Outcome Of Surgical Treatment Of Isolated Local Recurrence After Radical Nephrectomy For Renal Cell Carcinoma

Short time to recurrence after hepatic resection correlates with poor prognosis in colorectal hepatic metastasis

BACKGROUND

Early recurrence is a major problem after hepatic resection of colorectal hepatic metastasis (CHM). Our aim was to investigate the relationship between time to recurrence after CHM resection and overall survival.

METHODS

A retrospective analysis was performed for 101 consecutive patients who underwent hepatic resection for CHM and have been followed more than 5 years.

RESULTS

Among 101 patients, 82 (81%) had a recurrence. Overall survival of patients with recurrence within 6 months after CHM resection was significantly worse than that of patients with recurrence after more than 6 months (P < 0.01). Overall survival was poorer when time to recurrence was shorter. One of the reasons for poor prognosis of patients with recurrence within 6 months was that only a few patients could undergo a second resection for recurrence after CHM resection. Histological type, including poorly differentiated signet ring cell or mucinous adenocarcinoma in the primary tumor, bilobar metastases, microscopic positive surgical margin and carcinoembryonic antigen (CEA) above 15 ng/ml had predictive value for decreased recurrence-free survival after CHM resection.

CONCLUSION

Short time to recurrence after CHM resection correlates with a poor prognosis. Histological type of poorly differentiated signet ring cell or mucinous adenocarcinoma in the primary tumor might be a predictor for early recurrence after CHM resection.

Long-term outcomes of the surgical management of renal cell carcinoma

It has been 35 years since the radical nephrectomy was standardized by the work of Robson et al. (J Urol 101:297-301, 1969). Despite being based on a retrospective review of only 88 cases operated upon over a span of 15 years, this publication was an important milestone in the attempt to create uniformity in the staging of Renal cell carcinoma (RCC), and the measurement of surgical outcomes for RCC. Although this manuscript forms the basis for our contemporary measurement of the long-term results of RCC surgery and set the standard to which the entire subsequent literature was compared, contemporary research subsequently has questioned many of Robson's conclusions regarding RCC. In Robson's era, the majority of patients presented with large, symptomatic tumors, pre-operative staging was imprecise, and many patients had locally advanced disease at the time of surgery: of the 88 patients in Robson's series, 75% were managed through a thoracoabdominal incision. Since that time, advances in renal imaging and clinical staging have led to the increased detection of incidental, lower stage, organ-confined tumors more amendable to expanded surgical options. Surgical techniques have evolved and technological advances have made possible new methods of managing renal tumors in situ that have emphasized a transition from radical to less extirpative approaches. In addition, understanding of the basic biology and genetics of kidney cancer has led to improved prognostication and the development of effective immunotherapies for advanced disease. The current concepts and long-term outcomes of the surgical management of RCC will be reviewed to help elucidate some of these changes, from the evolution of open to laparoscopic to percutaneous, from radical to partial to ablative approaches.

MANAGEMENT OF ISOLATED RENAL FOSSA RECURRENCE FOLLOWING RADICAL NEPHRECTOMY

PURPOSE

Local recurrence of renal cell carcinoma in the renal fossa without distant metastatic disease is an infrequent occurrence. Management of this lesion can be challenging, with relatively few series in the literature. We describe our use of surgical extirpation with adjuvant intraoperative radiation.

MATERIALS AND METHODS

The University of California, San Francisco Urologic Oncology database and the University of California, San Francisco Radiation Oncology database were queried for all patients with locally recurrent renal fossa recurrence. Only patients with recurrence of renal cell carcinoma in the renal fossa were included. Survival, complications and the use of adjuvant therapy in the form of intraoperative radiation therapy were noted.

RESULTS

A total of 14 patients were treated for this lesion between 1990 and 2003. Mean time to recurrence was 40 months (range 5 to 180). Only 1 patient was symptomatic preoperatively, while in 13 disease had been detected on routine computerized tomography followup. Mean size of the recurrent tumor was 6.35 cm (range 2 to 17). 9 patients died of progressive, metastatic disease after a mean of 17 months (range 1 to 56) and 5 are alive with a mean survival of 66 months (range 14 to 86). The time to recurrence after nephrectomy approached statistical significance (p =0.06) when comparing the patients who were alive vs those who died of disease. Additionally, there was no statistical difference in size of mass recurrence between these 2 groups. There was no difference in survival due to adjuvant intraoperative radiation therapy. Local fossa re-recurrence developed in 2 patients. Survival was 40% at 2 years and 30% at 5 years from surgery. Complications, including minor complications, occurred in 42% of patients and there was no perioperative mortality.

CONCLUSIONS

Selected patients with isolated local recurrence in the renal fossa may have favorable and durable outcomes following surgical resection and possibly adjuvant intraoperative radiation therapy for isolated renal fossa recurrence following radical nephrectomy. Development of novel and effective systemic therapy is needed in high risk patients with renal cancer.

[When is aftercare useful in renal cell cancer?]

Diagnosis of tumor recurrence and of therapy-related side effects as well as psychological support are the main goals of a surveillance program of cancer patients. While the latter may represent a time-consuming effort, most diagnostic procedures are expensive. Whether we can efficiently detect tumor recurrence in renal cell carcinoma depends on various parameters of the recurrent disease (e.g., frequency, localization, or therapeutic options). Available data lend support to "lean" follow-up strategies in patients with renal cell carcinoma.

Surgery for metastatic renal cell cancer

Renal cell carcinoma (RCC) often presents in its metastatic form, or progresses after curative treatment. While the management of metastatic RCC has historically been mainly surgical, contemporary approaches often incorporate systemic immunotherapy. This review examines the current indications and scope of surgical treatment of patients with metastatic RCC. Surgery is sometimes indicated for symptom palliation at either the primary or secondary sites. However, other less invasive therapies may be equally effective, and should be considered carefully. Cytoreductive surgery prior to immunotherapy appears to confer a survival advantage, but only selected patients are suitable for this treatment regimen. Primary immunotherapy followed by surgical removal of the tumour in partial responders is an alternative treatment strategy, which has not yet been evaluated as in randomized trials. As immunotherapy develops further, the precise timing and role of surgery in multimodality treatment will need to be carefully evaluated. Occasionally, the complete surgical excision of metastases, and the primary tumour, if present, is feasible and this may prolong survival. Empirically, it would seem that such patients should also be treated with adjuvant immunotherapy, as eventual relapse is frequent. Surgery with the aim of inducing spontaneous tumour regression is not justifiable, given the rarity of this phenomenon.

Rezidivtumor beim Nierenkarzinom

Locally recurrent renal cell carcinoma (RCC) is 0-10% after nephron-sparing surgery, 2.5-4% after thermoablative interventions and 2-3% after (radical) nephrectomy. Risk-factors are: sporadic or hereditary origin, tumor size, multifocality, histologic phenotype and incomplete resection. To date, there are no significant differences in the incidence of locally recurrent tumors independently of whether open or laparoscopic techniques were preferred. Caution still has to be taken with the use of alternative tools for minimally invasive tumor ablation.Finally, no statistically proven standard therapy exists that would clearly provide a superior outcome for patients with an isolated local recurrence. However, meta-analyses strongly support the performance of a resection of the recurrence as the primary working principal.

Renal cell carcinoma: analysis of postoperative recurrence patterns

PURPOSE

To retrospectively analyze the recurrence patterns of renal cell carcinoma (RCC) and the factors affecting tumor recurrence.

MATERIALS AND METHODS

The institutional review board approved this study; patient informed consent was not required. There were 162 men (mean age, 54 years +/- 13 [standard deviation]) and 32 women (mean age, 56 years +/- 11) who had undergone complete surgical resection of RCC. Mean follow-up period was 45 months (range, 7-92 months). In consensus, two radiologists determined the presence or absence of tumor recurrence and recorded the time and sites of tumor recurrence. The relationships between tumor recurrence and tumor factors, including greatest diameter (> or =5 cm or <5 cm), T stage, N stage, stage group, histologic subtype, and nuclear grade, were evaluated by using Kaplan-Meier statistics.

RESULTS

Tumor recurred in 41 (21%) patients. The mean time of tumor recurrence was 17 months (range, 3-50 months). Tumor recurred within 2 years after surgery in 34 (83%) patients. Tumor recurrence sites included lung (n = 29), bone (n = 13), the nephrectomy site (n = 7), brain (n = 6), liver (n = 5), mediastinal lymph nodes (n = 5), the contralateral kidney (n = 4), and the neck muscles (n = 2). The recurrence rate was greater for tumors 5 cm or larger than for those smaller than 5 cm, greater for T3a or T3b tumors than for T1 tumors, greater for stage III tumors than for stage I tumors, and greater for tumors with a nuclear grade of 3 or 4 than for those with a nuclear grade of 1 or 2 (P < .05 for all).

CONCLUSION

RCC usually recurs within 2 years after surgery, with the lung being the most vulnerable site; greatest tumor diameter, T stage, stage group, and nuclear grade are important factors for recurrence.

Surveillance after radical or partial nephrectomy for localized renal cell carcinoma and management of recurrent disease

Surveillance after surgery for RCC is important because approximately 50% of these patients will develop a disease recurrence, two thirds of who will recur within the first year. Although the prognosis is generally poor in these patients, some may respond favorably to immunotherapy. The small subset of patients who develop solitary metastases has the greatest chance to achieve long-term survival. Aggressive surgical resection is an integral part of this success. Proposed surveillance protocols using a stage-based approach or an integrated approach combining stage with other important prognostic factors attempt to provide a rational approach to identifying treatable recurrences while minimizing unnecessary examinations and patient anxiety. However, strict adherence to follow-up guidelines may not be appropriate for all patients. Factors including patient comorbidities and patient willingness to pursue aggressive management in the event of recurrence may alter the follow-up for each individual.

Surgical management of renal tumors

Renal cell carcinoma is a relatively rare tumor, accounting for approximately 3% of malignancies in adults, but is the most common tumor of the kidney and the third most common tumor seen by urologists. Renal cell carcinoma is refractory to most traditional oncologic treatments, including chemotherapy, radiation therapy, and hormonal therapy. Because of recent advances in sophisticated radiologic studies, the surgeon can now make an accurate preoperative assessment of the nature and extent of kidney tumors. When evaluating renal tumors, the urologist looks for certain information to help in constructing a management plan. This article explores some of the points that contribute in the surgical decision-making.

Isolated local recurrence of renal cell carcinoma after radical nephrectomy: experience with 10 cases

OBJECTIVES

Isolated local recurrence of renal cell carcinoma after radical nephrectomy is very uncommon and the effect of aggressive surgical management of this clinical entity remains controversial. We report our experience with 10 such cases.

METHODS

Between 1994 and 2002, 10 patients with isolated local recurrence of renal cell carcinoma without any evidence of metastatic disease after radical nephrectomy were treated at our department. The mean patient age was 51.7 years (range 26 to 74); 7 patients were men and 3 were women. All patients underwent extensive surgery for local recurrence.

RESULTS

Only 3 patients were symptomatic, and the others were diagnosed during routine follow-up examinations. The mean time to local recurrence was 33.6 months (range 3 to 68), and the mean size of the recurrent tumor was 8.45 cm (range 3 to 12). An aggressive surgical approach was taken in all patients. One patient died in the postoperative period because of a surgical complication. Of the remaining 9 patients, 2 died of metastatic disease after a mean survival of 8.5 months (range 3 to 14). Seven patients were alive with a mean survival of 16.6 months (range 3 to 38+).

CONCLUSIONS

We believe that patients with isolated local recurrence after radical nephrectomy may benefit from an aggressive surgical approach, but this kind of surgery may also have significant complications.