PMCID: PMC9035798 DOI: 10.3389/fonc.2022.851552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 03/16/2022] [Indexed: 11/13/2022] Open
Abstract
Background Lymphatic metastasis is an important mechanism of renal cell carcinoma (RCC) dissemination and is an indicator of poor prognosis. Therefore, we aimed to identify predictors of lymphatic metastases (LMs) in RCC patients and to develop a new nomogram to assess the risk of LMs. Methods This study included patients with RCC from 2010 to 2018 in the Surveillance, Epidemiology, and Final Results (SEER) database into the training cohort and included the RCC patients diagnosed during the same period in the Second Affiliated Hospital of Dalian Medical University into the validation cohort. Univariate and multivariate logistic regression analysis were performed to identify risk factors for LM, constructing a nomogram. The receiver operating characteristic (ROC) curves were generated to assess the nomogram’s performance, and the concordance index (C-index), area under curve value (AUC), and calibration plots were used to evaluate the discrimination and calibration of the nomogram. The nomogram’s clinical performance was evaluated by decision curve analysis (DCA), probability density function (PDF) and clinical utility curve (CUC). Furthermore, Kaplan-Meier curves were performed in the training and the validation cohort to evaluate the survival risk of the patients with lymphatic metastasis or not. Additionally, on the basis of the constructed nomogram, we obtained a convenient and intuitive network calculator. Results A total of 41837 patients were included for analysis, including 41,018 in the training group and 819 in the validation group. Eleven risk factors were considered as predictor variables in the nomogram. The nomogram displayed excellent discrimination power, with AUC both reached 0.916 in the training group (95% confidence interval (CI) 0.913 to 0.918) and the validation group (95% CI 0.895 to 0.934). The calibration curves presented that the nomogram-based prediction had good consistency with practical application. Moreover, Kaplan-Meier curves analysis showed that RCC patients with LMs had worse survival outcomes compared with patients without LMs. Conclusions The nomogram and web calculator (https://liwenle0910.shinyapps.io/DynNomapp/) may be a useful tool to quantify the risk of LMs in patients with RCC, which may provide guidance for clinicians, such as identifying high-risk patients, performing surgery, and establishing personalized treatment as soon as possible.
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Affiliation(s)
- Wenle Li
- Clinical Medical Research Center, Xianyang Central Hospital, Xianyang, China
| | - Bing Wang
- Clinical Medical Research Center, Xianyang Central Hospital, Xianyang, China
| | - Shengtao Dong
- Department of Spine Surgery, Second Affifiliated Hospital of Dalian Medical University, Dalian, China
| | - Chan Xu
- Clinical Medical Research Center, Xianyang Central Hospital, Xianyang, China
| | - Yang Song
- Department of Gastroenterology and Hepatology, Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China
| | - Ximin Qiao
- Clinical Medical Research Center, Xianyang Central Hospital, Xianyang, China
- Department of Urology, Xianyang Central Hospital, Xianyang, China
- *Correspondence: Chengliang Yin, ; Meijin Huang, ; Xiaofeng Xu, ; Ximin Qiao,
| | - Xiaofeng Xu
- Clinical Medical Research Center, Xianyang Central Hospital, Xianyang, China
- Department of Urology, Xianyang Central Hospital, Xianyang, China
- *Correspondence: Chengliang Yin, ; Meijin Huang, ; Xiaofeng Xu, ; Ximin Qiao,
| | - Meijin Huang
- Department of Oncology, 920th Hospital of People's Liberation Army (PLA) Joint Logistics Support Force, Yunnan, China
- *Correspondence: Chengliang Yin, ; Meijin Huang, ; Xiaofeng Xu, ; Ximin Qiao,
| | - Chengliang Yin
- Faculty of Medicine, Macau University of Science and Technology, Macau, Macau SAR, China
- *Correspondence: Chengliang Yin, ; Meijin Huang, ; Xiaofeng Xu, ; Ximin Qiao,
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Genomics of Clear-cell Renal Cell Carcinoma: A Systematic Review and Meta-analysis. Eur Urol 2022; 81:349-361. [PMID: 34991918 DOI: 10.1016/j.eururo.2021.12.010] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 11/25/2021] [Accepted: 12/02/2021] [Indexed: 11/21/2022]
Abstract
CONTEXT Although antiangiogenic treatments and immunotherapies have significantly improved the prognosis of metastatic renal cell carcinoma (RCC), many patients will develop resistance, leading to treatment failure. Genetic tumor heterogeneity is a major cause of this resistance. OBJECTIVE To perform a meta-analysis of genomic data for clear-cell RCC obtained from primary tumors and metastases to assess the prevalence of gene mutations and copy number alterations (CNAs). EVIDENCE ACQUISITION Articles were selected from Medline and Embase libraries using the search algorithm ("Kidney Neoplasms"[Mesh] OR "Renal Cell Carcinoma") AND ("Genomics"[Mesh] OR "Mutation") from January 1999 to February 2021. A critical review was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement. Ninety-three publications were selected for inclusion in this meta-analysis. EVIDENCE SYNTHESIS Our meta-analysis included a total 14 696 patients, 14 299 primary tumor samples, and 969 metastatic samples. We evaluated the overall and subgroup prevalence of gene mutations and CNAs, including comparisons between primary tumors and metastases. In particular, for metastases we observed that the mutation prevalence was significantly more marked for ten genes compared to primary tumors, with no or little heterogeneity across studies. The VHL mutation prevalence increased significantly from 64% in primary tumors to 75% in metastases (p < 0.001). There was a significant increase in CNA prevalence from primary tumors to metastases for chromosomes 1p36.11, 9p21.3, and 18 in terms of losses, and for chromosomes 1q21.3, 7q36.3, 8q, and 20q11.21 in terms of gains. CDKN2A, also called p16 and involved in cell-cycle progression, is located at the 9p21.3 locus and was lost in 76% of metastatic samples. ASXL1, located on 20p11.21 and amplified in 50% of metastatic RCCs compared to 21% of primary tumors (p < 0.001), is closely linked to BAP1 function. CONCLUSIONS Our results underline the added value of preferential biopsies on RCC metastases to fully explore the biology of metastatic disease for therapeutic purposes. PATIENT SUMMARY We reviewed the literature on genetic mutations in primary tumors and metastatic lesions in kidney cancer. Our pooled results for all the relevant studies show a higher level of mutations in metastases than in primary tumors. This highlights the importance of taking biopsies of metastases to analyze genetic mutations and potentially guide selection of the most suitable treatment strategy.
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Winiarek M, Malinowska M, Saramak P, Szpakowski M, Olesiński T. Renal cell carcinoma metastasis to neuroendocrine pancreas tumor: case report and literature review. Chirurgia (Bucur) 2019. [DOI: 10.23736/s0394-9508.18.04852-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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6
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Campi R, Sessa F, Di Maida F, Greco I, Mari A, Takáčová T, Cocci A, Fantechi R, Lapini A, Serni S, Carini M, Minervini A. Templates of Lymph Node Dissection for Renal Cell Carcinoma: A Systematic Review of the Literature. Front Surg 2018; 5:76. [PMID: 30619877 PMCID: PMC6306033 DOI: 10.3389/fsurg.2018.00076] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 12/03/2018] [Indexed: 01/19/2023] Open
Abstract
Background: The role of lymph node dissection (LND) for renal cell carcinoma (RCC) is controversial. Notably, the conflicting evidence on the benefits and harms of LND is inherently linked to the lack of consensus on both anatomic templates and extent of lymphadenectomy. Herein, we provide a detailed overview of the most commonly dissected templates of LND for RCC, focusing on key anatomic landmarks and patterns of lymphatic drainage. Methods: A systematic review of the English-language literature was performed without time filters in July 2018 in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement recommendations. The primary endpoint was to summarize the most commonly dissected templates of LND according to the side of RCC. Results: Overall, 25 studies were selected for qualitative analysis. Of these, most were retrospective. The LND template was heterogeneous across studies. Indications and extent of LND were either not reported or not standardized in most series. The most commonly dissected template for right-sided tumors included hilar, paracaval, and precaval nodes, with few authors extending the dissection to the inter-aortocaval, retrocaval, common iliac or pre/paraaortic nodes. Similarly, the most commonly dissected template for left-sided tumors encompassed the renal hilar, preaortic and paraaortic nodes, with few authors reporting a systematic dissection of inter-aortocaval, retro-aortic, common iliac, or para-caval nodes. Conclusions: In light of the unpredictable renal lymphatic anatomy and the evidence from available prospective mapping studies, the extent of the most commonly dissected templates might be insufficient to catch the overall anatomic pattern of lymphatic drainage from RCC.
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Affiliation(s)
- Riccardo Campi
- Department of Urology, Careggi Hospital, University of Florence, Florence, Italy.,Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Francesco Sessa
- Department of Urology, Careggi Hospital, University of Florence, Florence, Italy
| | - Fabrizio Di Maida
- Department of Urology, Careggi Hospital, University of Florence, Florence, Italy
| | - Isabella Greco
- Department of Urology, Careggi Hospital, University of Florence, Florence, Italy
| | - Andrea Mari
- Department of Urology, Careggi Hospital, University of Florence, Florence, Italy.,Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Tána Takáčová
- Department of Internal Medicine IV, Rheumatology, Clinical Immunology, Nephrology, HELIOS Dr. Horst-Schmidt-Kliniken Wiesbaden, Wiesbaden, Germany
| | - Andrea Cocci
- Department of Urology, Careggi Hospital, University of Florence, Florence, Italy
| | - Riccardo Fantechi
- Department of Urology, Careggi Hospital, University of Florence, Florence, Italy
| | - Alberto Lapini
- Department of Urology, Careggi Hospital, University of Florence, Florence, Italy
| | - Sergio Serni
- Department of Urology, Careggi Hospital, University of Florence, Florence, Italy.,Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Marco Carini
- Department of Urology, Careggi Hospital, University of Florence, Florence, Italy.,Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Andrea Minervini
- Department of Urology, Careggi Hospital, University of Florence, Florence, Italy.,Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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Farber NJ, Rivera-Núñez Z, Kim S, Shinder B, Radadia K, Sterling J, Modi PK, Goyal S, Parikh R, Mayer TM, Weiss RE, Kim IY, Elsamra SE, Jang TL, Singer EA. Trends and outcomes of lymphadenectomy for nonmetastatic renal cell carcinoma: A propensity score-weighted analysis of the National Cancer Database. Urol Oncol 2018; 37:26-32. [PMID: 30446458 DOI: 10.1016/j.urolonc.2018.10.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 09/25/2018] [Accepted: 10/01/2018] [Indexed: 01/10/2023]
Abstract
PURPOSE Lymph node (LN) involvement in renal cell carcinoma (RCC) is associated with a poor prognosis. While lymph node dissection (LND) may provide diagnostic information, its therapeutic benefit remains controversial. Thus, the aim of our study is to analyze survival outcomes after LND for nonmetastatic RCC and to characterize contemporary practice patterns. MATERIALS AND METHODS The National Cancer Database was queried for patients with nonmetastatic RCC who underwent either partial or radical nephrectomy from 2010 to 2014. A total of 11,867 underwent surgery and LND. Chi-square tests were used to examine differences in patient demographics. To minimize selection bias, propensity score matching (PSM) was used to select one control for each LND case (n = 19,500). Cox regression analyses were conducted to examine overall survival (OS) in patients who received LND compared to those who did not. RESULTS Of all patients undergoing LND for RCC (n = 11,867), 5%, 23%, 31%, 47% were performed for tumors of clinical T stage 1, 2, 3, and 4, respectively. Proportions of LND have not significantly changed from 2010 to 2014. No significant improvement in median OS for patients undergoing LND compared to no LND was shown (34.7 vs. 34.9 months, respectively; P = 0.98). Similarly, no significant improvement in median OS was found for clinically LN positive patients undergoing LND compared to no LND (P = 0.90). On Cox regression analysis, LND dissection was not associated with an OS benefit (hazard ratio: 1.00; 95% confidence interval 0.97 to 1.04). CONCLUSIONS Among all RCC patients, LNDs are often performed for low stage disease, suggesting a potential overutilization of LND. No OS benefit was seen in any subgroup of patients undergoing LND. Further investigation is needed to determine which patient populations may benefit most from LND.
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Affiliation(s)
- Nicholas J Farber
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Zorimar Rivera-Núñez
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Sinae Kim
- Division of Biometrics, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Brian Shinder
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Kushan Radadia
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Joshua Sterling
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Parth K Modi
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Sharad Goyal
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Rahul Parikh
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Tina M Mayer
- Division of Medical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Robert E Weiss
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Isaac Y Kim
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Sammy E Elsamra
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Thomas L Jang
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Eric A Singer
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ.
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8
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Laguna MP. Re: Perioperative Morbidity of Lymph Node Dissection for Renal Cell Carcinoma: A Propensity Score-Based Analysis. J Urol 2018; 200:495-496. [PMID: 30412977 DOI: 10.1016/j.juro.2018.05.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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9
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Gershman B, Thompson RH, Boorjian SA, Larcher A, Capitanio U, Montorsi F, Carenzi C, Bertini R, Briganti A, Lohse CM, Cheville JC, Leibovich BC. Radical Nephrectomy with or without Lymph Node Dissection for High Risk Nonmetastatic Renal Cell Carcinoma: A Multi-Institutional Analysis. J Urol 2018; 199:1143-1148. [DOI: 10.1016/j.juro.2017.11.114] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Boris Gershman
- Division of Urology, Rhode Island Hospital and The Miriam Hospital, Providence, Rhode Island
| | | | | | | | - Umberto Capitanio
- Department of Urology, San Raffaele Scientific Institute, Milan, Italy
| | | | - Cristina Carenzi
- Department of Urology, San Raffaele Scientific Institute, Milan, Italy
| | - Roberto Bertini
- Department of Urology, San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Briganti
- Department of Urology, San Raffaele Scientific Institute, Milan, Italy
| | - Christine M. Lohse
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
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10
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Bhindi B, Wallis CJD, Boorjian SA, Thompson RH, Farrell A, Kim SP, Karam JA, Capitanio U, Golijanin D, Leibovich BC, Gershman B. The role of lymph node dissection in the management of renal cell carcinoma: a systematic review and meta-analysis. BJU Int 2018; 121:684-698. [PMID: 29319926 DOI: 10.1111/bju.14127] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Our objective was to evaluate the role of retroperitoneal lymph node dissection (LND) in non-metastatic (M0) and metastatic (M1) renal cell carcinoma (RCC). We searched Medline, EMBASE, Web of Science and Scopus from database inception to 29 August 2017 for studies of patients who underwent partial or radical nephrectomy for M0 or M1 RCC. Two investigators independently selected studies for inclusion. Risk of bias was assessed using the Newcastle-Ottawa scale, Cochrane Collaboration tool and National Heart, Lung and Blood Institute Quality Assessment Tool. Random effects meta-analysis was performed for all-cause-mortality. The GRADE approach was used to characterize quality of evidence. A total of 51 unique studies were included in the qualitative systematic review. Risk of bias was low in 41/51 (80%) studies. LND was not associated with all-cause mortality in either M0 (hazard ratio [HR] 1.02, 95% confidence interval [CI] 0.92-1.12; I2 = 0%; four studies), M1 (HR 1.04, 95% CI 0.83-1.29; I2 = 0%; two studies), or pooled M0 and M1 settings (HR 1.00, 95% CI 0.92-1.09; I2 = 0%; seven studies), with no statistically significant differences according to M stage subgroups (P = 0.50). In the three studies that examined M0 subgroups with a high risk of nodal metastasis, LND was not associated with improved oncological outcomes. Studies on the association of extent of LND with survival reported inconsistent results. Meanwhile, a small proportion of patients with pN1M0 disease demonstrate durable long-term oncological control after surgery, with 10-year cancer-specific survival of 21-31%. Nodal involvement is independently associated with adverse prognosis in both M0 and M1 settings. GRADE quality of evidence was moderate or low for the outcomes examined. Although LND yields independent prognostic information, the existing literature does not support a therapeutic benefit to LND in either M0 or M1 RCC. High-risk M0 patient groups warrant further study, as a subset of patients with isolated nodal metastases experience long-term survival after surgical resection.
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Affiliation(s)
- Bimal Bhindi
- Department of Urology, Mayo Clinic, Rochester, MN, USA
| | - Christopher J D Wallis
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Ann Farrell
- Mayo Clinic Libraries, Mayo Clinic, Rochester, MN, USA
| | - Simon P Kim
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Jose A Karam
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Umberto Capitanio
- Unit of Urology, San Raffaele Scientific Institute, University Vita-Salute, Milan, Italy
| | - Dragan Golijanin
- Division of Urology, Rhode Island Hospital and The Miriam Hospital, Providence, RI, USA.,Warren Alpert Medical School of Brown University, Providence, RI, USA
| | | | - Boris Gershman
- Division of Urology, Rhode Island Hospital and The Miriam Hospital, Providence, RI, USA.,Warren Alpert Medical School of Brown University, Providence, RI, USA
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11
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Gershman B, Moreira DM, Thompson RH, Boorjian SA, Lohse CM, Costello BA, Cheville JC, Leibovich BC. Perioperative Morbidity of Lymph Node Dissection for Renal Cell Carcinoma: A Propensity Score-based Analysis. Eur Urol 2017; 73:469-475. [PMID: 29132713 DOI: 10.1016/j.eururo.2017.10.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 10/23/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND There are little data regarding the morbidity of lymph node dissection (LND) for renal cell carcinoma (RCC) to assess its risk-benefit ratio. OBJECTIVE To evaluate the association of LND with 30-d complications among patients undergoing radical nephrectomy (RN) for RCC. DESIGN, SETTING, AND PARTICIPANTS A total of 2066 patients underwent RN for M0 or M1 RCC between 1990 and 2010, of whom 774 (37%) underwent LND. INTERVENTION RN with or without LND. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Associations of LND with 30-d complications were examined using logistic regression with several propensity score techniques. Extended LND, defined as removal of ≥13 lymph nodes, was examined in a sensitivity analysis. RESULTS AND LIMITATIONS A total of 184 (9%) patients were pN1 and 302 (15%) were M1. Thirty-day complications occurred in 194 (9%) patients, including Clavien grade ≥3 complications in 81 (4%) patients. Clinicopathologic features were well balanced after propensity score adjustment. In the overall cohort, LND was not statistically significantly associated with Clavien grade ≥3 complications, although there was an approximately 40% increased risk of any Clavien grade complication that did not reach statistical significance. Likewise, LND was not significantly associated with any Clavien grade or Clavien grade ≥3 complications when separately evaluated among M0 or M1 patients. Extended LND was not significantly associated with any Clavien grade or Clavien grade ≥3 complications. LND was not associated with length of stay or estimated blood loss. Limitations include a retrospective design. CONCLUSIONS LND is not significantly associated with an increased risk of Clavien grade ≥3 complications, although it may be associated with a modestly increased risk of minor complications. In the absence of increased morbidity, LND may be justified in a predominantly staging role in the management of RCC. PATIENT SUMMARY Lymph node dissection for renal cell carcinoma is not associated with increased rates of major complications.
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Affiliation(s)
- Boris Gershman
- Division of Urology, Rhode Island Hospital and The Miriam Hospital, Providence, RI, USA.
| | | | | | | | - Christine M Lohse
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
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12
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Minagawa T, Fukui D, Shingu K, Ogawa T, Okada K, Ishizuka O. Intraoperative detection of inferior vena caval tumor thrombus extending from metastatic lymph node of renal cell carcinoma using ultrasonography. J Med Ultrason (2001) 2017; 45:367-370. [PMID: 29079942 DOI: 10.1007/s10396-017-0838-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 10/02/2017] [Indexed: 11/30/2022]
Abstract
A 67-year-old man consulted our department with gross hematuria. Computed tomography (CT) revealed a huge renal tumor with a paracaval metastatic lymph node (mLN). Right total nephrectomy was planned for the renal tumor diagnosed as renal cell carcinoma preoperatively. Just before the resection of the renal vein and artery, intraoperative ultrasonography revealed an inferior vena caval tumor thrombus (IVCTT) extending from the mLN. Ultrasonography clearly and dynamically demonstrated a rhythmic flapping movement of the IVCTT with blood flow in the inferior vena cava. Following right radical nephrectomy, IVCTT resection with the vessel wall was performed to reduce the risk of pulmonary tumor thrombus. Histopathological diagnosis of the renal tumor was clear cell renal cell carcinoma, and the resected IVCTT was confirmed histopathologically as tumor involvement from the mLN of the renal cell carcinoma. Intraoperative ultrasonography can detect IVCTT extending from the mLN, whereas CT cannot.
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Affiliation(s)
- Tomonori Minagawa
- Department of Urology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, Japan.
| | - Daisuke Fukui
- Department of Cardiovascular Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Kunihiko Shingu
- Department of Laboratory Medicine, Shinshu University Hospital, Matsumoto, Japan
| | - Teruyuki Ogawa
- Department of Urology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, Japan
| | - Kenji Okada
- Department of Cardiovascular Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Osamu Ishizuka
- Department of Urology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, Japan
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Gershman B, Thompson RH, Moreira DM, Boorjian SA, Tollefson MK, Lohse CM, Costello BA, Cheville JC, Leibovich BC. Radical Nephrectomy With or Without Lymph Node Dissection for Nonmetastatic Renal Cell Carcinoma: A Propensity Score-based Analysis. Eur Urol 2017; 71:560-567. [DOI: 10.1016/j.eururo.2016.09.019] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 09/07/2016] [Indexed: 10/21/2022]
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Renal Cell Carcinoma with Isolated Lymph Node Involvement: Long-term Natural History and Predictors of Oncologic Outcomes Following Surgical Resection. Eur Urol 2017; 72:300-306. [PMID: 28094055 DOI: 10.1016/j.eururo.2016.12.027] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Accepted: 12/23/2016] [Indexed: 01/28/2023]
Abstract
BACKGROUND Renal cell carcinoma (RCC) with isolated lymph node (LN) involvement has historically been associated with poor prognosis. However, a subset of patients may experience long-term survival. OBJECTIVE To examine the natural history of RCC with isolated LN involvement following surgical resection with long-term follow-up, and to evaluate clinicopathologic features associated with disease progression and survival. DESIGN, SETTING, AND PARTICIPANTS A total of 138 patients with isolated pN1M0 RCC underwent partial or radical nephrectomy and LN dissection from 1980 to 2010. INTERVENTION Partial or radical nephrectomy with LN dissection. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Metastasis-free survival (MFS), cancer-specific survival (CSS), and overall survival (OS) were estimated using the Kaplan-Meier method. Associations between clinicopathologic features and oncologic outcomes were evaluated using Cox regression models. RESULTS AND LIMITATIONS Median follow-up among survivors was 8.5 yr. The 5-yr and 10-yr MFS, CSS, and OS rates were 16% and 15%, 26% and 21%, and 25% and 15%, respectively. The median time to development of metastases was only 4.2 mo. On multivariable analysis, symptoms at presentation (hazard ratio [HR] 2.40; p=0.03), inferior vena cava tumor thrombus (HR 1.99; p=0.003), clear cell (HR 2.21; p=0.01) and collecting duct/not otherwise specified (HR 4.28; p<0.001) histologic subtypes, pT4 stage (HR 2.64; p=0.005), and coagulative tumor necrosis (HR 2.51; p<0.001) were independently associated with development of metastases. MFS rates at 1 yr after surgery were 71%, 63%, 33%, and 7% for patients with one, two, three, and four to five adverse features, respectively. Limitations include surgical selection bias. CONCLUSIONS Although isolated pN1 disease portends a poor prognosis, a small subset of patients experience durable long-term survival after surgical resection of isolated lymphatic metastases. Adverse prognostic features may enhance patient risk stratification and facilitate multimodal management approaches. PATIENT SUMMARY Although isolated lymph node metastases portend a poor prognosis, a small subset of patients experience long-term survival following surgical resection.
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Abstract
The use of partial nephrectomy for renal cell carcinoma has continuously changed in the clinical practice. Previously it was mostly used in imperative cases, in patients with a solitary kidney or in patients with a risk of renal failure. An increased number of incidentally detected renal cell carcinomas are diagnosed due to the advances of the radiological methods. These tumours tend to be smaller and generally with a lower stage. The reported excellent results of partial nephrectomy have promoted the use of nephron-sparing surgery also in patients with a normal contralateral kidney and tumours smaller than 4-5 cm. The technical outcome is excellent with a low operative morbidity and a good oncologic control. Therefore partial nephrectomy has become a standard technique in the treatment of properly selected patients. Laparoscopy with its reduced postoperative pain and shorter rehabilitation time, has encouraged the interest in minimally invasive nephron sparing surgical techniques. Although low, the risk of local tumour recurrence and surgical complications are higher after nephron-sparing surgery compared with radical nephrectomy. Furthermore, long-term renal function remains adequate in most patients with a normally functioning contralateral kidney also after radical nephrectomy. Albeit these facts, there is convincing evidence justifying nephron-sparing surgery to be used routinely for patients with a small renal cell carcinoma and a normal functioning contralateral kidney.
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Affiliation(s)
- B Ljungberg
- Department of Surgical and Perioperative Sciences, Urology and Andrology, Umeå University, Umeå, Sweden.
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16
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Sbitti Y, Seddik H, Debbagh A, Benani F, Slimani K, Mahi M, Tarchouli M, Aitali A, Albouzidi A, Errihani H, Ichou M. Metachronous pancreatic metastases from renal cell carcinoma: is there a place of Active-Surveillance before deferred deliberately Molecular Target Agent? World J Surg Oncol 2016; 14:222. [PMID: 27553296 PMCID: PMC4995784 DOI: 10.1186/s12957-016-0939-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 07/08/2016] [Indexed: 12/15/2022] Open
Abstract
Background Metastatic renal cell cancer is a heterogeneous disease due to its diverse morphological features, the prognostic categories based on clinical criteria. Sometimes indolent course without any significant symptoms can be differentiated before the introduction of novel targeted agents. This observation led to interest in a strategy of deferring systemic therapy in the era of effective systemic therapies. Case presentation We report of a 78-year-old Moroccan man with pancreatic metastasis from renal cell carcinoma which occurred 14 years from right nephrectomy. Indolent disease based on body computed tomography imaging with 4 years follow-up was recognized. Active surveillance with deferred antiangiogenic multikinase inhibitor at disease progression was proposed. Nowadays, the patient is under oncological follow-up, he is in a good state of health, and he is disease-free for 48 months from the diagnosis of the tumor and for 20 months from the start of the treatment with Sunitinib Conclusions Active surveillance before target therapy may be a suitable approach to ensure long progression-free survival with minimal side-effects and better quality of life in asymptomatic, low-volume, metastatic disease. Further prospective studies with biomarker validation are required to define the patients most likely to benefit from this approach.
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Affiliation(s)
- Yassir Sbitti
- Department of Medical Oncology, University Military Hospital, Rabat, 10000, Morocco. .,Department Medical Oncology, Teaching University Military Hospital and Faculty of Medicine and Pharmacy of Fes, Hay Ryad, Rabat, 10000, Morocco.
| | - Hassan Seddik
- Department of Gastroenterology, University Military Hospital, Rabat, 10000, Morocco
| | - Adil Debbagh
- Department of Medical Oncology, University Military Hospital, Rabat, 10000, Morocco
| | - Fahd Benani
- Department of Medical Oncology, University Military Hospital, Rabat, 10000, Morocco
| | - Khaoula Slimani
- Department of Medical Oncology, University Military Hospital, Rabat, 10000, Morocco
| | - Mohamed Mahi
- Department of Pathology, University Military Hospital of Instruction, Rabat, 10000, Morocco
| | - Mohamed Tarchouli
- Department of Surgery, University Military Hospital of Instruction, Rabat, 10000, Morocco
| | - Abdelmounaim Aitali
- Department of Pathology, University Military Hospital of Instruction, Rabat, 10000, Morocco
| | - Abderrahmane Albouzidi
- Department of Radiology, University Military Hospital of Instruction, Rabat, 10000, Morocco
| | - Hassan Errihani
- Department of Medical Oncology, National Institute of Oncology, Rabat, 10000, Morocco
| | - Mohamed Ichou
- Department of Medical Oncology, University Military Hospital, Rabat, 10000, Morocco
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17
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Thomas AZ, Adibi M, Slack RS, Borregales LD, Merrill MM, Tamboli P, Sircar K, Jonasch E, Tannir NM, Matin SF, Wood CG, Karam JA. The Role of Metastasectomy in Patients with Renal Cell Carcinoma with Sarcomatoid Dedifferentiation: A Matched Controlled Analysis. J Urol 2016; 196:678-84. [PMID: 27036304 DOI: 10.1016/j.juro.2016.03.144] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2016] [Indexed: 01/14/2023]
Abstract
PURPOSE Management of metastatic renal cell carcinoma with sarcomatoid dedifferentiation remains a therapeutic challenge with no standard treatment strategies. We evaluated whether metastasectomy has any survival benefit in patients with metastatic sarcomatoid dedifferentiation treated with radical nephrectomy. MATERIALS AND METHODS From an institutional database of 273 patients with sarcomatoid dedifferentiation treated with nephrectomy we matched 80 with synchronous and asynchronous metastases for age, ECOG (Eastern Cooperative Oncology Group) performance status, histology and lymph node status. Matched pairs were then retained only if patients who did not undergo metastasectomy were alive at metastasectomy comparable to matched surgical patients to decrease the bias of survival outcomes. Overall survival from nephrectomy was studied using univariable and multivariable proportional hazards regression. RESULTS Median overall survival was 8.3 (95% CI 6.5-10.5) and 18.5 months (95% CI 11.5-42.9) in patients with synchronous and asynchronous metastases, respectively. Overall survival in patients who underwent metastasectomy for synchronous metastasis compared to nonsurgical patients was 8.4 and 8.0 months (p = 0.35), respectively. Similarly, overall survival in patients with asynchronous metastases treated with metastasectomy compared to the nonsurgical group was 36.2 and 13.7 months, respectively (p = 0.29). On multivariable analysis positive lymph nodes at nephrectomy were associated with an increased risk of death in the synchronous and asynchronous patient subgroups (HR 2.1, 95% CI 1.1-4.0, p = 0.03 and HR 3.3, 95% CI 1.2-9.2, p = 0.02, respectively). CONCLUSIONS In the current study there was no clear evidence of benefit in patients with sarcomatoid dedifferentiation who underwent metastasectomy after nephrectomy. Particularly, the group of patients with pathological lymph node positive disease at nephrectomy had considerably worse survival.
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Affiliation(s)
- Arun Z Thomas
- Department of Urology, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Mehrad Adibi
- Department of Urology, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Rebecca S Slack
- Department of Biostatistics, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Leonardo D Borregales
- Department of Urology, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Megan M Merrill
- Department of Urology, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Pheroze Tamboli
- Department of Pathology, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Kanishka Sircar
- Department of Pathology, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Eric Jonasch
- Department of Genitourinary Medical Oncology, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Nizar M Tannir
- Department of Genitourinary Medical Oncology, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Surena F Matin
- Department of Urology, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Christopher G Wood
- Department of Urology, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Jose A Karam
- Department of Urology, University of Texas M.D. Anderson Cancer Center, Houston, Texas.
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18
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Ismail I, Neuen BL, Mantha M. Solitary jejunal metastasis from renal cell carcinoma presenting as small bowel obstruction 19 years after nephrectomy. BMJ Case Rep 2015; 2015:bcr-2015-210857. [PMID: 26370628 DOI: 10.1136/bcr-2015-210857] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Metachronous metastatic disease may develop in up to 50% of patients with renal cell carcinoma (RCC) who have undergone a presumably curative radical nephrectomy. We describe a case of small bowel obstruction secondary to a solitary jejunal RCC metastasis affecting a 66-year-old man with a history of RCC, which was treated 19 years earlier by right radical nephrectomy. The patient underwent successful laparotomy and wide margin resection of the affected small bowel with end-to-end anastomosis. A subsequent staging CT revealed no other metastases. To our knowledge, only eight cases of isolated small bowel metastasis from RCC have been reported. Of these, only one previous report referred to a longer time interval to small bowel metastasis than our case. The case highlights that isolated bowel metastasis should be considered as a possible aetiology of small bowel obstruction, even in patients with a distant history of presumably curative cancer treatment.
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Affiliation(s)
- Ibrahim Ismail
- Department of Nephrology, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | | | - Murty Mantha
- Department of Nephrology, Cairns Hospital, Cairns, Queensland, Australia
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19
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Renal cell carcinoma metastases to the pancreas and the thyroid gland 19 years after the primary tumour. GASTROENTEROLOGY REVIEW 2015; 10:185-9. [PMID: 26516387 PMCID: PMC4607689 DOI: 10.5114/pg.2015.49000] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Revised: 09/12/2014] [Accepted: 10/28/2014] [Indexed: 11/17/2022]
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20
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Canter DJ, Cahn DB, Uzzo RG. Surgical Approaches to Early-Stage Renal Cell Carcinoma. KIDNEY CANCER 2015. [DOI: 10.1007/978-3-319-17903-2_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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21
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Altekruse SF, Dickie L, Wu XC, Hsieh MC, Wu M, Lee R, Delacroix S. Clinical and prognostic factors for renal parenchymal, pelvis, and ureter cancers in SEER registries: collaborative stage data collection system, version 2. Cancer 2014; 120 Suppl 23:3826-35. [PMID: 25412394 PMCID: PMC4612347 DOI: 10.1002/cncr.29051] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 07/07/2014] [Accepted: 07/08/2014] [Indexed: 11/08/2022]
Abstract
BACKGROUND The American Joint Committee on Cancer's (AJCC) 7th edition cancer staging manual reflects recent changes in cancer care practices. This report assesses changes from the AJCC 6th to the AJCC 7th edition stage distributions and the quality of site-specific factors (SSFs). METHODS Incidence data for renal parenchyma and pelvis and ureter cancers from 18 Surveillance, Epidemiology, and End Results (SEER) registries were examined, including staging trends during 2004-2010, stage distribution changes between the AJCC 6th and 7th editions, and SSF completeness for cases diagnosed in 2010. RESULTS From 2004 to 2010, the percentage of stage I renal parenchyma cancers increased from 50% to 58%, whereas stage IV and unknown stage cases decreased (18% to 15%, and 10% to 6%, respectively). During this period, the percentage of stage 0a renal pelvis and ureter cancers increased from 21% to 25%, and stage IV and unknown stage tumors decreased (20% to 18%, and 7% to 5%, respectively). Stage distributions under the AJCC 6th and 7th editions were about the same. For renal parenchymal cancers, 71%-90% of cases had known values for 6 required SSFs. For renal pelvis and ureter cancers, 74% of cases were coded as known for SSF1 (WHO/ISUP grade) and 47% as known for SSF2 (depth of renal parenchymal invasion). SSF values were known for larger proportions of cases with reported resections. CONCLUSIONS Stage distributions between the AJCC 6th and 7th editions were similar. SSFs were known for more than two-thirds of cases, providing more detail in the SEER database relevant to prognosis.
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Affiliation(s)
- Sean F. Altekruse
- National Cancer Institute, Division of Cancer Control and Population Sciences, Rockville, Maryland
| | - Lois Dickie
- National Cancer Institute, Division of Cancer Control and Population Sciences, Rockville, Maryland
| | - Xiao-Cheng Wu
- Louisiana State University, School of Public Health, Louisiana Tumor Registry, New Orleans, Louisiana
| | - Mei-Chin Hsieh
- Louisiana State University, School of Public Health, Louisiana Tumor Registry, New Orleans, Louisiana
| | - Manxia Wu
- Centers for Disease Control and Prevention, Division of Cancer Prevention and Control, Atlanta, Georgia
| | - Richard Lee
- Information Management Services, Calverton, Maryland
| | - Scott Delacroix
- Louisiana State University School of Medicine, Stanley S. Scott Cancer Center, New Orleans, Louisiana
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22
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Krabbe LM, Bagrodia A, Margulis V, Wood CG. Surgical management of renal cell carcinoma. Semin Intervent Radiol 2014; 31:27-32. [PMID: 24596437 DOI: 10.1055/s-0033-1363840] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Surgical resection of renal cell carcinoma (RCC) is the benchmark for long-term cure of the disease. Although open or laparoscopic radical nephrectomy is considered the gold standard for stage T1b-T4 tumors, nephron-sparing surgery is the preferred operative modality for small renal masses demonstrating equivalent oncologic efficacy and improved renal function outcomes compared with complete nephrectomy. With the advance of minimally invasive surgery, nephron-sparing procedures can safely be conducted laparoscopically with or without robotic assistance. RCC with intravenous tumor thrombus presents a surgical challenge, but multidisciplinary surgical approaches can provide long-term benefit in these patients. The role of cytoreductive nephrectomy and metastasectomy in patients with metastatic RCC (mRCC) is controversial, but seems to be beneficial for patients in the era of targeted therapy.
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Affiliation(s)
- Laura-Maria Krabbe
- Department of Urology, the University of Muenster Medical Center, Muenster, Germany ; Department of Urology, UT Southwestern Medical Center, Dallas, Texas
| | - Aditya Bagrodia
- Department of Urology, UT Southwestern Medical Center, Dallas, Texas
| | - Vitaly Margulis
- Department of Urology, UT Southwestern Medical Center, Dallas, Texas
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23
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Breda A, Konijeti R, Lam JS. Patterns of recurrence and surveillance strategies for renal cell carcinoma following surgical resection. Expert Rev Anticancer Ther 2014; 7:847-62. [PMID: 17555395 DOI: 10.1586/14737140.7.6.847] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Renal cell carcinoma (RCC) remains one of the most lethal urologic malignancies, with up to 40% of patients eventually dying of cancer progression. Despite advances in the diagnosis, staging and treatment of patients with RCC, approximately a third of patients who undergo surgery for clinically localized RCC will suffer a recurrence. Timely identification of recurrences following surgical extirpation is imperative in the treatment of these patients. RCC is known to metastasize through hematogenous routes of spread to distant organ sites and via lymphatic channels to regional lymph nodes. The path of tumor escape is associated with diverse clinical outcomes and a unique tumor biology. A consensus on surveillance regimens for patients following surgical resection of localized disease is lacking. The most extensively used system for providing prognostic information regarding survival and recurrence of disease has historically been the tumor-node-metastasis (TNM) classification system. As a result, most contemporary surveillance protocols have tailored follow-up regimens according to stage-based stratifications. Numerous studies have recently demonstrated that certain clinical and histopathological factors can improve the prediction of tumor recurrence. The incorporation of these prognostic factors into stage-based stratification models should be better than stage alone in attempting to provide a rational approach to identifying treatable recurrences while minimizing unnecessary exams and tests, as well as patient anxiety. Advances in the understanding of the pathogenesis, behavior and molecular biology of RCC have paved the way for developments that may enhance early diagnosis and prognostication, and improve survival for patients. Lastly, molecular markers should, in the future, revolutionize surveillance protocols for RCC by tailoring follow-up to specific molecular classifications.
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Affiliation(s)
- Alberto Breda
- David Geffen School of Medicine, University of California--Los Angeles, Department of Urology, Los Angeles, CA 90095-1738, USA.
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24
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Rassweiler J, Rassweiler MC, Kenngott H, Frede T, Michel MS, Alken P, Clayman R. The past, present and future of minimally invasive therapy in urology: A review and speculative outlook. MINIM INVASIV THER 2013; 22:200-9. [DOI: 10.3109/13645706.2013.816323] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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25
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Nunes TF, Szejnfeld D, Miiji LNO, Goldman SM. Isolated metachronous splenic metastasis from renal cell carcinoma after 5 years. BMJ Case Rep 2012; 2012:bcr-2012-006992. [PMID: 23242082 DOI: 10.1136/bcr-2012-006992] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Primary and metastatic tumours of the spleen are uncommon. The incidence of isolated metastasis from other organs is less than 1%. We report the case of a 55-year-old woman with clear cell carcinoma of the kidney, who underwent radical nephrectomy. After a 5-year follow-up period, a hypervascular nodule was detected in the spleen on MRI. Six months later, control MRI showed that its appearance had changed to a hypervascular mass with areas of central necrosis. A splenectomy was performed and histopathological examination of the spleen confirmed the presence of clear cell carcinoma with infiltration of the capsule. This is only the seventh case described in the literature of isolated splenic metastasis from clear cell carcinoma and the first such case containing MRI.
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Affiliation(s)
- Thiago Franchi Nunes
- Department of Clinical Radiology, Universidade Federal de São Paulo, São Paulo, Brazil.
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26
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Abstract
In 1999 it was estimated that renal cell carcinoma (RCC) would account for 29,990 new cancer cases diagnosed in the United States (61% in men and 39% in women), and lead to 11,600 deaths. RCC accounts for 2-3% of all malignancies in adults and causes 2.3% of all cancer deaths in the United States annually (1). Approx 4% of all RCC cases are bilateral at some point in the life of the patient. Data from over 10,000 cases of renal cancer entered in the Connecticut Tumor Registry suggests an increase in the incidence of renal cancer from 1935-1989; in women the incidence increased from 0.7 to 4.2 in 100,000, and in men from 1.6 to 9.6 in 100,000 (2). Factors implicated in the development of RCC include cigarette smoking, exposure to petroleum products, obesity, diuretic use, cadmium exposure, and ionizing radiation (3-9).
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27
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Kates M, Lavery HJ, Brajtbord J, Samadi D, Palese MA. Decreasing rates of lymph node dissection during radical nephrectomy for renal cell carcinoma. Ann Surg Oncol 2012; 19:2693-9. [PMID: 22526899 DOI: 10.1245/s10434-012-2330-6] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2011] [Indexed: 11/18/2022]
Abstract
BACKGROUND The utility of lymph node dissection (LND) during radical nephrectomy for renal cell carcinoma (RCC) continues to be controversial, yet its use by urologists in the United States is unknown. We analyzed the incidence of and trends in LND from a large, nationally representative cancer registry. METHODS Using the Surveillance, Epidemiology, and End Results registry we identified 37,279 patients with RCC who underwent radical nephrectomy from 1988 to 2005. LND was defined as a surgeon removing ≥5 nodes; however, sensitivity tests were performed using cutoffs of ≥3 and ≥1 nodes. We analyzed changes in LND rates over time and used multivariable logistic regression to predict those who underwent LND. RESULTS Of the 37,279 patients with RCC, 2,463 (6.6 %) received a LND. There was a gradual decline in LND beginning in 1988 that accelerated after 1997, with the period of 1998-2005 having significantly decreased odds of LND compared with the period 1988-1997 (odds ratio [OR]: 0.65; 95 % confidence interval [95 % CI]: 0.59-0.71). This decline was driven primarily by a 63 % reduction in LND rates among localized tumors (p < .001). CONCLUSIONS There has been a significant decline in LND rates during radical nephrectomy for localized kidney cancer over the past 7 years. In contrast to prior estimates, very few urologists in the United States are removing ≥5 nodes during lymph node dissection for RCC.
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Affiliation(s)
- Max Kates
- Department of Urology, Mount Sinai Medical Center, New York, NY, USA
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28
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Canter D, Teper E, Smaldone M, Kutikov A, Uzzo RG. Surgical Approaches to Early Stage Kidney Cancer. KIDNEY CANCER 2012. [DOI: 10.1007/978-3-642-21858-3_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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29
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Delacroix SE, Chapin BF, Wood CG. The role of lymph node dissection in renal cell carcinoma. Urol Clin North Am 2011; 38:419-28, vi. [PMID: 22045173 DOI: 10.1016/j.ucl.2011.07.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The role of lymph node dissection (LND) in the staging and treatment of renal cell carcinoma has long been a topic of debate. The controversy has focused on whether LND is purely an adjunctive staging procedure or has a therapeutic role in the management of this disease. Potential benefits include enhanced staging, better selection for adjuvant therapies/clinical trials, a decrease in recurrence rates, and improved disease-specific and overall survival. This article reviews the available literature on LND in renal cell carcinoma and discusses the potential benefits of aggressive surgical resection in select high-risk patients.
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Affiliation(s)
- Scott E Delacroix
- Department of Urology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1373, Houston, TX 77030, USA
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30
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Trinh QD, Schmitges J, Bianchi M, Sun M, Shariat SF, Sammon J, Jeldres C, Zorn K, Sukumar S, Perrotte P, Graefen M, Rogers CG, Peabody JO, Menon M, Karakiewicz PI. Node-positive renal cell carcinoma in the absence of distant metastases: predictors of cancer-specific mortality in a population-based cohort. BJU Int 2011; 110:E21-7. [PMID: 22044638 DOI: 10.1111/j.1464-410x.2011.10701.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
UNLABELLED Nodal metastases, even in the absence of distant metastases, portend a bad prognosis. The percentage of positive nodes (PPN) represents an important predictor of cancer-specific mortality (CSM) in patients in the group T(any) N(1) M(0) . In consequence, universal inclusion of PPN should be considered in prospective and retrospective CSM analyses. OBJECTIVES To examine the outcomes of patients with node-positive renal cell carcinoma (RCC) in the absence of distant metastases in a large population-based cohort of patients To examine the ability of standard risk factors to predict cancer-specific mortality (CSM). PATIENTS AND METHODS Using the Surveillance, Epidemiology, and End Results database, a total of 799 patients with RCC nodal metastases and absence of distant metastases undergoing nephrectomy were identified. Univariable and multivariable analyses was performed with the aim of identifying independent predictors of CSM in this cohort of patients. Specifically, we examined the effect of the number of removed nodes (NRN), the number of positive nodes (NPN) and the percentage of positive nodes (PPN) on CSM. RESULTS Actuarial survival estimates showed that 53.2, 37.8 and 25.7% of patients survived at 24, 60 and 120 months after nephrectomy. In Kaplan-Meier analyses, NRN failed to clearly discriminate between recorded CSM rates (log rank P = 0.07). Discrimination was noted when CSM was stratified according to NPN (log rank P = 0.02) and PPN (log rank P = 0.001). In multivariable analyses, age, Fuhrman grade, histological subtype, T stage and PPN were independent predictors of CSM. CONCLUSIONS Our data indicate that CSM of patients with exclusive nodal metastases differs according to PPN. Consequently, PPN warrants consideration in future prognostic schemes.
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Affiliation(s)
- Quoc-Dien Trinh
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, QC, Canada.
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Abstract
CONTEXT Although lymphadenectomy (lymph node dissection [LND]) is currently accepted as the most accurate and reliable staging procedure for the detection of lymph node invasion (LNI), its therapeutic benefit in renal cell carcinoma (RCC) still remains controversial. OBJECTIVE Review the available literature concerning the role of LND in RCC staging and outcome. EVIDENCE ACQUISITION A Medline search was conducted to identify original articles, review articles, and editorials addressing the role of LND in RCC. Keywords included kidney neoplasms, renal cell cancer, renal cell carcinoma, kidney cancer, lymphadenectomy, lymph node excision, lymphatic metastases, nephrectomy, imaging, and complications. The articles with the highest level of evidence were identified with the consensus of all of the collaborative authors and were critically reviewed. This review is the result of an interactive peer-reviewing process by an expert panel of co-authors. EVIDENCE SYNTHESIS Renal lymphatic drainage is unpredictable. The newer available imaging techniques are still immature in detecting small lymph node metastases. Results from the European Organization for Research and Treatment of Cancer trial 30881 showed no benefit in performing LND during surgery for clinically node-negative RCC, but the results are limited to patients with the lowest risk of developing LNI. Numerous retrospective series support the hypothesis that LND may be beneficial in high-risk patients (clinical T3-T4, high Fuhrman grade, presence of sarcomatoid features, or coagulative tumor necrosis). If enlarged nodes are evident at imaging or palpable during surgery, LND seems justified at any stage. However, the extent of the LND remains a matter of controversy. CONCLUSIONS To date, the available evidence suggests that an extended LND may be beneficial when technically feasible in patients with locally advanced disease (T3-T4) and/or unfavorable clinical and pathologic characteristics (high Fuhrman grade, larger tumors, presence of sarcomatoid features, and/or coagulative tumor necrosis). Although node-positive patients often harbor distant metastases as well, the majority of retrospective nonrandomized trials seem to suggest a possible benefit of regional LND even for this group of patients. In patients with T1-T2, clinically negative lymph nodes and absence of unfavorable clinical and pathologic characteristics, regional LND offers limited staging information and no benefit in terms of decreasing disease recurrence or improving survival.
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Abstract
Renal cell carcinoma represents the fifth most frequent malignant tumor in humans. At the time of diagnosis, 20% of the patients already manifest metastases. A further 20-30% of the patients develop systemic metastases in the postoperative course. Despite continued advances in pharmacological treatment options, cancer surgery tailored to the individual tumor findings constitutes the only curative treatment option.
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Affiliation(s)
- A Heidenreich
- Klinik und Poliklinik für Urologie, Universitätsklinikum Aachen, Pauwelsstrasse 30, Aachen, Germany.
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Abaza R, Lowe G. Feasibility and Adequacy of Robot-Assisted Lymphadenectomy for Renal-Cell Carcinoma. J Endourol 2011; 25:1155-9. [DOI: 10.1089/end.2010.0742] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Ronney Abaza
- Robotic Urologic Surgery, Department of Urology, Ohio State University Medical Center & James Cancer Hospital, Columbus, Ohio
| | - Gregory Lowe
- Robotic Urologic Surgery, Department of Urology, Ohio State University Medical Center & James Cancer Hospital, Columbus, Ohio
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The current role of lymph node dissection in the management of renal cell carcinoma. Int J Surg Oncol 2011; 2011:816926. [PMID: 22312526 PMCID: PMC3263665 DOI: 10.1155/2011/816926] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Accepted: 04/03/2011] [Indexed: 12/13/2022] Open
Abstract
The role of lymph node dissection remains controversial in the surgical management of renal cell carcinoma. Incidental renal masses are being diagnosed at increasing rates due to the routine use of CT scans. Despite the increase in incidental diagnosis of renal masses, 20% to 30% of patients present with metastatic disease. Currently, surgeons do not routinely perform lymph node dissection unless there is gross evidence of lymphadenopathy, as patients without clinical evidence of lymphadenopathy rarely have positive nodes at the time of surgery. Patients with metastatic disease to the regional lymph nodes have a poor overall prognosis. However, some evidence supports a therapeutic benefit of lymphadenectomy in these patients. Further, the staging information gained from diagnosing lymph node involvement may allow for the use of new agents to treat metastatic disease and effect outcomes.
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35
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Pulmonary metastasectomy in patients with renal cell carcinoma: a single-institution experience. Int J Clin Oncol 2011; 16:660-5. [DOI: 10.1007/s10147-011-0244-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2010] [Accepted: 04/14/2011] [Indexed: 12/31/2022]
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Whitson JM, Harris CR, Reese AC, Meng MV. Lymphadenectomy improves survival of patients with renal cell carcinoma and nodal metastases. J Urol 2011; 185:1615-20. [PMID: 21419453 DOI: 10.1016/j.juro.2010.12.053] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2010] [Indexed: 12/01/2022]
Abstract
PURPOSE In a population based cohort we determined whether an increase in the number of lymph nodes removed is associated with improved disease specific survival of patients with renal cell carcinoma treated with nephrectomy. MATERIALS AND METHODS Patients in the Surveillance, Epidemiology and End Results database with renal cell carcinoma and no evidence of distant metastases were identified. Those patients included in the study underwent radical or partial nephrectomy with lymphadenectomy. Cox regression analyses were performed to identify factors associated with disease specific survival including an interaction between lymph node status and the number of lymph nodes removed. RESULTS Between 1988 and 2006, 9,586 patients with renal cell carcinoma met the study inclusion criteria. Median followup was 3.5 years (range 1.4 to 6.8). Of the patients 2,382 (25%) died of renal cell carcinoma, including 1,646 (20%) with lymph node negative disease and 736 (58%) with lymph node positive disease. There was no effect on disease specific survival with increasing the extent of lymphadenectomy in patients with negative lymph nodes (HR 1.0, 95% CI 0.9-1.1, p = 0.93). However, patients with positive lymph nodes had increased disease specific survival with extent of lymphadenectomy (HR 0.8 per 10 lymph nodes removed, 95% CI 0.7-1.0, p = 0.04). An increase of 10 lymph nodes in a patient with 1 positive lymph node was associated with a 10% absolute increase in disease specific survival at 5 years (p = 0.004). CONCLUSIONS This study shows an association between increased lymph node yield and improved disease specific survival of patients with lymph node positive nonmetastatic renal cell carcinoma who underwent lymphadenectomy. Patients at high risk for nodal disease should be considered for regional or extended lymphadenectomy. Clinical variables to predict risk and validation of dissection templates are important areas for future research.
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Affiliation(s)
- Jared M Whitson
- Department of Urology, University of California San Francisco, San Francisco, California 94143, USA.
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37
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Crispen PL, Breau RH, Allmer C, Lohse CM, Cheville JC, Leibovich BC, Blute ML. Lymph node dissection at the time of radical nephrectomy for high-risk clear cell renal cell carcinoma: indications and recommendations for surgical templates. Eur Urol 2010; 59:18-23. [PMID: 20933322 DOI: 10.1016/j.eururo.2010.08.042] [Citation(s) in RCA: 137] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2010] [Accepted: 08/26/2010] [Indexed: 11/28/2022]
Abstract
BACKGROUND Observational studies suggest a proportion of patients with lymph node metastases will benefit from lymph node dissection (LND) at the time of nephrectomy for clear cell renal cell carcinoma (RCC). OBJECTIVE Our aim was to report the performance of five previously identified high-risk pathologic features assessed by intraoperative examination on prediction of lymph node metastases and propose a template for LND based on locations of lymph node involvement. DESIGN, SETTING, AND PARTICIPANTS The study included a historical cohort of consecutive patients from a single institution who received LND in conjunction with nephrectomy for high-risk clear cell RCC between 2002 and 2006. INTERVENTIONS All patients underwent nephrectomy and LND. MEASUREMENTS Patients were considered high risk for nodal metastasis if two or more of the following features were identified during intraoperative pathologic assessment of the primary tumor: nuclear grade 3 or 4, sarcomatoid component, tumor size ≥10 cm, tumor stage pT3 or pT4, or coagulative tumor necrosis. Based on these features, LND was performed at the time of nephrectomy, and the numbers and sites of regional lymph node metastasis were recorded for each patient. RESULTS AND LIMITATIONS Of the 169 high-risk patients, 64 (38%) had lymph node metastases. All patients with nodal metastases had nodal involvement within the primary lymphatic sites of each kidney prior to involvement of the nodes overlying the contralateral great vessel. A limitation of the study is the lack of a standardized LND performed throughout the study period. CONCLUSIONS Pathologic features of renal tumors are associated with the risk of regional lymph node metastases and lymph node metastases that appear to progress though the primary lymphatic drainage of each kidney. Based on these findings we recommend that when performing LND the lymph nodes from the ipsilateral great vessel and the interaortocaval region be removed from the crus of the diaphragm to the common iliac artery.
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Affiliation(s)
- Paul L Crispen
- Department of Urology, Mayo Clinic, Rochester, MN 55905, USA
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38
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Paparel P, Long JA, Baumert H, Meyer V, Escudier B, Grenier N, Hetet JF, Rioux-Leclercq N, Lang H, Poissonier L, Soulie M, Patard JJ. [Current role of lymph node dissection in renal cell carcinoma: review of the literature by the Oncology Committee of the French Association of Urology (CCAFU)]. Prog Urol 2010; 22:313-7. [PMID: 22541899 DOI: 10.1016/j.purol.2012.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Revised: 01/15/2012] [Accepted: 01/18/2012] [Indexed: 11/20/2022]
Abstract
Nowadays, most of renal cancers are incidental tumors less than 4 cm. Prevalence of lymph node involvement is low and does not require a systematic lymphadenectomy as described by Robson in the 1960s. Radiologic progress and particularly CT scan describe with high precision lymph node involvement in the initial work-up. In renal cancer with a high risk of recurrence, lymphadenectomy has a pronostic interest and therapeutic role in rare situations where lymph node involvement is isolated. In metastatic patients, the role of cytoreductive nephrectomy has to be assessed.
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Affiliation(s)
- P Paparel
- Service de chirurgie urologique, centre hospitalier Lyon Sud, 165, chemin du Grand-Revoyet, 69495 Pierre-Bénite cedex, France.
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39
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Russo P. Multi-modal treatment for metastatic renal cancer: the role of surgery. World J Urol 2010; 28:295-301. [PMID: 20364382 DOI: 10.1007/s00345-010-0530-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2010] [Accepted: 03/03/2010] [Indexed: 12/22/2022] Open
Abstract
Surgical intervention in the patients with metastatic renal cancer can occur in two settings: (1) to render a patient clinically free of all sites of primary disease and metastases, termed nephrectomy/metastasectomy, or (2) to resect the primary tumor in the face of unresectable metastatic disease prior to the initiation of systemic therapy, termed cytoreductive nephrectomy. Carefully selected patients with good performance status undergoing nephrectomy and subsequent metastasectomy may experience prolonged survival in the range of 30 months, which could be attributed to a combination of patient selection factors and the surgical resections. Randomized clinical trials from the United States and Europe have demonstrated a small but significant survival benefit to cytoreductive nephrectomy and cytokine therapy versus cytokine therapy alone which is measured in the range of 3-6 months and associated with overall survival of approximately 12 months. The precise mechanism by which cytoreductive nephrectomy improves survival is not known but may relate to reduction in the large primary immunosuppressive burden. Patient selection factors including performance status and serum factors (Hgb, corrected Ca++, LDH) stratify metastatic patients into risk groups, which are strongly associated with survival time in both medically and surgically treated patients with metastatic renal cancer. The development of multi-kinase and mTOR inhibitors has markedly improved survival in treatment naïve and previously treated patients with metastatic renal cancer , and these agents are currently under active clinical investigation in the neo-adjuvant and adjuvant setting.
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Affiliation(s)
- Paul Russo
- Department of Surgery, Urology Service, Weill Cornell College of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10021, USA.
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40
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Jakobsen EB, Eickhoff JH, Andersen JP, Ottesen M. Prognosis After Nephrectomy for Renal Cell Carcinoma. ACTA ACUST UNITED AC 2010. [DOI: 10.3109/00365599409181271] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
| | | | | | - Marianne Ottesen
- Department of Urology H, Copenhagen County Hospital, Herlev, Denmark
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41
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Abstract
PURPOSE OF REVIEW To critically appraise the current literature on the benefits of lymphadenectomy in patients with renal cell carcinoma. Many questions exist including: What is a 'standard' versus 'extended' lymph node dissection (LND)? What is the morbidity of a LND? What type of patient may derive the most benefit from LND? On the basis of preoperative staging, what is the benefit (therapeutic versus staging) for an individual patient? How does the performance of a LND impact current and future adjuvant and neoadjuvant studies? RECENT FINDINGS Results from the EORTC 30881 trial did not show a therapeutic benefit to performing a 'standard' LND in patients with renal cell carcinoma, but the population predominantly comprised patients at the lowest risk of harboring lymph node metastasis. There are no prospective randomized trials with sufficient statistical power to analyze the therapeutic or staging effects in high-risk patients. SUMMARY This review provides a synopsis of the available data regarding the therapeutic and staging benefits of lympadenectomy in the setting of renal cell carcinoma and should assist the urologist in educating affected patients as well as providing the urologist with the current evidenced-based data regarding this longstanding unanswered question.
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42
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González ER, Lorenzo LMP. [Current role of lymphadenectomy and adrenalectomy in radical surgery for renal cancer]. Actas Urol Esp 2009; 33:562-8. [PMID: 19658310 DOI: 10.1016/s0210-4806(09)74190-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Radical nephrectomy is the only curative treatment for renal cell cancer. Standard treatment includes ipsilateral adrenalectomy and lymph node dissection. In recent years, development of nephron-sparing surgery and early detection of small renal tumors has led to question this approach. The role of lymphadenectomy and adrenalectomy in surgical treatment of renal cancer is reviewed.
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43
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Zubac DP, Bostad L, Gestblom C, Kihl B, Seidal T, Wentzel-Larsen T, Bakke AM. Renal cell carcinoma: A clinicopathological follow-up study after radical nephrectomy. ACTA ACUST UNITED AC 2009; 41:191-7. [PMID: 17469026 DOI: 10.1080/00365590601016552] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To examine the prognostic significance of performance status, tumour stage, histological subtype, nuclear grade and histological tumour necrosis (HTN) in a population of consecutive patients subjected to radical nephrectomy for renal cell carcinoma (RCC). MATERIAL AND METHODS The cohort consisted of 110 males and 86 females with a mean age of 66 years (range 39-88 years). The Eastern Cooperative Oncology Group performance status (ECOG PS) was determined in all cases. The tumours were staged according to the 2002 TNM classification of the American Joint Committee on Cancer. Histological subtype was diagnosed using the Heidelberg classification. Nuclear grading was performed by means of Fuhrman's method. The median follow-up period was 65 months (mean 83 months; range 1-232 months). RESULTS Median overall survival (OS) was 65 months and median cancer-specific survival (CSS) was 171 months. CSS was correlated with TNM classification, with the longest survival occurring for stage I and II tumours, shorter survival for stage III tumours and shortest survival for stage IV tumours (p<0.001). A significant difference in CSS was found between T1N0M0 and T2N0M0 tumours (p<0.01). A 15-year CSS of 100% was revealed in patients with tumours </=4 cm in size. There was a significant difference in CSS between low nuclear grade (NG; 1+2) and high NG (3+4) tumours (p<0.001). HTN and ECOG PS were found to be independent prognostic factors (p<0.01). CONCLUSION ECOG PS, TNM stage, nuclear grade and tumour necrosis were found to be independent prognostic factors for survival.
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Affiliation(s)
- Dragomir P Zubac
- Section of Urology, Department of Surgery, The Gade Institute, Haukeland University Hospital, Bergen, Norway.
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44
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Abstract
Despite the considerable progress made in our understanding of the pathogenesis, genetics, and pathology of renal cell carcinoma (RCC), difficulties remain relating to the prediction of clinical outcome for individual cases. Although there is evidence to show that high-grade tumors have a poorer prognosis when compared to those of low grade, debate remains regarding the predictive value of grading, especially for those tumors classified into the intermediate grades. Numerous composite morphologic and nuclear grading systems have been proposed for RCC and although that of the Fuhrman classification have achieved widespread usage, the validity of the grading criteria of this classification has been questioned. In addition, there are few studies that have attempted to validate the Fuhrman system for RCCs beyond that of the clear cell subtype. Recent studies have indicated that grading of papillary RCC should be based on nucleolar prominence alone and that the components of the Fuhrman grading classification do not provide prognostic information for chromophobe RCC. Independent of tumor grade, the prognostic importance of tumor stage for RCC is well recognized. The Union Internationale Contre le Cancer/American Joint Committee for Cancer Staging and End Results Reporting TNM staging system is now in its sixth edition (2002) and recent refinements have focused on defining size cut points that will identify apparently localized tumors that will develop recurrence and/or metastases despite attempted curative surgery. In parallel with these studies it has been shown that infiltration of the renal sinus is an important prognostic factor, being observed in almost all tumors >7 cm in diameter. Questions remain as to the appropriate stratification of regional extension of RCC, as defined in the T3 tumor-staging category. Recent modifications to this category have been suggested combining the level of infiltration of the venous outflow tract with the presence or absence of infiltration of the adrenal gland and/or perirenal fat. Similarly, the utility of classifying lymph node involvement by tumor is debated, although it is well recognized that lymph node infiltration is associated with a poor prognosis. Although the current TNM classification does provide useful prognostic information it would appear that further modifications are justified to enhance the predictive value of staging for RCC.
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45
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The prognostic relevance of interactions between venous invasion, lymph node involvement and distant metastases in renal cell carcinoma after radical nephrectomy. BMC Urol 2008; 8:19. [PMID: 19099564 PMCID: PMC2635370 DOI: 10.1186/1471-2490-8-19] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2008] [Accepted: 12/19/2008] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To investigate a possible prognostic significance of interactions between lymph node invasion (LNI), synchronous distant metastases (SDM), and venous invasion (VI) adjusted for mode of detection, Eastern Cooperative Oncology Group performance status (ECOG PS), erythrocyte sedimentation rate (ESR) and tumour size (TS) in 196 patients with renal cell carcinoma treated with radical nephrectomy. METHODS Median follow-up was 5.5 years (mean 6.9 years; range 0.01-19.4). The mode of detection, ECOG PS, ESR and TS were obtained from the patients' records. Vena cava invasion and distant metastases were detected by preoperative imaging. The surgical specimens were examined for pathological stage, LNI and VI. RESULTS The univariate analyses showed significant impact of VI, LNI, SDM, ESR and TS (p < 0.001), as well as mode of detection (p = 0.003) and ECOG PS (p = 0.002) on cancer specific survival. In multivariate analyses LNI was significantly associated with survival only in patients without SDM or VI (p < 0.001) with a hazard ratio of 9.0. LNI lost its prognostic significance when SDM or VI was present. CONCLUSION Our findings underline the prognostic importance of the status of the lymph nodes. LNI, SDM, ESR, and VI were independently associated with cancer specific survival after radical nephrectomy. LNI provided the strongest prognostic information for patients without SDM or VI whereas SDM and VI had strongest impact on survival when there was no nodal involvement.
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46
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Matuschek I, Merseburger AS, Kuczyk MA. [Value of lymph node dissection for renal cell carcinoma]. Urologe A 2008; 48:46-50. [PMID: 19066837 DOI: 10.1007/s00120-008-1759-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
There are as yet no common standards regarding lymph node dissection during tumor nephrectomy. In order to assess prognoses and survival rates and ensure early detection of kidney tumors, a pathohistological staging following lymphadenopathy and new adjuvant therapies in metastatic disease have to be established in the future. The aims of lymph node dissection are - as far as the morbidity and performance status of the patient are concerned - accurate staging and a decrease in risk of tumor recurrence, particularly in organ-confined cancer disease.
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Affiliation(s)
- I Matuschek
- Klinik für Urologie und Urologische Onkologie, Medizinische Hochschule, Carl-Neuberg-Strasse 1, 30625 Hannover
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47
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Russo P, O'Brien MF. Surgical Intervention in Patients with Metastatic Renal Cancer: Metastasectomy and Cytoreductive Nephrectomy. Urol Clin North Am 2008; 35:679-86; viii. [PMID: 18992621 DOI: 10.1016/j.ucl.2008.07.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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48
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Goel MC, Mohammadi Y, Sethi AS, Brown JA, Sundaram CP. Pathologic Upstaging after Laparoscopic Radical Nephrectomy. J Endourol 2008; 22:2257-61. [DOI: 10.1089/end.2008.0399] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Mahesh C. Goel
- Department of Urology, Indiana University School of Medicine Indianapolis, Indiana
| | - Yousef Mohammadi
- Department of Urology, Indiana University School of Medicine Indianapolis, Indiana
| | - Amanjot S. Sethi
- Department of Urology, Indiana University School of Medicine Indianapolis, Indiana
| | - James A. Brown
- Division of Urology, Medical College of Georgia, Augusta, Georgia
| | - Chandru P. Sundaram
- Department of Urology, Indiana University School of Medicine Indianapolis, Indiana
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49
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Radical nephrectomy with and without lymph-node dissection: final results of European Organization for Research and Treatment of Cancer (EORTC) randomized phase 3 trial 30881. Eur Urol 2008; 55:28-34. [PMID: 18848382 DOI: 10.1016/j.eururo.2008.09.052] [Citation(s) in RCA: 277] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2008] [Accepted: 09/23/2008] [Indexed: 12/14/2022]
Abstract
BACKGROUND Until now the therapeutic value of lymphadenectomy for renal-cell carcinoma has remained controversial. Several studies attempting to solve this controversy have been published, but none of them were set up as prospective randomized trials. OBJECTIVE To assess whether a complete lymph-node dissection in conjunction with a radical nephrectomy for renal-cell cancer is more effective than a radical nephrectomy alone. DESIGN, SETTING, AND PARTICIPANTS In 1988, the European Organization for Research and Treatment of Cancer (EORTC) Genitourinary Group started a randomized phase 3 trial comparing radical nephrectomy with a complete lymphadenectomy to radical nephrectomy alone. After the renal-cell carcinoma was judged to be N0M0 and resectable, patients were randomly selected prior to surgery to undergo either a radical nephrectomy with a complete lymph-node dissection or to undergo a radical nephrectomy alone. Postoperatively all patients were followed for progression of disease and mortality. INTERVENTION All patients underwent a radical nephrectomy with or without a complete lymph-node dissection. MEASUREMENTS All patients were postoperatively evaluated for time-to-progression, overall survival, and progression-free survival. Time-to-event curves were estimated based on the Kaplan-Meier method and compared using a two-sided log-rank test. RESULTS AND LIMITATIONS Of the 772 patients selected for randomization, 40 were not eligible for the study. 383 patients were randomly selected to receive a complete lymph-node dissection together with a radical nephrectomy, and 389 patients were randomly selected to undergo a radical nephrectomy alone. The complication rate did not differ significantly between the two groups. Complete lymph-node dissections in 346 patients revealed an absence of lymph-node metastases in 332 patients. The study revealed no significant differences in overall survival, time to progression of disease, or progression-free survival between the two study groups. CONCLUSIONS This study shows that, after proper preoperative staging, the incidence of unsuspected lymph-node metastases is low (4.0%) and that, notwithstanding a possible relationship to this low incidence rate, no survival advantage of a complete lymph-node dissection in conjunction with a radical nephrectomy could be demonstrated.
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50
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Interferon-alpha in combination with either imatinib (Gleevec) or gefitinib (Iressa) in metastatic renal cell carcinoma: a phase II trial. Anticancer Drugs 2008; 19:527-33. [PMID: 18418219 DOI: 10.1097/cad.0b013e3282fa4ad2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Treatments for metastatic renal cell carcinoma (MRCC) are limited. RCCs frequently overexpress epithelial growth factor receptor and express c-Kit and platelet-derived growth factor receptor-beta. Combination of interferon with tyrosine kinase inhibitors of epithelial growth factor receptor [gefitinib (Iressa)] or c-Kit and platelet-derived growth factor receptor-beta [imatinib (Gleevec)] was evaluated for efficacy and safety. Patients with MRCC received 12-week cycles of interferon [3 million units (MU) subcutaneously thrice in week 1 and 6 MU thrice weekly thereafter] and either gefitinib (500 mg daily) or imatinib (600 mg daily). The gefitinib/imatinib dose was reduced as needed owing to toxicity. The primary endpoint was objective tumor response. Secondary endpoints were time to tumor progression, overall survival, and safety. Seventeen patients were enrolled. Most had clear cell [36% (6/17)] or papillary [36% (6/17)] tumors. Most (n=14) were treated on the gefitinib arm, including two patients who crossed over from the imatinib arm after experiencing disease progression. Objective tumor responses were evaluable in 14 patients (82%). Of these 14, partial responses occurred in three (21%), stable disease in seven (50%), and progressive disease in four (29%). The most frequent treatment-related adverse events were skin rash, flu-like symptoms, and fatigue (both treatment arms); diarrhea (gefitinib arm only); and thrombocytopenia and leukopenia (imatinib arm only). Median time to tumor progression (range) for patients on the gefitinib arm only was 4.27 (1.13-15.97) months and median overall survival (range) was 11.42+ (1.13-29.07+) months. Combination of gefitinib with interferon safely delays progression of refractory MRCC. Further studies in this setting are warranted.
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