The results of radical nephrectomy for renal cell carcinoma

A prognostic study of urothelial renal pelvic tumors: comparison between the prognosis of patients treated with intrafascial nephrectomy and perifascial nephroureterectomy

A comparison of the prognosis between 2 series of patients with urothelial renal pelvic tumors is presented. One series comprising 70 patients was operated with intrafascial nephrectomy with extirpation of varying length of the ureter. The other series comprising 38 patients was operated with transabdominal perifascial nephrectomy with homolateral adrenalectomy, total ureterectomy and in 28 patients retroperitoneal lymphadenectomy. The 5-year survival was 51% in the patients operated with intrafascial nephrectomy and 84% in the patients operated with perifascial nephrectomy. The difference in prognosis is statistically significant (p less than or equal to 0.01) and cannot be explained by differences in extent of tumor infiltration, tumor grade or tumor size. The main difference in prognosis between the two series was in patients with high stage tumors (Grabstald stage 3 and 4). The 5-year survival was 74% in patients with stage 3 and 4 tumors in the patients operated with perifascial nephrectomy compared with 37% in the patients operated with intrafascial nephrectomy. Since it is not possible with absolute certainty to determine tumor stage before the operation, an aggressive attitude against urothelial renal pelvic tumors is recommended. Thus the patients should undergo transabdominal perifascial nephroureterectomy including a cuff of the bladder wall and homolateral adrenalectomy. In patient with bilateral tumors, renal insufficiency of tumor in a single kidney parenchyma saving partial resection must be performed.

Calcified renal cell carcinoma: a clinical, radiographic and pathologic study

A retrospective review from 1954 to 1977 revealed 17 patients with radiographically calcified renal cell carcinoma. Any calcified renal lesion, regardless of the characteristics of the calcification, must be regarded as suspicious for a malignant neoplasm. Calcified renal cell carcinoma appears to be a biologically distinct subgroup of renal parenchymal tumors. The angiographic diagnosis of these tumors often was difficult since most were either hypovascular or avascular. Most calcified renal parenchymal tumors were relatively large but tended to be localized and histologically well differentiated. These tumors were associated with a predicted 5-year survival rate of 77 per cent.

Surgery for renal cell carcinoma extending into the inferior vena cava

We have reviewed 26 patients with renal cell carcinoma extending into the inferior vena cava, 21 of whom underwent radical nephrectomy with either venacavotomy and tumor thrombectomy, or vena cava resection. Of 12 patients who presented with localized neoplasm 6 (50 per cent) are currently alive. Poor results were obtained in 9 patients who had preoperative metastatic disease. Over-all operative mortality was 14 per cent and morbidity was minimal, with no pulmonary emboli intraoperatively or postoperatively.

Renal cell carcinoma: natural history and results of treatment

We reviewed 166 cases of renal cell carcinoma. The presenting symptoms varied from vague backache to hypovolemic shock. The most common symptoms were pain, hematuria, a palpable mass and hypertension. Most cases involved were clear cell carcinoma (83 per cent) and survival was no better than in cases of granular cell carcinoma. The tumors metastasized to almost every organ of the body. Bilateral simultaneous primary renal cell carcinoma is described in 1 patient, who has survived for more than 5 years. The over-all 5-year survival rates of simple and radical nephrectomy were 32 and 66.6 per cent, respectively. Radiation therapy does not improve survival irrespective of stage. The 5-year survival rate with renal vein involvement was 32 per cent. Nephrectomy in patients with distant metastasis did not alter survival. Among the patients with metastasis 74 per cent were dead before 1 year and 96 per cent before 3 years.

Coagulation factors in renal adenocarcinoma

Coagulation factors, including plasma fibrinogen, serum fibrinogen-fibrin degradation products, platelet counts and prothrombin times, were studied in patients with renal adenocarcinoma. Plasma fibrinogen levels were elevated and correlated with tumor stage, disease activity and therapy. Fibrinogen-fibrin degradation product levels also were elevated, although such elevations did not correlate with other parameters. Platelet count and prothrombin times were normal. Fibrinogen may be a valuable marker of disease activity in patients with renal carcinoma. In addition, since significant intratumoral fibrin deposits have been demonstrated anticoagulants or fibrinolytic agents may enhance cytotoxic therapy and should be considered in adjunctive chemotherapeutic protocols.

Radical retroperitoneal surgery: a 25-year experience

A review of 210 radical retroperitoneal excisions performed through an abdominal or flank thoracoabdominal incision showed these procedures to be relatively safe. The flank approach had less morbidity and provided better exposure of the renal hilus and suprarenal areas. Pulmonary complications in the flank thoracoabdominal incision were reduced by closing the thorax with an indwelling pleural drainage tube. The flank thoracoabdominal approach is suitable for all radical retroperitoneal excision when extensive bilateral renal exposure is not needed.

Nephrectomy: indications and complications in 347 patients

The indications, complications and mortality rate in a recent 12-year experience with 347 nephrectomies were reviewed. Renal tumor is the most frequent condition requiring nephrectomy, probably because of the improved, non-ablative methods to treat inflammatory, obstructive, calculous and hypertensive renal disease. The over-all mortality rate was 1.4 per cent but was almost nil in the absence of malignancy.

Partial nephrectomy in the treatment of renal adenocarcinoma

During a 20-year period 17 patients underwent partial nephrectomy as primary curative therapy for renal adenocarcinoma. In 15 patients (88 per cent) partial nephrectomy was performed satisfactorily in situ with free margins of resection. Eleven patients are alive (65 per cent) and only 3 (17 per cent) died of recurrent malignant disease. There was no operative mortality and postoperative complications were minimal. A review of the literature reveals that partial nephrectomy is an effective form of therapy for patients with bilateral renal carcinoma or carcinoma occurring in a solitary kidney.

Preoperative irradiation of renal cell carcinoma

Since 1967 we have been using preoperative radiation therapy for renal cell carcinoma as proposed by Riches. Radiation therapy, to include the para-aortic lymph nodes, is given in 250-rad increments four times weekly to a total dose of 3,000 rads. After an interval of three weeks following radiation therapy, we performed radical nephrectomy. The object of this preoperative treatment is devitalization of growing cells in the periphery of the tumor, thus preventing metastases and local recurrence, and and decreasing the size of the tumor and thereby facilitating surgery. In one third of the cases there is radiologically demonstrable decrease in the size of the tumor, probably secondary to obliteration of the dilated veins in the capsule. The delay of six weeks has had no adverse effect on the outcome of metastases.

Renal cell carcinoma presenting with metastases to pulmonary hilar nodes

Mediastinal and hilar renal cell carcinoma metastases are reported in 9 patients, representing an incidence rate of 8 per cent in the series. This observation indicated an ominous prognosis since the mean survival of these patients was only 1.4 months after the discovery of the neoplasm. It is postulated that this poor prognosis is attributable to the size of the primary lesion, with direct extension into retroperitoneal structures and perhaps to an associated exhaustion of immunologic defense mechanisms of the patients. Dissemination from the involved retroperitoneal lymphatics to the thoracic duct and then in retrograde fashion via the bronchomediastinal and paratracheal trunks is advocated as the pathway for this tumor dissemination.

Successful extraction of intracardiac tumor thrombus of renal carcinoma

Successful management of a patient with an intracardiac tumor thrombus of renal carcinoma is described. Important considerations in the management include precise localization of the upper limits of the tumor thrombus preoperatively, early ligation of the renal artery, control of the circulation through the inferior vena cava by temporary occlusion of the vena cava below the renal veins, the left renal vein and the hepatic circulation, and a team approach, using the expertise of the urologist and the cardiac surgeon, as well as cardiopulmonary bypass.

Adenosine deaminase activity in patients with renal adenocarcinoma

Erythrocyte and lymphocyte adenosine deaminase (ADA) levels were studied in 31 patients with renal cell carcinoma (RCC). Decreased lymphocyte ADA levels occurred in patients with RCC. Erythrocyte ADA levels were reduced only in blood type B and O patients. Nephrectomy resulted in a rise in lymphocyte and erythrocyte ADA levels. Progression of clinical disease was associated with a fall in lymphocyte ADA values in all patients and with a rise in erythrocyte levels only in blood type A patients. Our results suggest that changes in erythrocyte and lymphocyte ADA levels in RCC patients are acquired and may offer insight into host-tumor interactions.

Renal adenocarcinoma: prognostics and treatment reflected by survival

A retrospective study of 164 patients with renal adenocarcinoma has reconfirmed the highly malignant potential of this neoplasm. Stage and size of the tumor appear to be the best prognostic parameters. Radical surgery appears to have improved survival statistics. Follow-up must be indefinite since late metastases are not uncommon.

Hormones in renal cancer

Plasma renin, erythropoietin and chorionic gonadotropin levels were evaluated in 57 patients with renal adenocarcinoma. Renin elevation, found in 37 per cent, was unrelated to blood pressure levels but was associated with high grade, high stage lesions of mixed histologic cell type and predicted a poor prognosis. Erythropoietin was raised in 63 per cent of patients and was more sensitive than renin in indicating the presence of renal adenocarcinoma. However, it was less specific and did not correlate directly with tumor grade, stage, histologic type, prognosis or hematocrit and hemoglobin levels. None of the patients had elevated chorionic gonadotropin levels. Therefore, we believe that renin and erythropoietin determinations may be of value as biochemical tumor markers in renal adenocarcinoma.

Minimal mortality of renal surgery

Eight hundred fourteen renal operative procedures were reviewed to determine overall mortality and to identify patients at risk. The over-all mortality was 1.35%, but as high as 30% in patients with uremia and spesis. Carcinomatosis contributed to higher mortality in other groups. In the absence of these three factors renal surgery was associated with very low or no postoperative (thirty day) mortality.

Papillary renal cell carcinoma: a clinical, radiologic, and pathologic study of 34 cases

Papillary renal cell carcinoma (RCC) is known by its tendency to avascularity by angiography; however, data concerning its clinicopathologic spectrum and prognosis are not available. In a review of 224 renal cell carcinomas accesioned in our files, 34 were found to be papillary and 190 of other histologic types. A comparative analysis of these two gropus revealed marked differences. The majority of papillary tumors (85.3%) were in pathologic stage I, whereas more than half of the nonpapillary tumors had extended beyond the limits of the kidney. Follow-up data revealed that the survival for papillary RCC was significantly higher than that for nonpapillary tumors. This difference held true even when tumors in the same pathologic stage were compared. Many papillary tumors, particularly those with a favorable course, were massively necrotic, densely infiltrated by macrophages, or both. In view of these findings, the possibility that host mechanisms are involved in destruction and confinement of the tumor is discussed. Examination of kidney tissue distant from the tumor disclosed, in some cases, atypical hyperplastic changes of collecting tubules; this raises the possibility that some papillary tumors arise from distal tubular epithelium. Hypo- or avascularity was present in all papillary RCC's studied by angiography.

Multiple expanding renal lesions

Unilateral or bilateral multiplicity of expanding lesions in the kidneys is not too unusual and different types of lesions may be combined. This stresses the need for detailed angiography of both kidneys in order to establish an exact diagnosis.

Clinical comparison between vascular and avascular renal cell carcinoma

Of 72 patients with renal cell carcinoma 19 were found to have an angiographic avascular neoplasm. These avascular tumors have a lower incidence of vein and capsule invasion than vascular tumors. Among these avascular cancers papillary adenocarcinoma was the predominant histologic pattern. Patients with papillary tumors seem to have a lower clinical stage and increased survival rate than patients with non-papillary tumors.

Bacillus Calmette-Guerin in the treatment of adenocarcinoma of the kidney

Of 18 patients with renal adenocarcinoma 10 with metastatic disease received Bacillus Calmette-Guerin immunotherapy. Objective responses were recorded in 4 patients. When the intradermal route and relatively small amounts of vaccine were used the complications were minimal and self-limiting. Bacillus Calmette-Guerin immunotherapy appears to be more effective than other modalities in the treatment of renal adenocarcinoma. However, definitive conclusions cannot be drawn since there is no control group. A prospective clinical trial is now in progress at this institution.

Evaluation of renal masses including retrograde renal brushing

1. The evaluation of renal masses has become an increasingly important topic because of the increasing incidence of kidney cancer, the improved cure rate of renal carcinoma with the proper preoperative diagnosis, and the proliferation in renal mass diagnostic methodology. 2. A variety of benign entities can produce an abnormal renal mass with attendant difficulties in being distinguished from malignant neoplasms. Among these benign lesions are: simple renal cysts, polycystic kidneys, congenital variations in renal size and shape, segmental renal hypertrophy, renal infarcts, intrarenal hematomas, renal hamartomas, renal leiomyomas, renal adenomas, renal angiomas, renal fibrolipomatosis, hydronephrosis of a duplicated collecting system, renal abscesses, and xanthogranulomatous pyelonephritis. 3. Nephrotomography, nephrosonography (ultrasound), adrenalin renal arteriography, selective magnification renal arteriography, renal venography and cavography, lymphangiography, renal scintillation scanning, abnormal levels of enzymes in blood and urine, immunologic studies (circulating antibodies and tumor-associated antigens), percutaneous needle aspirations, and retrograde renal brushing have all increased the diagnostic accuracy of determining the etiology of renal masses. None of these diagnostic procedures is infallible. A judicious combination of procedures gives the most reliable diagnostic results. 4. A search continues for (a) chemical agent(s) or a chemical profile in the blood or urine which is (are) specific for renal carcinoma, but as yet this is an investigational area and not a practical clinical reality.

Hormones in the treatment of metastatic renal cancer

Metastatic renal adenocarcinoma has been highly resistant to most therapeutic approaches. However, hormonal treatment has been reported to induce significant subjective or objective improvement. Two groups of patients receiving either androgens or progestogens were evaluated. The number of responses was disappointing. Furthermore, neither of the 2 regimens appeared to increase the mean surival between detection of metastases and fatal outcome.

An analysis of factors affecting survival in 150 patients with renal carcinoma

A review of 150 patients with renal carcinoma revealed that 45 per cent were hospitalized with distant metastases or tumors that were unresectable. Although the behavior of the neoplasm in the 55 per cent who were theoretically curable was generally unpredictable, longevity and survival were markedly increased in patients with tumors less than 8 cm. in size and concomitantly with other acknowledged features of low stages of the disease. Since patients can survive with tumor for long periods and metastases may occur many years after the operation prognosis must be guarded and long followup is needed to assess the results of therapy at any stage of the disease.

The place of bone scan in the diagnosis of renal cell carcinoma

We herein review 12 cases of renal cell carcinoma evaluated by bone scan and skeletal survey. Comparison of these techniques revealed a high incidence of falsely negative results (42 per cent) when using skeletal survey alone. It is now our policy to include the bone scan in our initial evaluation of patients with renal cell carcinoma.

The staging of renal parenchymal tumours

The relation between the anatomical features in the development of renal parenchymal tumours and the prognosis are analysed. It is suggested that the clinical and anatomical classification must be revised.